Endovascular treatment of vertebral artery dissecting aneurysms : a 20-year institutional experience

Evaluation of flow diverter use in acutely ruptured vertebral artery dissecting Aneurysms: A focus on safety and efficacy for rapid Aneurysm obliteration

OBJECTIVE

Flow diverter device (FDD) has emerged as the reconstruction technique for treating ruptured dissecting vertebral artery Aneurysms (VADA), but data on feasibility regarding re-rupture risk and timing of Aneurysm obliteration following FDD treatment is still limited. Therefore, this study aimed to evaluate the safety and efficacy of FDD in the treatment of VADAs presenting with subarachnoid hemorrhage (SAH).

METHODS

We retrospectively reviewed patients with ruptured VADA presenting with subarachnoid hemorrhage who underwent FDD placement at our institution between 2015 and 2023. Patient demographic data, Aneurysm configuration, and occlusion status were analyzed.

RESULTS

Thirteen patients with SAH from VADA rupture underwent FDD implantation. The average size of the largest diameter of the Aneurysm was 11.2 mm (range 6.5-21 mm). Eight of 13 (61.5 %) patients had their Aneurysms completely obliterated within 2 weeks after the procedure. The small dissecting Aneurysm (d = 0.636, p = 0.002) and degree of intra-Aneurysmal contrast stasis (d = 0.524, p = 0.026) were associated with rapid Aneurysm occlusion, according to the Somer's d coefficient. There were no ischemic or hemorrhagic complications at the average clinical follow-up of 28.4 months (range 5-67 months) and average angiographic follow-up of 20.1 months (range 3-60 months). A favorable outcome (mRS 0-2) was achieved in 12 patients (92.3 %).

CONCLUSIONS

FDD is safe and effective for the reconstruction of acutely ruptured VADAs. In addition, our study emphasizes that small dissecting Aneurysms tend to be rapidly obliterated after flow diversion, which eliminates the risk of re-rupture during the acute phase of subarachnoid hemorrhage.

Comparing the safety and effectiveness of overlapping stents with flow diverters for unruptured vertebral artery dissecting aneurysms

BACKGROUND

Endovascular treatment for vertebral artery dissecting aneurysms (VADAs) includes overlapping stents and flow diverters. This study compared the safety and effectiveness of overlapping stents and flow diverters for unruptured VADAs.

METHODS

We retrospectively enrolled patients with unruptured VADAs who underwent overlapping stents or flow diverters at two tertiary hospitals in South Korea. The primary clinical outcome was the occurrence of stroke. The primary angiographic outcomes (>12 months) were categorized as regression, no decrease in size, recanalization, or stent occlusion, of which only regression was defined as a favorable angiographic outcomes.

RESULTS

Of the 146 patients with VADAs, 25 (17.1%) had flow diverters and 121 (82.9%) had overlapping stents. For the primary angiographic outcomes over 12 months, the rate of favorable angiographic outcomes for flow diverters was 81.8% and for overlapping stents (triple stents) was 98.8% (P=0.006). In the multivariale analysis, after adjusting for partially thrombosed aneurysms, aneurysm shape, non-dominant vessel, posterior inferior cerebellar artery involvement, and procedure type, overlapping stents (triple stents) was not associated with favorable angiographic outcomes compared with flow diverters (OR 7.040, 95% CI 0.549 to 90.294; P=0.134), but partially thrombosed aneurysms was inversely associated with favorable angiographic outcomes (OR 0.056, 95% CI 0.005 to 0.589; P=0.016). The primary clinical outcome followed up to the last angiography did not occur in all patients.

CONCLUSION

There was no difference in safety and effectiveness between overlapping stents and flow diverters in unruptured VADAs. Further endovascular treatment studies are needed regarding the association of partially thrombosed aneurysms with unfavorable angiographic outcomes.

Comparative meta-analysis of endovascular strategies for intracranial dissecting aneurysms: Flow diverters versus stents with or without coiling

BACKGROUND

Intracranial dissecting aneurysms present a challenging subset linked to considerable morbidity and mortality, necessitating effective therapeutic strategies to prevent complications. Traditional treatments face technical limitations, while emerging endovascular modalities like stent-assisted coiling, multiple stenting, and flow-diverting devices (FDDs) offer promise in reducing periprocedural risks and enhancing patient outcomes. The aim of this study is to compare the safety and efficacy outcomes of endovascular treatment for intracranial dissecting aneurysms using FDDs versus stents (with or without coiling).

METHODS

A systematic review and meta-analysis were conducted following established guidelines. The search included PubMed, Scopus, Web of Science, and Embase databases up to July 30, 2023. Eligible studies reporting outcomes of interest in both FDD and stent-treated groups were included, and the data was extracted and analyzed using STATA software.

RESULTS

Six studies were analyzed, involving 131 patients in the FDD group and 199 patients in the stent group. The pooled rates for favorable functional outcomes (86.8% vs. 86%), mortality (3.9% vs. 6%), adequate occlusion (79.7% vs. 86.3%), aneurysm recurrence (1.3% vs. 13.3%), in-stent stenosis/thrombosis (7% vs. 6.9%), ischemic events/infarctions (6.7% vs. 7.8%), retreatment (7% vs. 8.6%), and technical success (100% vs. 98.7%) were comparable in individuals treated with FDDs and stents (p > 0.05 in all cases). Additionally, complete occlusion rates were not significantly different between FDD (62.7%) and stent-treated patients (75.2%) (p = 0.06). However, after excluding one study in a leave-one-out analysis of the random effects meta-analysis, a significant difference in the pooled rates of this outcome was observed between the FDD (59.2%) and stent (75.2%) groups (p = 0.034).

CONCLUSION

FDDs present a promising approach for the treatment of intracranial dissecting aneurysms, yielding outcomes that are roughly comparable to stent-based methods. However, the absence of randomized trials and data limitations highlight the need for further research to enhance treatment strategies.

Posterior Inferior Cerebellar Artery-Posterior Inferior Cerebellar Artery Bypass versus Occipital Artery-Posterior Inferior Cerebellar Artery Bypass for Treating Posterior Circulation Aneurysms: A Systematic Review and Comparative Meta-Analysis

BACKGROUND

When traditional therapies are unsuitable, revascularization becomes essential for managing posterior inferior cerebellar artery (PICA) or vertebral artery aneurysms. Notably, the PICA-PICA bypass has emerged as a promising option, overshadowing the occipital artery-PICA (OA-PICA) bypass. The objective was to compare the safety and efficacy of OA-PICA and PICA-PICA bypasses.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review and meta-analysis to evaluate the safety and efficacy of OA-PICA and PICA-PICA bypasses for treating posterior circulation aneurysms.

RESULTS

We analyzed 13 studies for the PICA-PICA bypass and 16 studies on the OA-PICA bypass, involving 84 and 110 patients, respectively. The median average follow-up for PICA-PICA bypass was 8 months (2-50.3 months), while for OA-PICA, it was 27.8 months (6-84 months). The patency rate for OA-PICA was 97% (95% confidence interval [CI]: 92%-100%) and 100% (95% CI: 95%-100%) for PICA-PICA. Complication rates were 29% (95% CI: 10%-47%) for OA-PICA and 12% (95% CI: 3%-21%) for PICA-PICA. Good clinical outcomes were observed in 71% (95% CI: 52%-90%) of OA-PICA patients and 87% (95% CI: 75%-100%) of PICA-PICA patients. Procedure-related mortality was 1% (95% CI: 0%-6%) for OA-PICA and 1% (95% CI: 0%-10%) for PICA-PICA.

CONCLUSIONS

Both procedures have demonstrated promising results in efficacy and safety. PICA-PICA exhibits slightly better patency rates, better clinical outcomes, and fewer complications, but with a lack of substantial follow-up and a smaller sample size. The choice between these procedures should be based on the surgeon's expertise and the patient's anatomy.

Flow-Diverting Devices in the Treatment of Vertebral Artery Aneurysms: Insights into Efficacy and Safety from a Systematic Review and Meta-analysis

The objective of this study is to conduct a systematic review and meta-analysis aimed at evaluating the efficacy and safety of flow-diverting devices (FDs) treatment for intracranial vertebral artery (VA) aneurysms. We searched PubMed, Web of Science, OVID, and Embase for English-language studies up to February 2024 and included clinical studies on FD treatment of intracranial VA aneurysms. Sensitivity analysis evaluated outcome stability. Of 2273 articles, 29 studies involving 541 aneurysms treated with FDs were included. Based on the Methodological Index for Non-Randomized Studies (MINORS), six were high-quality and 23 moderate quality. FD treatment showed a 95% rate of favorable clinical outcomes (95% CI, 89-99%), 81% (95% CI, 74-88%) complete aneurysmal occlusion, 4% (95% CI, 2-7%) ischemic complication incidence, 1% (95% CI, 0-3%) hemorrhagic complication incidence, 95% (95% CI, 87-100%) posterior inferior cerebellar artery (PICA) preservation, and 6% (95% CI, 3-10%) in-stent stenosis or occlusion across clinical and angiographic follow-up periods of 13.62 months (95% CI, 10.72-16.52) and 11.85 months (95% CI, 9.36-14.33), respectively. Subgroup analyses, based on a 12-month angiographic follow-up threshold, indicated no statistically significant differences in rates of complete aneurysm occlusion, PICA preservation, or in-stent stenosis or occlusion incidence (p > 0.05) between subgroups. Moreover, significant differences were observed in clinical and angiographic outcomes between ruptured and unruptured aneurysms, particularly in hemorrhagic complications (p < 0.05), without significant disparity in ischemic complications (p > 0.05). The results' stability was confirmed via sensitivity analysis. FDs treatment for VA aneurysms is efficacious and safe, offering high rates of positive clinical and angiographic outcomes with minimal complications, underscoring FDs' viability as a treatment option for VA aneurysms. The study was registered with PROSPERO (registration number: CRD42024499894).

Endovascular Treatment for Intracranial Artery Dissections in Posterior Circulation

Intracranial artery dissections (IADs), although uncommon, are an important cause of cerebral infarction and subarachnoid hemorrhage (SAH). Some IADs can heal spontaneously after reconstitution of the vessel lumen with excellent prognosis. Meanwhile, others can progress to stroke that requires treatment. The incidence of IAD in the posterior circulation is higher than that in the anterior circulation. Anterior circulation dissections are more likely to develop into ischemia and posterior circulation lesions into hemorrhage. The mortality rate after IAD among patients with SAH is 19%-83%. Further, the mortality rate of IAD without SAH is 0%-3%. Patients with SAH commonly undergo surgery or receive neuroendovascular treatment (EVT) to prevent rebleeding. However, the treatment of IADs is empirical in the absence of data from randomized controlled trials. Recently, EVT has emerged and is considered for IADs because of its less invasiveness and perceived low rates of procedure-related morbidity with good efficacy. EVT strategies can be classified into deconstructive (involving sacrifice of the parent artery) and reconstructive (preserving blood flow via the parent vessel) techniques. In particular, the number of reports on reconstructive techniques is increasing. However, a reconstructive technique for ruptured IADs has not yet been established. This review aimed to provide an overview of IADs in the posterior circulation managed with EVT by performing a literature search.

Flow diverters in the treatment of intracranial dissecting aneurysms: a systematic review and meta-analysis of safety and efficacy

BACKGROUND

Intracranial dissecting aneurysms present clinical challenges, demanding immediate intervention due to their high bleeding risk. While traditional treatments have limitations, the potential of flow diverters shows promise but remains a subject of ongoing debate for optimal management. The aim of this study was assess the safety and efficacy of flow diverters in the treatment of intracranial dissecting aneurysms.

METHODS

A systematic review and meta-analysis was performed following established guidelines. The search encompassed PubMed, Scopus, Web of Science, and Embase databases up to July 20, 2023. Eligible studies reporting outcomes of interest were included, and relevant data were extracted and analyzed using R software.

RESULTS

The analysis, based on data pooled from 20 included studies involving 329 patients, revealed a favorable functional outcome rate of 89.7% at the last follow-up. The mortality rate during the follow-up period was 2.4%, decreasing to 0.9% when excluding the outlier study. In the final angiographic follow-up, a complete occlusion rate of 71.7% and an adequate occlusion rate of 88.3% were observed. Notably, studies with longer angiographic follow-up times exhibited lower rates of complete (P=0.02) and adequate (P<0.01) occlusion. A minimal aneurysm recurrence/rebleeding rate of 0.1% was noted, while in-stent stenosis/thrombosis occurred at a rate of 1.14%. Additionally, ischemic events/infarctions were seen in 3.3% of cases. The need for retreatment was minimal, with a rate of 0.9%, and the technical success rate was impressively high at 99.1%.

CONCLUSION

This study highlights the safety and efficacy of flow diverters in treating intracranial dissecting aneurysms. Further research, encompassing larger multicenter studies with extended follow-up periods, is crucial for comprehending occlusion dynamics, refining treatment strategies, improving long-term outcomes, and addressing methodological limitations.

Far-lateral approach without C1 laminectomy for microsurgical treatment of vertebral artery and proximal posterior inferior cerebellar artery aneurysms: Experience from 48 patients

Background

In the endovascular era, most of vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms were mainly treated with endovascular procedures. This study aimed to demonstrate the microsurgical treatment via the far-lateral approach without C1 laminectomy and its clinical outcomes.

Methods

Forty-eight patients with VA and proximal PICA aneurysms treated by microsurgery through the far-lateral approach without C1 laminectomy, between January 2016 and June 2021, were retrospectively evaluated.

Results

Most patients (87.5%) presented with subarachnoid hemorrhage. Grading at presentation was poor in 41.7%. The rates of VA dissecting aneurysms, saccular aneurysms of the VA-PICA junction, and true PICA saccular aneurysms were 54.2, 18.7, and 14.6%, respectively. All aneurysms were located above the lower margin of the foramen magnum. The far-lateral approach without C1 laminectomy was successfully used in all patients without residual aneurysms. Various surgical strategies were applied depending on the characteristics of the aneurysm. Good outcomes 3 months postoperatively were achieved in 77.1% and 89.3% for the overall and good-grade groups, respectively.

Conclusions

Microsurgery is a safe and effective treatment of VA and proximal PICA aneurysms. Moreover, the far-lateral approach without C1 laminectomy was adequate and effective for aneurysms located above the lower border of the foramen magnum.

Clinical and Radiological Outcomes of Vertebral Artery Dissecting Aneurysms Treated with Endovascular Treatments: A 12-year Single-Center Experience

OBJECTIVE

We aimed to compare the clinical and radiological outcomes of vertebral artery dissecting aneurysms (VADAs) stratified using different endovascular treatment methods.

METHODS

We retrospectively reviewed 116 patients with VADAs treated at a single tertiary institute between September 2008 and December 2020. We analyzed and compared the clinical and radiological parameters according to different treatment methods.

RESULTS

In total, 127 endovascular procedures were performed in 116 patients. We initially treated 46 patients with parent artery occlusion, 9 with coil embolization without stent, 43 with single stent with or without coil, 16 with multiple stents with or without coils, and 13 with flow-diverting stent. At the last follow-up (mean 37.8 ± 30.9 months), the complete occlusion rate (85.7%) was higher in the multiple-stent group than in the groups that received other reconstructive treatment methods. Moreover, the recurrence (0%) and retreatment (0%) rates were significantly lower in the multiple stent group (P < 0.001). The coil embolization-only group showed the highest recurrence (n = 5, 62.5%) and incomplete occlusion (n = 1, 12.5%) rates. The single-stent group showed higher recurrence (n = 9, 22.5%) and retreatment (n = 3, 7%) rates. Multivariate logistic regression analyses showed that coil embolization without stent placement (odds ratio = 172.76, 95% confidence interval = 6.83-4366.85; P = 0.002) was significantly associated with recurrence. At the last follow-up (mean, 42.1 ± 37.7 months), we achieved favorable clinical outcomes (modified Rankin Scale ≤2) in 106 of 127 patients.

CONCLUSION

When treating VADAs, multiple stent placements may play a key role in achieving favorable long-term radiological outcomes.

Periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms

OBJECTIVE

The authors undertook an evaluation of periprocedural cerebrovascular complications and 30-day outcomes of endovascular treatment for intracranial vertebral artery dissecting aneurysms (IVADAs) and assessed the relevant risk factors.

METHODS

The authors included a series of 195 patients who had undergone endovascular treatment for 198 IVADAs. Clinical data, morphological characteristics, treatment details, and periprocedural cerebrovascular complications including intraprocedural rupture, intraprocedural thrombosis, intracranial hemorrhage (ICH), transient ischemic attack (TIA), and ischemic stroke (IS) were recorded. After evaluation of the 30-day modified Rankin Scale (mRS) scores, the authors applied univariate and multivariate logistic regression analyses to identify the risk factors for complications and 30-day unfavorable clinical outcomes.

RESULTS

There were no intraprocedural ruptures, but the authors recorded intraprocedural thrombosis (n = 5), ICH (n = 3), TIA (n = 1), and IS (n = 13), comprising an 11.1% (22/198) complication rate. Multivariate logistic regression analysis indicated that hyperlipidemia (odds ratio [OR] 3.17, 95% confidence interval [CI] 1.20-8.41, p = 0.020), IS history (OR 5.55, 95% CI 1.46-21.01, p = 0.012), and subarachnoid hemorrhage (SAH) (OR 4.48, 95% CI 1.52-13.20, p = 0.007) were risk factors for overall complications, whereas aneurysmal height (OR 0.77, 95% CI 0.61-0.98, p = 0.032) was a protective factor. SAH (OR 6.44, 95% CI 1.54-26.89, p = 0.011) and preprocedural mRS score > 2 (OR 5.07, 95% CI 1.01-25.59, p = 0.049) were independent risk factors for perforator occlusion stroke. Periprocedural cerebrovascular complications (OR 32.09, 95% CI 3.00-343.94, p = 0.004) and preprocedural mRS score > 2 (OR 319.92, 95% CI 30.28-3379.98, p < 0.001) were independent risk factors for 30-day unfavorable clinical outcomes.

CONCLUSIONS

Hyperlipidemia, IS history, and SAH were independent predictors for overall periprocedural cerebrovascular complications of endovascular treatment for IVADAs, but aneurysmal height was an independent protective factor. SAH and preprocedural mRS score > 2 were independent risk factors for perforator occlusion stroke. Preprocedural mRS score > 2 and periprocedural complications were independent risk factors for 30-day unfavorable clinical outcomes.

Diagnostic Performance of High-Resolution Vessel Wall MR Imaging Combined with TOF-MRA in the Follow-up of Intracranial Vertebrobasilar Dissecting Aneurysms after Reconstructive Endovascular Treatment

BACKGROUND AND PURPOSE

Few studies have reported the utility of high-resolution vessel wall MR imaging in the follow-up of endovascularly treated vertebrobasilar dissecting aneurysms. This study aimed to evaluate the diagnostic performance of high-resolution vessel wall MR imaging combined with TOF-MRA in the follow-up of intracranial vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment.

MATERIALS AND METHODS

Patients with intracranial vertebrobasilar dissecting aneurysms with reconstructive endovascular treatment and followed up with TOF-MRA, high-resolution vessel wall MR imaging, and DSA were included. With DSA as the criterion standard, the diagnostic performance of TOF-MRA, high-resolution vessel wall MR imaging, and high-resolution vessel wall MR imaging combined with TOF-MRA in the evaluation of aneurysm occlusion status and parent artery patency was assessed. Visualization of the stented artery on TOF-MRA and high-resolution vessel wall MR imaging was rated on a 5-point scale.

RESULTS

Twenty-seven patients with 29 aneurysms were included. The sensitivity, specificity, positive predictive value, and negative predictive value of TOF-MRA, high-resolution vessel wall MR imaging, and high-resolution vessel wall MR imaging combined with TOF-MRA for diagnosing aneurysm remnants were 80.0%, 100.0%, 100.0%, and 82.4%; 53.3%, 100.0%, 100.0%, and 66.7%; and 93.3%, 100.0%, 100.0%, and 93.3%, respectively. For the visualization of the stented artery, the mean score of high-resolution vessel wall MR imaging was significantly higher than that of TOF-MRA (4.88 [SD, 0.32] versus 2.53 [SD, 1.25], P < .001). In the evaluation of parent artery patency (normal or pathologic), whereas TOF-MRA had a sensitivity, specificity, positive predictive value, and negative predictive value of 100.0%, 8.0%, 14.8%, and 100.0%, respectively, high-resolution vessel wall MR imaging was completely consistent with the DSA.

CONCLUSIONS

High-resolution vessel wall MR imaging combined with TOF-MRA at 3T showed good diagnostic performance in the follow-up of intracranial vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment.

Effect and safety of Tubridge flow diverter in the treatment of unruptured intracranial aneurysms

The effect and safety of the Tubridge flow diverting device are unknown in the treatment of intracranial aneurysms after optimization of the device, improvement in the deployment of the device, and accumulation of experience of using the device. This retrospective one-center study was performed to investigate the clinical effect and safety of the Tubridge flow diverting device in the treatment of unruptured intracranial aneurysms. Twenty-three patients with 33 unruptured intracranial aneurysms which were treated with the Tubridge device were retrospectively enrolled. The clinical data, endovascular procedure, complications, and follow-up were analyzed. Twenty-seven Tubridge devices were deployed to treat the 33 aneurysms, and the deployment was failed in 1 case, resulting in the success stenting rate of 96.3%. In 5 (15.2%) aneurysms, coils were loosely packed. Peri-procedural complications occurred in 2 patients (8.7%), including 1 procedure-related complication in which the distal end of a Tubridge device herniated into the aneurysm cavity. In another case, weakness of left upper limb occurred on the second day post procedure, with instent thrombosis being suspected, which was recovered after medication. No other complications occurred. Twenty-three (100%) patients had clinical follow-up 6 months later, with the mRS of 0 in 21 patients, 1 in 1, and 2 in 1. Five (21.7%) patients with 11 aneurysms underwent digital subtraction angiography at 6-month follow-up, with 8 aneurysms being completely occluded (Raymond grade I) and 3 aneurysms still visible (Raymond grade III). The Tubridge flow diverter may be safe and effective in the treatment of unruptured intracranial aneurysms with low perioperative complications and good follow-up outcomes even though multi-center and prospective clinical studies with a large size sample are still needed to validate these results.

Stent-alone treatment of unruptured vertebral artery fusiform aneurysms: A comparison of flow diverter and conventional stents

Background

Treatment of vertebral artery fusiform aneurysms (VAFAs) is complex and controversial. This study aimed to compare the safety and efficacy between flow diverter and conventional stents in patients with VAFAs undergoing endovascular stent-alone treatment (SAT).

Methods

Thirty-six patients with 36 VAFAs who underwent SAT between January 2014 and December 2018 were retrospectively analyzed. Patient and aneurysm characteristics, procedural details, complications, and angiographic and clinical outcomes were compared between flow diverter stent patients (n = 22) and conventional stent patients (n = 14).

Results

More branches covered with stent were found in the conventional stent group (88.9 vs. 33.3%; p = 0.008). The number of stents placed was significantly higher in the conventional stent group (1.57 ± 0.76 vs. 1.09 ± 0.29; p = 0.016). The proportion of patients with significant or moderate stasis within the aneurysm immediately after stent placement was higher in the flow diverter stent group (95.5 vs. 57.1%; p = 0.004). The proportion of patients with complete obliteration or only a residual neck on follow-up angiography was significantly higher in the flow diverter stent group (86.3 vs 50.0%; p = 0.047). However, the incidence of parent artery stenosis or occlusion was also higher in the flow diverter stent group (27.3% vs. zero; p = 0.032). The rate of complications did not significantly differ between the groups.

Conclusions

SAT was safe and effective in patients with VAFAs. Flow diverter stents are associated with a significantly better complete occlusion rate than conventional stents; however, they are also associated with an increased risk of parent artery stenosis.