Endovascular reconstructive treatment using a fill-and-tunnel technique for a fusiform vertebral artery dissecting aneurysm with ipsilateral dominance

Endovascular treatments of intracranial vertebral and internal carotid arteries dissections: An interactive systematic review and meta-analysis

INTRODUCTION

Management of intracranial artery dissection (IAD) remains elusive in medical practice. Intracranially, vertebral artery dissection (VAD) is more commonly encountered than internal carotid artery dissection (ICAD). Deconstructive (EVT-d) and reconstructive (EVT-r) endovascular techniques have been utilized to treat VAD and ICAD. This meta-analysis investigates the safety and efficacy of EVT-r and EVT-d in the management of VAD and ICAD.

METHODS

The literature was searched for all studies with consecutive patient series evaluating EVT-d or EVT-r for VAD or ICAD management. Baseline characteristics and outcomes were compared between EVT-r and EVT-d groups using the random-effect model and meta-regression approaches.

RESULTS

Overall, 1095 cases pooled from 56 studies were included. There was no statistically significant difference in baseline characteristics between VAD and ICAD. EVT-r was applied in 647 cases (59.1%) and EVT-d in the rest There was no statistical difference in the rate of procedural complications between EVT-r and EVT-d. Although EVT-d was significantly associated with higher rates of complete aneurysm occlusion (86.4%), lower rates of good clinical outcomes (72.1%) and higher mortality (15.1%) were achieved compared to EVT-r (70.2%, 83.3%, and 9.5%; respectively). The mortality rate was higher, and good clinical outcomes were less common in ruptured aneurysms. Ischemic presentation was statistically associated with poor outcomes (mRS 3-5) but low mortality. ICAD often tended to grow following treatment and resulted in poor neurological outcomes.

CONCLUSIONS

IAD has favorable outcomes when treated appropriately. Novel reconstructive endovascular techniques are promising and should be integrated well in endovascular practice. Further studies are warranted.

Additional rescue stenting with Neuroform Atlas stents during stent-assisted coiling of saccular aneurysms

OBJECTIVE

Overlapping stenting is sometimes attempted during endovascular treatment of cerebral aneurysm as a rescue for coil herniation, stent mal-positioning, or in-stent thrombosis. We retrospectively evaluated the efficacy and safety of additional rescue stenting (ARS) in telescoping fashion with Neuroform Atlas stent (NAS) during stent-assisted coiling of saccular aneurysms.

METHODS

We collected clinical and radiological data of patients with saccular aneurysms treated with ARS using NASs between March 2018 and December 2021. Y or X-stent-assisted coiling technique was excluded.

RESULTS

Eighteen unruptured and 5 ruptured aneurysms in 23 patients were treated with ARS using NASs. Sizes of aneurysms ranged from 2.0 mm to 10.0 mm (mean: 5.0 mm). Immediate angiographic results were complete occlusion in 11 aneurysms, residual neck in 4 aneurysms, and residual sac in 8 aneurysms. Peri-operative morbidity was 4.3 %. Nineteen of 23 patients underwent follow-up conventional angiography (mean, 9.9 months). Results showed progressive occlusion in 10 (52.6 %) cases and asymptomatic in-stent stenosis in 3 (15.8 %) cases. At the end of the observation period (mean, 17.4 months), all 18 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS of 0), except one (mRS of 1). Of five patients with subarachnoid hemorrhage, four had a favorable outcome (mRS of 0-1), while the other one was dependent (mRS of 4).

CONCLUSION

In this report on 23 patients, ARS with NASs for treating saccular aneurysms showed good technical safety with favorable clinical and angiographic outcomes. However, delayed in-stent stenosis was not uncommon. Thus, regular imaging follow-up is required.

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.

Intracranial Fusiform and Circumferential Aneurysms of the Main Trunk: Therapeutic Dilemmas and Prospects

Intracranial fusiform and circumferential aneurysms (IFCAs), especially those located on the main trunk, are uncommon and difficult to manage. Currently, literature focused on IFCAs on the main trunk of cerebral arteries is lacking. The treatment of IFCAs is still under debate. Therefore, in this review, we further explore the treatment of this complicated entity. In addition, we also present some interesting cases. Based on the literature review and our experience, we found that IFCAs are often located in the vertebrobasilar system and that ruptured or large symptomatic IFCAs are associated with increased mortality and higher rebleeding rates. The treatment strategies for IFCAs can be classified as deconstructive and reconstructive methods via open surgery and/or endovascular treatment (EVT). Currently, EVT is a popular method and the main therapeutic choice. In particular, flow diversion has revolutionized the treatment of IFCAs. Parent artery occlusion (PAO) with or without revascularization may still be considered a suitable choice. Complex IFCAs that cannot be resolved by EVT can also be treated via open surgery with or without extracranial–intracranial bypass. Targeted embolization for the weak points of IFCAs is a temporary or palliative choice that is rarely used. In summary, despite complications, both surgical treatment and EVT are effective options for appropriately selected cases. Due to the development of endovascular implants, EVT will have better prospects in the future.