Use of pCONUS HPC for the treatment of unruptured wide-necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy

Endovascular treatment of wide-neck bifurcation aneurysms using pCONUS2 HPC bridging device with single antiplatelet: A Case Series

RATIONALE

Wide neck bifurcation aneurysms (WNBA) are technically challenging for both surgical and endovascular treatments. Endovascular treatment for WNBA often requires dual antiplatelet therapy (DAPT) post stent insertion. Novel devices such as the pCONUS2 HPC neck bridging device have an HPC coating which reduces the device thrombogenicity. This theoretically allows for use of single antiplatelet therapy (SAPT), which would be advantageous, particularly in treating ruptured aneurysms. This case series aims to evaluate the safety of SAPT regimen only post stent insertion, by presenting our center early clinical experience in using pCONUS2 HPC neck bridging device in patients that are not suitable for DAPT.

PATIENT CONCERNS

We report the cases of 3 patients (2 females, 1 male; range: 64-71 years old) who underwent coil embolization for WNBA using the pCONUS2 HPC device (2 unruptured WNBA, and 1 ruptured WNBA). As all 3 patients were allergic to Aspirin, they could only be started on SAPT post endovascular therapy.

DIAGNOSIS

All 3 patients were diagnosed with WNBA on angiographic studies. Patient 1 had an unruptured left middle cerebral artery aneurysm; Patient 2 had a ruptured basilar tip aneurysm; Patient 3 had an unruptured anterior communicating artery (ACOM) aneurysm.

INTERVENTIONS

All 3 WNBA were treated with pCONUS2 HPC neck bridging device.

OUTCOMES

There were no immediate complications. The immediate angiographic result of aneurysm treatment in Patient 1 and Patient 2 demonstrated incomplete occlusions, with delayed complete occlusion of aneurysm in Patient 1 and growth of aneurysmal neck in Patient 2 on follow-up angiograms (range: 6-9 months). No major thrombo-embolic or hemorrhagic complications in the first 2 patients. For Patient 3, the immediate angiographic result of the treated aneurysm demonstrated complete occlusion. However, the patient readmitted 11 days post procedure with cerebral infarction, scoring 5 on the modified Rankin scale on discharge.

LESSONS

pCONUS2 HPC as a neck bridging device in treating WNBA has yet to be shown superior to traditional techniques and devices. The theoretical advantage of HPC coating reducing its thrombogenicity requiring only SAPT is yet to be proven safe in clinical practice.

The pCONUS2 and pCONUS2 HPC Neck Bridging Devices : Results from an International Multicenter Retrospective Study

INTRODUCTION

Bifurcation aneurysms represent an ongoing endovascular challenge with a variety of techniques and devices designed to address them. We present our multicenter series of the pCONUS2 and pCONUS2 HPC devices when treating bifurcation aneurysms.

METHODS

We performed a retrospective review of our prospectively maintained databases at 3 tertiary neurointerventional centers to identify all patients who underwent coil embolization with the pCONUS2 or pCONUS2 HPC device between February 2015 and August 2021. We recorded baseline demographics, aneurysm data, complications, immediate and delayed angiographic results.

RESULTS

We identified 55 patients with 56 aneurysms, median age 63 years (range 42-78 years), 67.3% female (n = 37). The commonest aneurysm location was the MCA bifurcation (n = 40, 71.4%). Average dome height was 8.9 ± 4.2 mm (range 3.2-21.5 mm), average neck width 6.4 ± 2.5 mm (range 2.6-14 mm), and average aspect ratio 1.3 ± 0.6 (range 0.5-3.3). The pCONUS2 was used in 64.3% and the pCONUS2 HPC in 35.7%. The procedural technical success rate was 98.2%. Intraoperative complications occurred in 5 cases (8.9%), 4 of which were related to the coils with partial thrombus formation on the pCONUS2 HPC seen in 1 case that was resolved with heparin. In relation to the procedure and treatment of the aneurysm the overall permanent morbidity was 1.8% (n = 1/55) and mortality 0%. Delayed angiographic follow-up (48 aneurysms) at median 12 months postprocedure (range 3-36 months) demonstrated adequate occlusion of 83.4% of aneurysms.

CONCLUSION

The pCONUS2 and pCONUS2 HPC devices carry a high technical success rate, low complication and retreatment rate, and good rates of adequate occlusion. Larger prospective confirmatory studies are required.

Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Y-stent assisted coiling of ruptured wide neck intracranial aneurysm in the acute phase

BACKGROUND

The objective of the present study is to analyze the outcomes of patients with subarachnoid hemorrhage (SAH) in the acute phase after treatment with Y-stent-assisted coiling (YSAC) embolization.

METHODS

This retrospective study assessed of 30 patients with acutely ruptured wide-neck aneurysms following YSAC treatment between April 2013 and October 2019. The demographic data, aneurysm occlusion grade, procedural and periprocedural complications, and clinical outcomes were assessed.

RESULTS

The procedure was completed in 30 cases (90.1%) and technical failure occurred in 3 cases (9.1%). Immediate control angiography revealed that total occlusion Raymond-Ray Class 1 (RR1) was achieved in 21 (70%), neck filling (RR2) in eight (26.6%) and sac filling (RR1) in one (3.3%) aneurysm. Upon angiographic follow-up, RR1 occlusion was observed in 15 (71.4%) patients, RR2 in three (14.3%) patients and RR3 in three (14.3%) patients. In-stent thrombus developed in five (16.6%) patients; procedural ischemic events were observed in four (13.3%) patients; and two (6.6%) patients were symptomatic. A periprocedural asymptomatic intracranial hemorrhage was detected in two patients. At discharge, 17 (56.6%) patients were in good clinical condition, six (20%) were in a severe disability condition, and seven (23.3%) patients had died. At the final follow-up visit (mean: 18.9 months), 16 (76,2%) of 21 patients were in a good clinical condition and five (23.8%) had severe disabilities.

CONCLUSIONS

Y-stent assisted coiling in might be a feasible and promising option for treatment in acute phase in selected wide-necked ruptured intracranial aneurysms.