Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters

Clinical Outcomes On Tubridge Flow Diverter in Treatmenting Intracranial Aneurysms: a Retrospective Multicenter Registry Study

PURPOSE

In China, the application of nitinol Tubridge flow diverter (TFD) has become popular for treating intracranial aneurysms (IAs). In this study, we investigated the safety outcomes of the application of TFD for treating IAs in real-world scenarios.

METHODS

We retrospectively analyzed aneurysms treated with TFD in 235 centers throughout China between April 2018 and April 2020. The primary endpoint was the event-free survival rate at 12 months, defined as the occurrence of morbidity (spontaneous rupture, intraparenchymal hemorrhage (IPH), ischemic stroke, and permanent cranial neuropathy) or death. Univariate and multivariate analyses were performed to assess the risk factors. A good outcome was defined as a modified Rankin Score (mRS) of 0-2.

RESULTS

We included 1281 unruptured aneurysms treated with TFD. The overall neurological morbidity and death rates after 12 months were 5.4 and 2.8%, respectively. Ischemic strokes were the most common complication (4.2%, P < 0.001). Cranial neuropathy, IPH, and spontaneous rupture occurred in 0.3%, 0.3%, and 0.5% of aneurysms, respectively. Univariate and multivariate analyses indicated that the male gender, older age, larger aneurysm diameter, and aneurysm located on BA were the independent risk factors for neurologic events. Aneurysm located on BA was the independent risk factor for ischemic strokes. Most patients (1222) had access to the mRS, and 93.2% of them achieved good outcomes.

CONCLUSION

Treatment of IAs with TFD was associated with low morbidity and mortality, most of which were ischemic events. Large posterior aneurysms might be associated with a higher complication rate.

TRIAL REGISTRATION

Retrospectively registered.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

A novel flow diverter device (Tubridge) for the treatment of intracranial aneurysms: a systematic review and meta-analysis

The flow diverter (FD) device has become a feasible and effective option for treating intracranial aneurysms. This study aimed to evaluate the efficacy and safety of Tubridge FD (TFD) in treating intracranial aneurysms and provide evidence for further research and clinical application. Electronic databases, including PubMed, Web of Science, Embase, and the Cochrane Library from inception to July 31, 2022, were searched. The eligible studies should include TFD investigations in treating intracranial aneurysms. Pooled technical success rate, complete occlusion rate, improvement rate, stable rate, symptom elimination rate, and adverse events rate were calculated with either the fixed-effects model or the random-effects model, depending on the results of tests for heterogeneity. Egger's tests were performed to assess the potential publication bias. A total of 7 studies (145 patients) were included in this study. The pooled technical success rate was 0.98, the complete occlusion rate was 0.79, the improvement rate was 0.21, and the stable rate was 0.05. One included study reported that the surgery-related mortality rate in the Tubridge group was higher than that in the control group (3.66% vs. 1.61%), while the surgery-related morbidity rate in the Tubridge group was 2.4% and that in the control group was 0. Findings of this meta-analysis indicate that TFD manifests promising and effective performance with acceptable adverse events in the treatment of intracranial aneurysms.

The incidence and predictors of in-stent stenosis after pipeline flow-diverter stenting for intracranial aneurysm treatment

Background and purpose

Data on in-stent stenosis (ISS) following the flow diverter (FD) implantation method are scarce and inconsistent. In the present study, we sought to determine the incidence of ISS and identify the factors that predict its severity via the use of ordinal logistic regression.

Methods

A retrospective review of our center's electronic database was conducted to identify all patients with intracranial aneurysms (IAs) who received pipeline embolization device (PED) implantation between 2016 and 2020. Patient demographics, aneurysm characteristics, procedural information, and clinical and angiographic outcomes were reviewed. ISS was quantitatively assessed on angiographic follow-ups and graded as mild (<25%), moderate (25-50%), or severe (>50%). Ordinal logistic regression was conducted to determine the predictors of stenosis severity.

Results

A total of 240 patients with 252 aneurysms treated in 252 procedures were enrolled in this study. ISS has been detected in 135 (53.6%) lesions, with a mean follow-up time of 6.53 ± 3.26 months. The ISS was mild in 66 (48.9%) cases, moderate in 52 (38.5%) cases, and severe in 17 (12.6%) cases. All patients were asymptomatic, except for two of them with severe stenosis who presented with symptoms of acute cerebral thrombosis. Ordinal logistic regression identified that younger age and a longer procedure duration were independent predictors of a higher likelihood of ISS.

Conclusion

ISS is a common angiographic finding after PED implantation for IAs and is presented as a largely benign course through long-term follow-up. Patients who were younger in age and had a longer procedure duration were found to be at a greater risk of developing ISS.

Tubridge Flow Diverter for the Treatment of Unruptured Dissecting Cerebral Aneurysms

BACKGROUND

The Tubridge flow diverter is a device widely used in China aimed at reconstructing parent artery and occluding complex aneurysm. The experience of the Tubridge in treating unruptured vertebrobasilar artery dissecting aneurysms is still limited. In this study, we aimed to evaluate the safety and efficacy of the Tubridge flow diverter for the treatment of vertebrobasilar artery dissecting aneurysms.

METHODS

We reviewed the clinical records of aneurysms treated with the Tubridge flow diverter between 2019 and 2021 in a national cerebrovascular disease center. Therapeutic process, occlusion rate, and clinical outcome were compared.

RESULTS

Twenty-three patients with 23 vertebrobasilar artery aneurysms were identified. The results showed that the mean length and mean maximal width were 15.14 and 9.14 mm, respectively, in the vertebrobasilar artery. Twenty-four Tubridge flow diverters were successfully implanted without unfold failure. A complete occlusion rate at the last angiographic follow-up was achieved in 78.26% of vertebrobasilar artery aneurysms. Fifteen branch arteries were covered, and only 1 branch artery disappeared at follow-up. Mild asymptomatic cerebral infarction occurred in 3 patients (13.04%); intracranial hemorrhage was not found in the patients.

CONCLUSIONS

Our preliminary experience suggests that the Tubridge flow diverter might be a safe and effective tool for dissecting cerebral aneurysms. Branch arteries were well protected and mild asymptomatic cerebral infarction occurred in some patients. Adequate evidence is required to clear the definite indications and complications in a multicenter randomized controlled trial with a long-term follow-up.

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.

Case Report: Tubridge flow diverter for a ruptured fusiform aneurysm of the M1 segments of the middle cerebral artery

We report a case of the middle cerebral artery (MCA) M1 segment ruptured fusiform aneurysm that was successfully treated using a domestic Tubridge flow diverter (TFD). A 40-year-old man was admitted to the hospital because of a headache and was diagnosed with subarachnoid hemorrhage. Cerebral angiography revealed a ruptured fusiform aneurysm in the M1 segment of the right MCA. TFD, combined with coil embolization, was used for perioperative treatment. No obvious complications were observed. Follow-up digital subtraction angiography 2 and 12 months after the surgery showed that the aneurysm was occluded, and the patient recovered well. This is the first known case of this treatment with this type of stent in such an aneurysm and demonstrates that TFD can be used to treat ruptured fusiform aneurysms in the M1 segment of the MCA.

Flow diversion effect of the leo braided stent for aneurysms in the posterior and distal anterior circulations: A multicenter cohort study

Background and purpose

The treatment of aneurysms located in the posterior and distal anterior circulations remains a challenge. Leo stents with a flow diversion (FD) effect may be a potential option, which needs to be clearly studied.

Methods

From January 2016 to October 2021, 133 patients with 145 aneurysms in the posterior and distal anterior circulations, treated with Leo stents, were retrospectively analyzed in three neurosurgical centers. Data on demographic information, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were retrospectively analyzed.

Results

After immediate surgery, 90 aneurysms (60.1%) were in complete occlusion [Raymond-Ray Occlusion Class (RROC) 1 and O'Kelly Marotta (OKM) grade D], 29 aneurysms (20%) in good occlusion (RROC 2 and OKM grade C), 17.9% in incomplete occlusion (RROC 3a or OKM grade B), and no aneurysms in invalid occlusion (RROC 3b and OKM grade A). A total of 112 patients with 117 aneurysms received angiographic follow-up (mean 11.4 months), and the degree of occlusion showed a significant improvement (Z = 3.900, p < 0.001). The complete occlusion rate increased to 84.6% (99/117), while good and incomplete occlusion decreased to 6.8% (8/117) and 8.6% (10/117), respectively. A total of 14 cases (10.5%) presented narrowing of the parent artery, and nine cases (6.8%) had injured side branches. Cerebral hemorrhage occurred in four patients (3.0%), and symptomatic ischemic infarction occurred in six patients (4.5%). The final permanent morbidity (mCS ≥3) and mortality were 2.8% (3/133) and 0.8% (1/133), respectively. For 82 aneurysms treated by stent-assisted with coiling (SAC), large-sized, ruptured aneurysms (χ² = 7.767, p = 0.005) occurred. For 63 aneurysms treated by LEO stent monotherapy (LSM), multiple aneurysms, fusiform aneurysms (χ² = 18.958, p < 0.01), and/or small-sized aneurysms (Z = −2.692, p = 0.007) occurred.

Conclusions

Leo stents are safe and effective for aneurysms located in the posterior and distal anterior circulations. The overall degree of occlusion improved during a follow-up because of the FD effect of Leo stents. Aneurysms in these areas should be treated with personalized measures.

Use of flow diverter device in basilar artery for aneurysm treatment: Case series and literature review

Background

Flow diverters (FDs) for the treatment of basilar artery (BA) aneurysms remain controversial. In this study, we report our initial experience of flow diversion for treatment of this pathology.

Methods

Consecutive patients with an aneurysm of the BA that was treated by implantation of the FD were included in our retrospective study. Procedural complications, aneurysm occlusion, and a functional outcome were evaluated. FD placement in BA for aneurysm treatment reported in the literature was also reviewed and summarized.

Results

Sixteen patients with 16 BA aneurysms were treated by FD implantation with (n = 8) or without (n = 8) adjunctive coiling. The Tubridge was used in 13 (81.3%) and Pipeline in 3 (18.8%) procedures. Average aneurysm size was 15.7 mm. Four aneurysms were located at the basilar apex, six at the basilar trunk, and six at the vertebrobasilar junction. Three patients experienced procedural complications (18.8%), including two ischemic strokes and one hydrocephalus, with resultant mortality in one case (6.3%). Median follow-up was 7.7 months and available for 15 aneurysms. Complete/near-complete occlusion was seen in 13 (86.7%) aneurysms.

Conclusion

In our initial experience, flow diversion is feasible and safe in the treatment of BA aneurysms with promising occlusion rates at mid-term follow-up. Larger cohort studies are required to validate these results.

Management of Complex Cerebral Aneurysms

BACKGROUND

Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.

METHODS

Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible.

RESULTS

Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery.

CONCLUSIONS

Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome.

Giant Aneurysm Management

The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.