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de Castro-Afonso LH, Machado JP, Nakiri GS, Abud TG, Monsignore LM, Freitas RK, de Oliveira RS, Colli BO, Abud DG. Two year follow-up of distal unruptured intracranial aneurysms treated with a surface modified flow diverter under prasugrel monotherapy. J Neurointerv Surg 2024; 16:1163-1166. [PMID: 37524519 DOI: 10.1136/jnis-2023-020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND A new generation of modified surface flow diverters (FDs) and monotherapy using new antiplatelets may reduce both ischemic and hemorrhagic complications during the treatment of intracranial aneurysms. Previous preliminary safety analysis of distal unruptured intracranial aneurysms treated with the FD p48 MW HPC (phenox-Wallaby, Bochum, Germany) under antiplatelet monotherapy with prasugrel showed promising results. However, the long term outcomes of distal intracranial aneurysms treated with FDs under antiplatelet monotherapy are not known. METHODS This was a single center, prospective, pivotal, open single arm study. The primary (safety) endpoint was absence of any new neurological deficits after treatment until the 24 month follow-up. The primary (efficacy) endpoint was the incidence of complete aneurysm occlusion 24 months after treatment. The secondary (efficacy) endpoints were any incidence of aneurysm dome reduction 24 months after treatment. RESULTS 21 patients harboring 27 distal aneurysms of the anterior circulation were included. No patient had neurologic deficits in the time from treatment to the 24 month follow-up. Complete aneurysm occlusion occurred in 20 (74%) of 27 aneurysms at the 24 month follow-up. Four aneurysms (14.8%) had dome reduction, and three aneurysms (11.1%) remained unchanged. CONCLUSIONS In this pilot trial, treatment of distal unruptured intracranial aneurysms with an FD under monotherapy with prasugrel, followed by monotherapy with aspirin, appeared to be safe and effective. Randomized studies with long term follow-up are needed to confirm these results.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - João Paulo Machado
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Guilherme Seizem Nakiri
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Thiago Giansante Abud
- Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Rafael Kiyuze Freitas
- Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Ricardo Santos de Oliveira
- Division of Neurosurgery, Department of Surgery, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
| | - Daniel Giansante Abud
- Interventional Neuroradiology, Universidade de São Paulo Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, Brazil
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Gaub M, Murtha G, Lafuente M, Webb M, Luo A, Birnbaum LA, Mascitelli JR, Al Saiegh F. Flow Diversion for Endovascular Treatment of Intracranial Aneurysms: Past, Present, and Future Directions. J Clin Med 2024; 13:4167. [PMID: 39064207 PMCID: PMC11278297 DOI: 10.3390/jcm13144167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/04/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Flow diversion for intracranial aneurysms emerged as an efficacious and durable treatment option over the last two decades. In a paradigm shift from intrasaccular aneurysm embolization to parent vessel remodeling as the mechanism of action, the proliferation of flow-diverting devices has enabled the treatment of many aneurysms previously considered untreatable. In this review, we review the history and development of flow diverters, highlight the pivotal clinical trials leading to their regulatory approval, review current devices including endoluminal and intrasaccular flow diverters, and discuss current and expanding indications for their use. Areas of clinical equipoise, including ruptured aneurysms and wide-neck bifurcation aneurysms, are summarized with a focus on flow diverters for these pathologies. Finally, we discuss future directions in flow diversion technology including bioresorbable flow diverters, transcriptomics and radiogenomics, and machine learning and artificial intelligence.
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Affiliation(s)
| | | | | | | | | | | | | | - Fadi Al Saiegh
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, MC 7843, San Antonio, TX 78229, USA; (M.G.); (G.M.); (M.L.); (M.W.); (A.L.); (L.A.B.); (J.R.M.)
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Lylyk I, Scrivano E, Lundquist J, Bleise C, Perez N, Lylyk PN, Nella-Castro R, Lylyk P. Angiographic and clinical outcomes from 396 aneurysms treated with the pipeline flex embolization device with shield technology. Interv Neuroradiol 2024:15910199241231018. [PMID: 38689478 DOI: 10.1177/15910199241231018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The PEDESTRIAN registry demonstrated high rates of complete long-term occlusion and good clinical outcomes among patients with intracranial aneurysms treated with the pipeline embolization device. The pipeline flex embolization device with shield technology was introduced to minimize thromboembolic complications. In this study, we investigated the safety and effectiveness of pipeline embolization device with shield technology among all patients treated for intracranial aneurysms at our center. METHODS This was a single-arm retrospective study of prospectively collected data of patients treated with pipeline embolization device with shield technology at our high-volume center between January 2018-January 2021. The primary efficacy endpoint was complete occlusion as measured by a class 1 Raymond-Roy score at 1-year and 2-year follow-up. The primary safety endpoint was major morbidity and neurological mortality up to 1 year following intervention. RESULTS A total of 328 patients (mean age 56.1 ± 14.7 years; 81.1% female), 80 of whom were previously included in PEDESTRIAN, with 396 aneurysms, were analyzed. A total of 378 devices were deployed, with 93.9% (372/396) of aneurysms requiring only one device. Follow-up angiography was available for 90.2% (296/328) of the procedures after a mean time of 14.0 ± 8.2 months. Complete occlusion was demonstrated for 78.5% (132/168) of aneurysms at 12 months and 90.7% (98/108) at 24 months. The overall rates of major morbidity and neurological mortality after 2 years were 1.5% (5/328) and 0.6% (2/328), respectively. CONCLUSION Our results demonstrate high rates of complete long-term occlusion among patients treated with pipeline embolization device with shield technology. We also observed low rates of mortality and morbidity consistent with fewer thromboembolic complications with pipeline embolization devices with shield technology.
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Affiliation(s)
- Ivan Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Javier Lundquist
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Carlos Bleise
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Nicolas Perez
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Pedro Nicolas Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Rodolfo Nella-Castro
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI, Clínica La Sagrada Familia, Jose Hernandez, Buenos Aires, Argentina
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Jebrin R, El Nekidy WS, Abidi E, John TLS, Kesav P, Hussain SI, Abdelsalam M, Khaled L, Raj D, John S. Racial differences in P2Y12 inhibitor responsiveness in patients undergoing neuro-endovascular procedures: A cohort from the Middle East. Clin Neurol Neurosurg 2024; 239:108167. [PMID: 38402103 DOI: 10.1016/j.clineuro.2024.108167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Data on P2Y12 inhibitors responsiveness from the middle east is scarce. We sought to investigate patient responsiveness to P2Y12 inhibitors within a cohort of major races that characterize the UAE population. The secondary objective was to assess risk factors for hyper and hypo-responsiveness in this population. METHODS We conducted a cross-sectional study on adults who received either clopidogrel or ticagrelor treatments and had platelet responsiveness testing before undergoing neuro-endovascular interventions at our quaternary care hospital between March 2015 and April 2019. RESULTS During the study period, 249 subjects met the inclusion criteria. Overall, 17.3 % were hyper-responsive and 25.7 % were hypo-responsive to P2Y12 inhibitors. When comparing between the P2Y12 inhibitors, rates of hyper-responsiveness were significantly higher to ticagrelor when compared to clopidogrel (11 versus 6 %, p = 0.02 respectively). Contrarily, hypo-responsiveness rates were significantly higher in clopidogrel treated patients compared to their ticagrelor treated counterparts (23 versus 2 %, p < .001 respectively). Patients of Middle-Eastern origin showed a significantly higher rate of hypo-responsiveness to both clopidogrel and ticagrelor when compared to other races (41.1 % and 26.7 %, P < 0.001 respectively). Asians showed the highest rates of hyper-responsiveness for both agents. Multivariate logistic regression analysis showed that proton pump inhibitors and statin combination, (OR: 6.39, 95 %CI [1.60, 25.392]), and Middle East vs. Indian subcontinent patients (OR: 4.67, 95 %CI [1.79-12.14]) were independent predictors of hypo-responsiveness to both P2Y12 inhibitors. CONCLUSION This study demonstrated a high rate of hypo-responsiveness to P2Y12 inhibitors in a UAE cohort of patients undergoing neuro-endovascular procedures. In addition, therapeutic responsiveness to P2Y12 inhibitors varied markedly based on the racial background. Future larger studies are needed to evaluate genetic variations that may contribute to this rate of hypo-responsiveness in our population.
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Affiliation(s)
- Rita Jebrin
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Wasim S El Nekidy
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Emna Abidi
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Praveen Kesav
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Syed I Hussain
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | | | - Luna Khaled
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Divya Raj
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates
| | - Seby John
- Cleveland Clinic Abu Dhabi, Abu Dhabi, the United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States.
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Senol YC, Orscelik A, Bilgin C, Kobeissi H, Ghozy S, Arul S, Kallmes DF, Kadirvel R. Safety and efficacy profile of off-label use of the Pipeline Embolization Device: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107586. [PMID: 38242183 PMCID: PMC10939757 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE The off-label utilization of the Pipeline Embolization Device (PED) is a common practice in numerous medical centers globally. Therefore, we conducted a systematic review and meta-analysis to evaluate the overall outcomes of this off-label usage of PEDs. METHODS PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to February 2023 using the Nested Knowledge platform to identify studies assessing the off-label use of PEDs. Any use of PED outside of the FDA-approved indication granted in 2018 is considered off-label use. Overall angiographic occlusion rates, ischemic and hemorrhagic complications, mortality, retreatment rates, and favorable clinic outcomes were included. Statistical analyses were performed to compare the overall outcome rates of anterior cerebral artery(ACA) vs. middle cerebral artery(MCA) and anterior vs posterior circulation subgroups. RESULTS We included 26 studies involving a total of 1,408 patients. The overall rate of complete occlusion was 80.3 % (95 % CI= 76.0-84.1). Subgroup analysis demonstrated a statistically significant difference in the rate of complete occlusion between anterior circulation (78.9 %) and posterior circulation (69.2 %) (p value=0.02). The rate of good clinical outcomes was 92.8 % (95 % CI= 88.8-95.4). The mortality rate was 1.4 % (95 % CI= 0.5-2.7). The overall rate of ischemic complications was 9.5 % (95 % CI= 7.7-11.6), with a comparable difference between anterior circulation (7.7 %) and posterior circulation (12.8 %) (p value=0.07). There was no statistically significant difference in MCA vs ACA subgroups in all parameters. CONCLUSIONS Off-label use of PEDs can be a safe and effective treatment option for intracranial aneurysms. However, there is a need for more prospective, high-quality, non-industry-funded registry studies and randomized trials to test the efficacy and safety of off-label usage of PEDs and to expand its indications.
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Affiliation(s)
- Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Atakan Orscelik
- Department of Neurosurgery, Medical University of South Carolina, SC, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ramanathan Kadirvel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Ma Y, Deng X, Chen J, Fan F, Han K, Guan S, Guo X. Predictors of In-Stent Stenosis Following the Implantation of Pipeline Embolization Devices for the Treatment of Aneurysms Located at or beyond the Circle of Willis in the Anterior Circulation. AJNR Am J Neuroradiol 2024; 45:ajnr.A8144. [PMID: 38388683 PMCID: PMC11288563 DOI: 10.3174/ajnr.a8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE In-stent stenosis is commonly observed after stent implantation. There is no consensus on the contributing factors for in-stent stenosis, especially for aneurysms located at or beyond the circle of Willis in the anterior circulation. This study aimed to investigate the morbidity and determinants of in-stent stenosis in distal anterior circulation aneurysms following the implantation of Pipeline Embolization Devices. MATERIALS AND METHODS Patients who underwent Pipeline Embolization Device treatment at our center between January 1, 2018, and June 15, 2023, were enrolled. Distal anterior circulation aneurysms were defined as those occurring at or beyond the circle of Willis, including anterior communicating artery aneurysms, anterior cerebral artery aneurysms, and MCA aneurysms. Baseline information, aneurysm characteristics, and follow-up data of patients were analyzed. Patients were divided into 2 groups: the in-stent stenosis group (patients with a loss of >25% of the lumen diameter of the parent artery) and the non-in-stent stenosis group. Binary logistic regression and restricted cubic spline curves were used to explore risk factors. RESULTS We included 85 cases of 1213 patients treated with flow-diverter devices at our hospital. During an average follow-up period of 9.07 months, the complete occlusion rate was 77.64%. The overall incidence of in-stent stenosis was 36.47% (31/85), of which moderate stenosis accounted for 9.41% (8/85), and severe stenosis, 5.88% (5/85) (triglyceride-glucose index ≥ 8.95; OR = 6.883, P = .006). The difference in diameters between the stent and parent artery of ≥0.09 mm (OR = 6.534, P = .015) and 55 years of age or older (OR = 3.507, P = .036) were risk factors for in-stent stenosis. The restricted cubic spline curves indicated that the risk of in-stent stenosis increased as the difference in diameter between stent and parent artery and the triglyceride-glucose index increased. CONCLUSIONS Compared with the on-label use of Pipeline Embolization Devices, the rate of in-stent stenosis did not obviously increase when treating distal anterior circulation aneurysms with these devices. The incidence of in-stent stenosis was 36.47% when defined as a lumen diameter loss of >25%, and 15.2% when defined as a lumen diameter loss of >50%. Stent-size selection and biochemical indicators can potentially impact the incidence of in-stent stenosis.
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Affiliation(s)
- Yajing Ma
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Xin Deng
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Junfan Chen
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Feng Fan
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Kaihao Han
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Sheng Guan
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
- Neurointerventional Engineering Research Center of Henan Province (S.G.), Henan Province, China
| | - Xinbin Guo
- From the Department of Interventional Neuroradiology (Y.M., X.D., J.C., F.F., K.H., S.G., X.G.), The Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
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Hosseini EM, Zafarshamspour S, Ghasemi-Rad M, Benndorf G, Rasekhi A, Rafieossadat R. Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature. Childs Nerv Syst 2024; 40:345-357. [PMID: 37750891 DOI: 10.1007/s00381-023-06161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.
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Affiliation(s)
| | - Saber Zafarshamspour
- Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Goetz Benndorf
- Department of Radiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza Rasekhi
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Rafieossadat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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Hanel RA, Cortez GM, Benalia VHC, Sheffels E, Sutphin DJ, Pederson JM, Pereira VM. Patient outcomes after treatment of brain aneurysm in small diameter vessels with the silk vista baby flow diverter: A systematic review. Interv Neuroradiol 2024; 30:5-13. [PMID: 35392703 PMCID: PMC10956459 DOI: 10.1177/15910199221091645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB, BALT) is a first-in-class flow-diverter device delivered using a 0.017" microcatheter, designed for the treatment of intracranial aneurysms, including those in small diameter vessels. This study reports a systematic literature review (SLR) to evaluate the safety and efficacy of using SVB to treat intracranial aneurysms in vessels less than 3.5 mm in diameter. METHODS We performed a PRISMA-compliant SLR to evaluate the outcomes of SVB in the treatment of aneurysms in small intracranial vessels. Primary outcomes were occlusion status and major stroke, and secondary outcomes included all-cause mortality, procedure-related neurologic death, and post-operative aneurysm rupture. Data were expressed as descriptive statistics only. RESULTS A total of four studies, including 163 patients with 173 intracranial aneurysms, were included. The most common aneurysm locations were the anterior cerebral artery (24.9% [43/173]), the middle cerebral artery (24.3% [42/173]), and the anterior communicating artery (23.1% [40/173]). Parent artery diameter ranged from 0.9 mm to 3.6 mm, and 29% were acutely or previously ruptured aneurysms. Overall, complete or near-complete occlusion was 72.1% on early-term follow-up. Mortality rate among the studies was 2.5%, with 3 instances adjudicated as neurologic deaths (1.8%). Major stroke was noted in 1.2% of cases, and branch occlusion or stent thrombus formation in 5.5%. CONCLUSION Our review suggests that SVB is a safe and effective treatment for intracranial aneurysms in small vessels. Further prospective and comparative studies with patient outcome data specific to aneurysm location are needed to confirm the safety and efficacy of SVB.
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Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | - Victor H C Benalia
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | | | | | | | - Vitor M Pereira
- Departments of Surgery and Medical Imaging, Division of Neurosurgery, St Michaels Hospital, University of Toronto, Ontario, Canada
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Ma Y, Deng X, Chen Z, Yuan Y, Guan S, Guo X. Safety and efficacy analysis of the off-label use of pipeline embolization devices for intracranial aneurysms: a propensity score matching study. Front Neurol 2024; 14:1278366. [PMID: 38239324 PMCID: PMC10794508 DOI: 10.3389/fneur.2023.1278366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/05/2023] [Indexed: 01/22/2024] Open
Abstract
Background and objective The safety and efficacy of on-label use of pipeline embolization devices (PEDs) are well established; however, there is much controversy over their off-label use. This study aimed to investigate the safety and efficacy of the off-label use of PEDs for treating intracranial aneurysms. Methods This single-center study retrospectively included patients with digital subtraction angiography, computed tomographic angiography, or magnetic resonance angiography confirmed intracranial aneurysms treated with PEDs who were admitted to our institution between 1 January 2018 and 1 July 2022. Patients were divided into on- and off-label groups according to the Food and Drug Administration criteria published in 2021. Propensity score matching (PSM) was used to balance disparities in baseline information between the two groups. Safety outcomes included postoperative mortality and complication rates, whereas effectiveness outcomes included aneurysm occlusion rate (O'Kelly-Marotta grading system C + D grades), retreatment rate within 12 months, and postoperative functional score [modified Rankin scale (mRS) score]. The study was approved by the Ethics Committee of Scientific Research and Clinical Trial of the First Affiliated Hospital of Zhengzhou University (Ethics number: KY 2018-098-02). All patients provided informed consent. Results A total of 242 patients with 261 aneurysms (160 on-label and 101 off-label aneurysms) were included in this study. PSM yielded 81 pairs of patients matched for baseline information. Postoperative hemorrhagic, ischemic, and procedure-related complication rates did not reach statistical significance. In addition, no statistically significant differences in the aneurysm occlusion rate, retreatment rate within 12 months, postoperative functional score (mRS score), or mRS score deterioration rate were observed between the two groups. A higher incidence of in-stent stenosis was observed in the off-label (4.9% vs. 21%, p = 0.002) group than in the on-label group; however, all patients were asymptomatic. Conclusion Compared with on-label use, off-label use of PEDs for treating intracranial aneurysms did not increase the risk of complications, and the occlusion rates were comparable. Therefore, decisions regarding clinical management should not rely solely on on- or off-label indications.
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Affiliation(s)
- Yajing Ma
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xin Deng
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Zhen Chen
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Yongjie Yuan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Sheng Guan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xinbin Guo
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Neurointervention Engineering Research Center of Henan Province, Zhengzhou, Henan, China
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10
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Liu J, Cao F, Zhenmei N, Guo Y, Li Y, Yuan D, Jiang W, Yan J. Flow-diverter stents in intracranial aneurysm treatment: impact on covered cerebral artery branches. Int J Surg 2024; 110:53-65. [PMID: 37851516 PMCID: PMC10793757 DOI: 10.1097/js9.0000000000000762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/10/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Flow diverter stents (FDSs) have attracted interest for intracranial aneurysm (IA) treatment; however, occlusion of side branches and related complications have been reported. This study aimed to investigate the effects of FDSs in IA management when different branches of intracranial arteries are covered. MATERIALS AND METHODS A cross-sectional study was conducted using PUBMED, Embase, Web of Science, and Cochrane databases to include randomized or nonrandomized comparative-designed studies from January 2000 to August 2022 which reported outcomes of occlusion/narrowing of branches after IA treatment using FDSs. The PRISMA guidelines were used for our report. A random-effects meta-analysis was conducted to pool the outcomes, which included incidence rates of occlusion/narrowing of FDS-covered branches, branch occlusion-related symptoms, obliteration of IAs, and ideal clinical outcomes (modified Rankin Scale score ≤2). RESULTS The authors identified 57 studies involving 3789 patients with IA managed by FDSs covering different branches. During the median imaging follow-up at 12 months, the IA obliteration rate was satisfactory (>70%) when covering the ophthalmic artery (OA), posterior communicating artery (PComA), anterior choroidal artery (AChoA) or anterior cerebral artery (ACA), but not the middle cerebral artery-M2 segment (MCA-M2; 69.5%; 95% CI: 60.8-77.5%) and posterior inferior cerebellar artery (PICA; 59.1%, 13/22). The overall ideal clinical outcome was observed in 97.4% of patients (95% CI: 95.5-98.9%). Higher rates of occlusion/narrowing of branches were identified when FDSs covered the ACA (66.6%; 95% CI: 45.1-85.3%), PComA (44.3%; 95% CI: 34.2-54.6%), or MCA-M2 (39.2%; 95% CI: 24.5-54.7%); the risks were lower when covering the OA (11.8%; 95% CI: 8.8-15.1%), PICA (6.8%; 95% CI: 1.5-14.5%), and AchoA (0.5%; 95% CI: 0.0-2.9%). The risk of branch occlusion-related complications was low (incidence rate <5%) for each of the six evaluated branches. CONCLUSIONS Acceptable outcomes were identified following treatment of IAs when FDSs were placed across each of the six studied cerebral arteries. Treatment decisions regarding FDS placement across branch arteries should be made with the risk of complications from branch occlusion in mind.
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Affiliation(s)
- Junyu Liu
- Department of Neurosurgery, XiangYa Hospital
- Department of Pharmacology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Fang Cao
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
| | | | - Yuxin Guo
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
| | - Yifeng Li
- Department of Neurosurgery, XiangYa Hospital
| | - Dun Yuan
- Department of Neurosurgery, XiangYa Hospital
| | - Weixi Jiang
- Department of Neurosurgery, XiangYa Hospital
| | - Junxia Yan
- Hunan Provincial Key Laboratory of Clinical Epidemiology
- Department of Epidemiology and Health Statistics, XiangYa School of Public Health, Central South University, Changsha, People’s Republic of China
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11
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Conte M, Cagil E, Lanzino G, Keser Z. Fusiform aneurysms of anterior cerebral artery: center experience and systematic literature review. Neurosurg Rev 2023; 47:11. [PMID: 38087068 DOI: 10.1007/s10143-023-02247-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/12/2023] [Accepted: 12/05/2023] [Indexed: 12/18/2023]
Abstract
Fusiform aneurysms of the anterior cerebral artery (ACA) are uncommon, and the natural history of this entity is poorly characterized. Along with our center experience, we conducted a systematic literature review to help shed light on the clinical course of ACA fusiform aneurysms. We queried our institutional database to identify cases with fusiform aneurysms of ACA. In addition, following the PRISMA algorithm, we identified all reported cases published in the English literature from the inception of PubMed until December 2022. We categorized clinical presentations into three categories: (i) traumatic/iatrogenic, (ii) spontaneous symptomatic ruptured/unruptured, and (iii) spontaneous asymptomatic aneurysms. We utilized descriptive statistics. We identified seven cases from our center along with 235 patients from published literature. Blunt trauma was responsible for the development of 19 aneurysms. Sixty-three percent of these aneurysms tend to rupture within 2 weeks from the initial trauma, and despite treatment, only 74% of these patients had good clinical outcomes. Spontaneous symptomatic presentation occurred in 207 patients and was often associated with previous/concomitant ACA dissection. Subarachnoid hemorrhage from ruptured aneurysms was the most common presentation. Spontaneous symptomatic fusiform aneurysm is rapidly evolving lesions, and treatment is necessary. Three of our own cases were treated with an endovascular flow diverter (pipeline) stenting with good outcomes. Spontaneous asymptomatic aneurysms were reported in nine patients. These lesions are often associated with other vascular abnormalities. Treatment included surgical clipping with good clinical outcomes. Instead, four patients from our center database were managed conservatively with equally good outcomes. Our study demonstrates good clinical outcomes when fusiform aneurysms of ACA, especially when symptomatic, are treated promptly with either reconstructive or deconstructive therapies.
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Affiliation(s)
- Matteo Conte
- University of Padua, Padua, Italy
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Emin Cagil
- Department of Neurosurgery, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | | | - Zafer Keser
- Department of Neurology, Cerebrovascular Division, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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12
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Benalia VHC, Cortez GM, Mounayer C, Saatci I, Cekirge HS, Kocer N, Islak C, Dabus G, Brinjikji W, Baltacioglu F, Pereira VM, Nishi H, Siddiqui AH, Monteiro A, Lopes DK, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and Efficacy of Flow Diverters for Treatment of Unruptured Anterior Communicating Artery Aneurysms: Retrospective Multicenter Study. J Neurointerv Surg 2023; 15:1181-1186. [PMID: 37845019 DOI: 10.1136/jnis-2023-020673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/16/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The anterior communicating artery (AComm) region is the most common site of intracranial aneurysms, with increased rupture risk compared with other locations. Overall, flow diverters present as a safe and efficacious treatment for intracranial aneurysms, but there is paucity of data for their use in the treatment of unruptured AComm aneurysms. We present the largest multicentric analysis evaluating the outcomes of flow diverters in AComm aneurysm treatment. METHODS Databases from 10 centers were retrospectively reviewed for unruptured AComm aneurysms treated with flow diverters. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. RESULTS A total of 144 patients harboring 147 AComm aneurysms were treated between January 2012 and December 2021. Seventy-four were women (51.4%) and median age was 60 (IQR 50-67) years. All were unruptured AComm aneurysms. Half of the cohort had similar anterior cerebral artery sizes (51.4%). The most common morphology was saccular (94.6%), with a branch involvement in 32.7% of cases. Median vessel diameter was 2.4 mm, and the Pipeline Flex was the most prevalent device (32.7%). Median follow-up time was 17 months, with complete occlusion in 86.4% at the last follow-up. Functional independence (modified Rankin Scale score 0-2) was reported in 95.1%. Intraprocedural complications occurred in 5.6%, and postoperative complications were noted in 9.7% of cases. Combined major complication and mortality rate was 2.1%. CONCLUSIONS Our study suggests that flow diverters are a useful treatment for AComm aneurysms. Mid-term results indicated favorable aneurysm occlusion with a good safety profile. Additional prospective studies with longer follow-up periods and independent adjudication are warranted to better assess these results.
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Affiliation(s)
- Victor H C Benalia
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Charbel Mounayer
- Interventional Neuroradiology Department, University Hospital Centre of Limoges, Limoges, France
| | - Isil Saatci
- Interventional Neuroradiology Department, Koru Health Group, Ankara, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Department, Koru Health Group, Ankara, Turkey
| | - Naci Kocer
- Department of Radiology, Istanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, Fatih, Istanbul, Turkey
| | - Civan Islak
- Department of Radiology, Istanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, Fatih, Istanbul, Turkey
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
| | - Waleed Brinjikji
- Department of Neurosurgery and Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Feyyaz Baltacioglu
- Department of Radiology, Division of Interventional Radiology/Neuroradiology, VKV Amerikan Hastanesi, Istanbul, Turkey
| | - Vitor M Pereira
- Department of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Hidehisa Nishi
- Department of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Andre Monteiro
- Departments of Neurosurgery and Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Demetrius K Lopes
- Neurosurgery, Brain and Spine Institute-Advocate Aurora Health, Chicago, Illinois, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
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13
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Flow Diverting Stents in Cerebral Small Caliber Vessels (< 2 mm) for Aneurysm Treatment : A Three Center Retrospective Study. Clin Neuroradiol 2023; 33:99-105. [PMID: 35768696 DOI: 10.1007/s00062-022-01187-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The off-label use of flow diverting stents (FDS) for treating cerebral aneurysms in small distal vessels is increasing in clinical practice with encouraging results; however, data directly addressing the parent vessel size are still scarce. Our aim was to evaluate the safety and efficacy of FDS placement in anterior and posterior circulation aneurysms with parent arteries ≤ 2 mm in a real-world representative setting. METHODS We retrospectively reviewed patients treated with FDS at the three participating university hospitals between 2009 and 2021. The inclusion criteria were the placement of at least one FDS in a parent vessel with a maximum diameter of 2 mm or less. The primary clinical safety endpoint was the absence of death, major or minor symptomatic stroke, transient ischemic attack and procedure-related intracranial hemorrhage. Clinical outcome was assessed using the modified Rankin Scale (mRS) score at the follow-up visit at 1 year. The primary efficacy endpoint was defined as complete and near-complete occlusion at the 1‑year follow-up. RESULTS We identified 55 patients harboring 56 aneurysms. The primary clinical safety endpoint was obtained in 93% of cases. The hemorrhagic and thromboembolic complication rates were 4% and 9%, respectively. No patient died or had a relevant discrepancy (> 1 point) at the pre-mRS and post-mRS. The primary efficacy endpoint was reached in 80% of cases. CONCLUSION The use of FDS in vessels < 2 mm is technically feasible with good aneurysm occlusion rates and an acceptable safety profile. Nevertheless, it is essential to be aware of the of the main complications associated when operating in small diameter vessels.
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14
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Piano M, Lozupone E, Milonia L, Pero G, Cervo A, Macera A, Quilici L, Visconti E, Valvassori L, Cenzato M, Boccardi E. Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging. J Stroke Cerebrovasc Dis 2022; 31:106760. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/17/2022] [Accepted: 09/04/2022] [Indexed: 11/21/2022] Open
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15
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El Naamani K, Saiegh FA, Chen CJ, Abbas R, Sioutas GS, Amllay A, Shehabeldine M, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Treatment of cerebral aneurysms with the FRED Jr flow-diverting stent: A case series and meta-analysis. Clin Neurol Neurosurg 2022; 223:107483. [DOI: 10.1016/j.clineuro.2022.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/30/2022]
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16
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Ma C, Zhu H, Liang S, Liang F, Han J, Jia Z, Zhang Y, Jiang C. Pipeline for the treatment of distal cerebral circulation aneurysms: A multicenter study focusing on periprocedural Complications. Interv Neuroradiol 2022; 28:708-718. [PMID: 34913765 PMCID: PMC9706258 DOI: 10.1177/15910199211063703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/11/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIM Distal cerebral circulation aneurysms (DCCAs) remain treatment challenges for neurointervention. The off-label use of the pipeline embolization device (PED) for these aneurysms remains controversial. This study aimed to evaluate the safety and efficacy of PED for DCCAs in a multicenter cohort of patients. METHODS Between March 2016 and June 2021, we retrospectively analyzed the neurointerventional data on the clinical and radiological records of all patients undergoing PED treatment of DCCAs at three medical centers. RESULTS A total of 53 consecutive patients with 53 DCCAs were treated with PED. The mean aneurysm size was 12.3 ± 5.7 mm. In total, 75.4% (40/53) were fusiform and 24.5% (13/53) were saccular. Of these, 17.0% (9/53) were recurrent aneurysms that were previously treated with endovascular or microsurgical approaches. The technical success rate was 100%, among which 81.1% (43/53) procedures were completed with a single PED, and the rest (10/53, 18.8%) required telescoping with two devices. Angiographic follow-up data were available for 51 patients, with a median follow-up time of 12 months. At the latest follow-up, 46/51 (90.2%) aneurysms showed complete obliteration, and 4/51 (7.8%) showed reduced filling. Periprocedural complications such as hemorrhage were observed in two patients with MCA aneurysms (3.8%, 2/53), and ischemic events occurred in six patients (11.3%, 6/53). The overall mortality and morbidity rates were 7% (4/53). CONCLUSIONS PED is a viable option for treating DCCAs, especially for recurrent aneurysms. Coverage of bifurcation branches and perforator may increase the risk of complications.
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Affiliation(s)
- Chao Ma
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital,
School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Jintao Han
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Zichang Jia
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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17
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Piano M, Trombatore P, Lozupone E, Pero G, Cervo A, Macera A, Quilici L, Peschillo S, Valvassori L, Boccardi E. Flow Diverter Devices in the Treatment of Anterior Communicating Artery Region Aneurysms: Would the Regional Anatomy and the Aneurysm Location Affect the Outcomes? Brain Sci 2022; 12:1524. [PMID: 36358450 PMCID: PMC9688233 DOI: 10.3390/brainsci12111524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND In this study, the authors evaluated the efficacy and the safety of flow diverter devices (FDD) in anterior communicating artery (ACoA) region aneurysms, focusing on anatomical factors that could affect the outcome, such as the location of the aneurysm along the ACoA (centered on ACoA or decentered on the A1-A2 junction) and the anatomy of the ACoA region. METHODS Clinical, procedural and follow-up data were analyzed. Aneurysms were classified according to the location along the ACoA (centered or decentered on the A1-A2 junction) and on the basis of the anatomical configuration of the ACoA region. Safety was assessed by recording intraprocedural, periprocedural and delayed complications to determine the morbidity and mortality rates. The functional outcome was evaluated with the modified Rankin scale (mRS) prior to and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded. Subgroup analysis according to the different ACoA regional anatomical configurations and the ACoA aneurysm locations were performed. RESULTS 33 patients (17 males; 16 females) with ACoA region aneurysms were treated with FDDs. 27 aneurysms were located at the A1-A2 junction (82%) while the remaining six aneurysms were centered on the ACoA. No mortality was recorded. The overall morbidity rate was 6% (2/33 procedures). Major complications occurred in 33% (2/6) of ACoA aneurysms and in the 0% of A1-A2 junction aneurysms. Mid-term and long-term neuroimaging follow-ups showed the occlusion of the aneurysm in 28/33 cases (85%). Complete occlusion rates were 93% in the A1-A2 junction aneurysms and 50% in ACoA aneurysms. CONCLUSIONS The FDD is a safe and effective tool that can be used in the treatment of selected cases of ACoA region aneurysms. The location of the aneurysm along the ACoA and the regional anatomy of the ACoA complex could affect the efficacy and safety.
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Affiliation(s)
- Mariangela Piano
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Pietro Trombatore
- Department of Neuroradiology, Ospedale San Gerardo, 20900 Monza, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Antonio Macera
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
| | - Luca Quilici
- Department of Neuroradiology, ASST Ospedale Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Simone Peschillo
- Department of Neurosurgey, UniCamillus-Saint Camillus International University of Health Sciences, 00131 Rome, Italy
- Endovascular Neurosurgery, Pia Fondazione Cardinale Giovanni Panico Hospital, 73039 Lecce, Italy
| | - Luca Valvassori
- Department of Neuroradiology, ASST Santi Paolo e Carlo, 20142 Milano, Italy
| | - Edoardo Boccardi
- Department of Neuroradiology, Niguarda Hospital, 20162 Milano, Italy
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18
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Budohoski KP, Thakrar R, Voronovich Z, Rennert RC, Kilburg C, Grandhi R, Couldwell WT, Brockmeyer DL, Taussky P. Initial experience with Pipeline embolization of intracranial pseudoaneurysms in pediatric patients. J Neurosurg Pediatr 2022; 30:465-473. [PMID: 36057120 DOI: 10.3171/2022.7.peds22195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow-diverting devices have been used successfully for the treatment of complex intracranial vascular injuries in adults, but the role of these devices in treating iatrogenic and traumatic intracranial vascular injuries in children remains unclear. The authors present their experience using the Pipeline embolization device (PED) for treating intracranial pseudoaneurysms in children. METHODS This single-center retrospective cohort study included pediatric patients with traumatic and iatrogenic injuries to the intracranial vasculature that were treated with the PED between 2015 and 2021. Demographic data, indications for treatment, the number and sizes of PEDs used, follow-up imaging, and clinical outcomes were analyzed. RESULTS Six patients with a median age of 12 years (range 7-16 years) underwent PED placement to treat intracranial pseudoaneurysms. There were 3 patients with hemorrhagic presentation, 2 with ischemia, and 1 in whom a growing pseudoaneurysm was found on angiography. Injured vessels included the anterior cerebral artery (n = 2), the supraclinoid internal carotid artery (ICA, n = 2), the cavernous ICA (n = 1), and the distal cervical ICA (n = 1). All 6 pseudoaneurysms were successfully treated with PED deployment. One patient required re-treatment with a second PED within a week because of concern for a growing pseudoaneurysm. One patient experienced parent vessel occlusion without neurological sequelae. CONCLUSIONS Use of the PED is feasible for the management of iatrogenic and traumatic pseudoaneurysms of the intracranial vasculature in children, even in the setting of hemorrhagic presentation.
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Affiliation(s)
- Karol P Budohoski
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Raj Thakrar
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Zoya Voronovich
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Robert C Rennert
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
| | - Craig Kilburg
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Ramesh Grandhi
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - William T Couldwell
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Douglas L Brockmeyer
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- 1Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City; and
- 2Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
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19
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Benalia VHC, Cortez GM, Brasiliense LBC, Starke RM, Killer-Oberpfalzer M, Lopes DK, Kan PT, Nogueira RG, Johnson JN, Pereira VM, Kilburg C, Khalili S, Hanel RA. Silk Vista Baby for the Treatment of Complex Posterior Inferior Cerebellar Artery Aneurysms. Neurosurgery 2022; 91:547-554. [PMID: 35830269 DOI: 10.1227/neu.0000000000002072] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/09/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Treatment of small-caliber vessel lesions using flow diverters remains challenging because of vasculature's narrow luminal diameter and tortuosity. This in turn makes navigation and delivery of conventional devices with standard microcatheters more difficult. The Silk Vista Baby (SVB, Balt) flow diversion device was designed for ease of use in vessels with a smaller diameter, distal lesions, and 0.017 ″ microcatheter delivery systems. OBJECTIVE To report the outcomes of the SVB device on the treatment of posterior inferior cerebellar artery (PICA) aneurysms. METHODS Databases from different centers were retrospectively reviewed for PICA aneurysms treated with SVB. Demographic information, clinical presentation, radiographic characteristics, procedural complications, and immediate postprocedure outcomes were obtained. RESULTS Fourteen patients harboring 15 true PICA aneurysms were treated between January 2019 and June 2021. Nine were female (n = 9/14; 64.2%), and the mean age was 51 ± 14.9 years. Most patients had previously ruptured aneurysms, treated by another endovascular technique. Six aneurysms were located distally (n = 6/15; 40%). The mean neck size was 3 mm (SD 1.35, range 2.5-5 mm), whereas the mean PICA diameter was 1.6 mm (SD 0.26, range 1.5-1.7 mm). The mean length of follow-up was 6 months (SD 8.28, range 4.5-16 months). Treatment-related adverse events included 1 case of transient hypoesthesia. Two additional events were reported, but adjudicated as unrelated to the procedure. Complete occlusion, measured as Raymond-Roy class I, was achieved in all cases. CONCLUSION The SVB device was safely and effectively used in the treatment of PICA aneurysms. The smaller delivery system profile reduces the risk of procedure complications and creates new treatment options for distal lesions.
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Affiliation(s)
- Victor H C Benalia
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA.,Research Department, Jacksonville University, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA.,Research Department, Jacksonville University, Jacksonville, Florida, USA
| | - Leonardo B C Brasiliense
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA.,Department of Neurosurgery, College of Medicine Tucson, University of Arizona, Tucson, Arizona, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention/Department of Neurology, University Hospital Salzburg, Salzburg, Austria
| | - Demetrius K Lopes
- Brain and Spine Institute, Advocate Aurora Health, Chicago, Illinois, USA
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Raul G Nogueira
- Neuroendovascular Service Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, University of California, Los Angeles, California, USA
| | - Vitor M Pereira
- Division of Neurosurgery, Departments of Surgery and Medical Imaging, St Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Craig Kilburg
- Neurosurgery Department, University of Utah Health, Salt Lake City, Utah, USA
| | - Susan Khalili
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
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Cler SJ, Lauzier DC, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. Comparative study of on-label versus off-label treatment of intracranial aneurysms with the Pipeline embolization device. J Neurosurg 2022; 137:685-690. [PMID: 35090133 DOI: 10.3171/2021.11.jns212481] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) is widely used for the treatment of intracranial aneurysms, including in off-label applications. In this work, the authors compared the real-world efficacy and safety of PED use in on-label and off-label aneurysm treatments. METHODS Clinical and angiographic data of patients who underwent PED placement at a high-volume academic medical center were retrospectively obtained. Treatments were classified as on-label if they fell within the applications approved by the United States Food and Drug Administration as of 2021. Recorded outcomes included aneurysm occlusion, procedural complications, ischemic events, in-stent stenosis, intracranial hemorrhage, postprocedural functional status, and death. RESULTS In total, 416 aneurysms in 330 patients were treated with PED, comprising 256 aneurysms that received on-label treatments and 160 that received off-label treatments. The overall rate of complete aneurysm occlusion was 76.4% for on-label aneurysms and 75.6% for off-label aneurysms (p = 0.898). The risk of ischemic stroke in patients who underwent off-label treatments was 15.2%, which was higher than the 4.2% rate in patients who underwent on-label treatment (p = 0.003). All other clinical complications, procedural complications, and long-term functional status were comparable between the on-label and off-label groups. CONCLUSIONS In real-world practice, off-label use of PED is common and can achieve similar efficacy as on-label use. However, in aggregate, off-label use was found to carry an increased rate of ischemic complications. With judicious attention to safety and individual patient characteristics, these results highlight the scale and general feasibility of off-label PED use by experts.
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Affiliation(s)
- Samuel J Cler
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - David C Lauzier
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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21
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Ma C, Zhu H, Liang S, Liang F, Sun J, Zhang Y, Jiang C. Comparison of Pipeline Embolization Device and Traditional Endovascular Therapeutic Approaches in Distal Cerebral Circulation Aneurysms Using Propensity Score Matching Analysis. Front Neurol 2022; 13:755122. [PMID: 35665044 PMCID: PMC9157485 DOI: 10.3389/fneur.2022.755122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Coiling and stent-assisted coiling remain the first-line treatments for distal cerebral circulation aneurysms (DCCAs). The off-label use of the pipeline embolization device (PED) for these aneurysms has been explored recently but remains controversial. Objective To compare traditional endovascular therapeutic approaches (coiling and stent-assisted coiling) and PED for DCCAs in a multicenter cohort of patients. Methods A multicenter, retrospective cohort comparison study was conducted that included consecutive patients with unruptured DCCAs treated with either traditional endovascular therapeutic approaches or PED placement at three centers between 2016 and 2020. Propensity score matching analysis was applied to adjust for baseline risk factors between the PED and TET groups. Matching was based on age, sex, aneurysm size, location, morphology, adjunctive coiling, treatment history, and preoperative mRS score. Results In total, 209 patients with DCCAs treated with PED or traditional endovascular therapeutic approaches were identified. Thirty-seven patients underwent PED treatment, and 172 patients underwent traditional endovascular therapeutic approaches. After propensity score matching, 37 aneurysm pairs were matched, and the baseline characteristics of the patients were balanced between the groups. The complete occlusion rate between PED and traditional endovascular therapeutic approach in both matched cohorts (91.7 vs. 92.3%, p > 0.78) was similar. The rate of periprocedural treatment-related complications in both the PED and traditional endovascular therapeutic groups was 13.5%. Univariate analysis identified average parent vessel diameter as the only predictor of complete occlusion (p = 0.038). Conclusions PED is a viable option for treating DCCAs by providing occlusion and complication rates similar to those of traditional endovascular therapeutic approaches. A rigid patient selection procedure and proper planning should be undertaken to reduce treatment-related complications.
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Affiliation(s)
- Chao Ma
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jidian Sun
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Yupeng Zhang
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Chuhan Jiang
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22
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Choi JH, Sim SY, Shin YS, Chung J. A Single Flow Re-direction Endoluminal Device for the Treatment of Large and Giant Anterior Circulation Intracranial Aneurysms. Yonsei Med J 2022; 63:349-356. [PMID: 35352886 PMCID: PMC8965426 DOI: 10.3349/ymj.2022.63.4.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The purpose of this study was to report the author's experiences in treating large (10-25 mm) and giant (>25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications. MATERIALS AND METHODS A total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients. RESULTS Six (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335-17.816; p=0.034) was the only independent risk factor for procedure-related complications on multivariate logistic regression analysis. CONCLUSION The procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sook Young Sim
- Department of Neurosurgery, Ilsan Paik Hospital, College of Medicine, Inje University, Goyang, Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joonho Chung
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Li S, Lu Z, Tang H, Shang C, Zhao R, Dai D, Li Q, Hong B, Huang Q, Zhou Y, Liu J. Flow diversion for aneurysms beyond the circle of Willis: A preliminary experience. J Clin Neurosci 2021; 95:63-69. [PMID: 34929653 DOI: 10.1016/j.jocn.2021.11.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/12/2021] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the safety and efficacy of flow diversion (FDs) for the aneurysms beyond the circle of Willis. METHODS AND MATERIALS We retrospectively reviewed the prospectively maintained database in our center and enrolled patients with aneurysms beyond the circle of Willis (defined as at or distal to the M1, A2, and P2 segments) that were treated with FDs. RESULTS Between July 2017 to December 2020, 28 patients with 28 aneurysms met the inclusion criteria and were included in this study, with a median age of 50 years old (IQR, 36-63 years). Thirty FDs, including 5 Pipelines and 25 Tubridge FDs, were deployed. Perioperative complications were noticed in 2 patients (7.1%), while asymptomatic adverse events occurred in another three patients (10.7%). Delayed complications occurred in 3.6% of patients (1/28). All patients received clinical follow-up, with the mortality and long-term morbidity of 0 and 3.6% (1/28), respectively. Angiographic follow-up data were available for 26 patients (92.9%) with an interval of 10 ± 7 months (ranged 2-26 months). Sixteen patients (61.5%) showed complete or nearly complete occlusion of aneurysms (OKM grading scale D and C); 6 cases (23.1%) were revealed incomplete occlusion (OKM grading scale B), and 4 cases (15.4%) remained unchanged (OKM grading scale A). The existence of the perforators derived from aneurysms was associated with a lower occlusion rate (p = 0.032). CONCLUSION Flow diversion is reliable in the treatment of distal aneurysms with a high technical success rate and low permanent disability rate. The presence of side branches derived from aneurysms was associated with a lower aneurysm occlusion rate.
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Affiliation(s)
- Sisi Li
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zhiwen Lu
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Haishuang Tang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China; Naval Medical Center of PLA, Navy Medical University, Shanghai 200050, China
| | - Chenghao Shang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Rui Zhao
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Dongwei Dai
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qiang Li
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Bo Hong
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qinghai Huang
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yu Zhou
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
| | - Jianmin Liu
- Department of Stroke Center, Changhai Hospital, Naval Medical University, Shanghai 200433, China.
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Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
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Abbasi M, Savasatano LE, Brinjikji W, Kallmes KM, Mikoff N, Reierson N, Abdelmegeed M, Pederson J, Warren B, Touchette JC, Khan S, Kamrowski S, Barrett A, Kallmes DF, Kadirvel R. Endoluminal flow diverters in the treatment of sidewall and bifurcation aneurysm: A systematic review and meta-analysis of complications and angiographic outcomes. Interv Neuroradiol 2021; 28:229-239. [PMID: 34154429 DOI: 10.1177/15910199211026713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM The use of endoluminal flow diversion in bifurcation aneurysms has been questioned due to the potential for complications and lower occlusion rates. In this study we assessed outcomes of endovascular treatment of intracranial sidewall and bifurcation aneurysms with flow diverters. METHODS In July 2020, a literature search for all studies utilizing endoluminal flow diverter treatment for sidewall or bifurcation aneurysms was performed. Data were collected from studies that met our inclusion/exclusion criteria by two independent reviewers and confirmed by a third reviewer. Using random-effects meta-analysis the target outcomes including overall complications (hematoma, ischemic events, minor ischemic stroke, aneurysm rupture, side vessel occlusion, stenosis, thrombosis, transient ischemic stroke, and other complications), perioperative complications, and follow-up (long-term) aneurysm occlusion were intestigated. RESULTS Overall, we included 35 studies with 1084 patients with 1208 aneurysms. Of these aneurysms, 654 (54.14%) and 554 (45.86%) were classified as sidewall and bifurcation aneurysm, respectively, based on aneurysm location. Sidewall aneurysms had a similar total complication rate (R) of 27.12% (95% CI, 16.56%-41.09%), compared with bifurcation aneurysms (R, 20.40%, 95% CI, 13.24%-30.08%) (p = 0.3527). Follow-up angiographic outcome showed comparable complete occlusion rates for sidewall aneurysms (R 69.49%; 95%CI, 62.41%-75.75%) and bifurcation aneurysms (R 73.99%; 95% CI, 65.05%-81.31%; p = 0.4328). CONCLUSIONS This meta-analysis of sidewall and bifurcation aneurysms treated with endoluminal flow diverters demonstrated no significant differences in complications or occlusion rates. These data provide new information that can be used as a benchmark for comparison with emerging devices for the treatment of bifurcation aneurysms.
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Affiliation(s)
- Mehdi Abbasi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Luis E Savasatano
- Department of Neurosurgery, 6915Mayo Clinic, Mayo Clinic, Rochester, MN, USA
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Lylyk I, Scrivano E, Lundquist J, Ferrario A, Bleise C, Perez N, Lylyk PN, Viso R, Nella-Castro R, Lylyk P. Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms, Single-Center Registry: Long-Term Angiographic and Clinical Outcomes from 1000 Aneurysms. Neurosurgery 2021; 89:443-449. [PMID: 34098575 PMCID: PMC8374967 DOI: 10.1093/neuros/nyab183] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prospective studies have established the safety and efficacy of the PipelineTM Embolization Device (PED; Medtronic) for treatment of intracranial aneurysms (IA). OBJECTIVE To investigate long-term outcomes from the Pipeline Embolization Devices for the Treatment of Intracranial Aneurysms (PEDESTRIAN) Registry. METHODS The PEDESTRIAN Registry data were retrospectively reviewed, which included patients (March 2006 to July 2019) with complex IAs treated with PED. Patients with unfavorable anatomy and/or recurrence following previous treatment were included and excluded those with acute subarachnoid hemorrhage. The primary angiographic endpoint was complete occlusion and long-term stability. Clinical and radiological follow-up was performed at 3 to 6 mo, 12 mo, and yearly thereafter. RESULTS A total of 835 patients (mean age 55.9 ± 14.7 yr; 80.0% female) with 1000 aneurysms were included. Aneurysms varied in size: 64.6% were small (≤10 mm), 25.6% were large (11-24 mm), and 9.8% were giant (≥25 mm). A total of 1214 PEDs were deployed. Follow-up angiography was available for 85.1% of patients with 776 aneurysms at 24.6 ± 25.0 mo (mean). Complete occlusion was demonstrated in 75.8% of aneurysms at 12 mo, 92.9% at 2 to 4 yr, and 96.4% at >5 yr. During the postprocedural period, modified Rankin Scale scores remained stable or improved in 96.2% of patients, with stability or improvement in 99.1% of patients >5 yr. The overall major morbidity and neurological mortality rate was 5.8%. CONCLUSION This study demonstrated high rates of long-term complete aneurysm occlusion, stable or improved functional outcomes, and low rates of complications and mortality. Clinical and angiographic outcomes improved over long-term follow-up, demonstrating that endovascular treatment of IA with PED is safe and effective.
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Affiliation(s)
- Ivan Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Javier Lundquist
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Angel Ferrario
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Carlos Bleise
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Nicolas Perez
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Pedro Nicolas Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Rene Viso
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Rodolfo Nella-Castro
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Neuroradiology and Neurosurgery, Instituto Médico ENERI-Clínica La Sagrada Familia, Buenos Aires, Argentina
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Bhogal P, Makalanda H, Wong K, Keston P, Downer J, Du Plessis JC, Nania A, Simonato D, Fuschi M, Chong W, O'Reilly S, Rennie I. The Silk Vista Baby - The UK experience. Interv Neuroradiol 2021; 28:201-212. [PMID: 34078155 DOI: 10.1177/15910199211024061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB) flow diverter (FDS) is the only FDS deliverable via a 0.017 inch microcatheter and is specifically designed for the distal vasculature. We sought to evaluate the safety and efficacy of the SVB. MATERIALS AND METHODS We performed a retrospective review to identify SVB cases at 4 tertiary neurosurgical centres within the U.K. Clinical, procedural, angiographic and follow-up data were collected. RESULTS We identified 60 patients (35 female, 58%) of average age 54 ± 10.5 (range 30-72) with 61 aneurysms, 50 (81.9%) located in the anterior circulation. The majority of the aneurysms treated were unruptured (46, 75.4%) and saccular (46, 75.4%). Dome size was 6.2 ± 6.2 mm (range 1-36mm) and parent vessel diameter was 2.3 ± 0.4 mm (range 1.2-3.3 mm).An average number of 1.07 devices were implanted. Coils or other devices were implanted in 14 aneurysms (23.3%). At last angiographic follow-up (n = 55), 7.5 ± 4.2 months post-procedure, 32 aneurysms (57.1%) were graded as RRC I, 7 (12.5%) RRC II, and 17 RRC III (30.4%).Clinical complications, excluding death, were seen in 4 patients (6.8%) including 1 delayed aneurysm rupture and 3 symptomatic ischaemic events. Only one patient had permanent morbidity (mRS 1). 3 patients died during follow-up (5.1%); 2 deaths were related to the aneurysms (3.4%) - one ruptured dissecting MCA aneurysm, and one giant partially thrombosed posterior circulation aneurysm. 93% of patients were mRS ≤ 2 at last follow-up. CONCLUSION The SVB has high rates of technical success and an acceptable safety profile. Distal aneurysms may occlude slower due to relative oversizing of the devices.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, London, UK
| | | | - K Wong
- The Royal London Hospital, London, UK
| | - P Keston
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J Downer
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J C Du Plessis
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - A Nania
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - D Simonato
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - M Fuschi
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - W Chong
- Department of Interventional Neuroradiology, University Hospitals Coventry and Warwickshire, Warwickshire, UK
| | - S O'Reilly
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
| | - I Rennie
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
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Tonetti DA, Casillo SM, Jankowitz BT. Telescoping flow diverters for a pediatric fusiform distal anterior cerebral artery aneurysm: technical case report. Childs Nerv Syst 2021; 37:999-1002. [PMID: 32671531 DOI: 10.1007/s00381-020-04797-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND IMPORTANCE Pediatric intracranial aneurysms are rare, with fusiform aneurysms of the distal anterior circulation even more so. A limited number of prior reports detail the management of this pathology. CLINICAL PRESENTATION We report a case of a 15-year-old boy presenting with new-onset headache found to have a 3.1 cm × 1.4 cm × 1.4 cm fusiform partially thrombosed aneurysm of the A2 segment of the left anterior cerebral artery. Subsequent treatment with flow diversion resulted in the placement of five telescoping PEDs (2.5 mm × 20 mm, 2.75 mm × 20 mm, 2.75 mm × 20 mm, 3 mm × 25 mm, and 3 mm × 20 mm) from the left pericallosal artery to the left A1 segment. Catheter-based angiography at 6 months post-placement indicated normal vessel caliber, no residual aneurysm, and no in-stent stenosis. The patient's headache resolved after treatment. CONCLUSION Telescoping PEDs are a feasible low-risk treatment option for long-segment fusiform distal ACA aneurysms in children that can have optimal clinical and radiographic outcomes.
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Affiliation(s)
- Daniel A Tonetti
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite B-400, 200 Lothrop St., Pittsburgh, PA, 15213, USA.
| | - Stephanie M Casillo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite B-400, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Brian T Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian, Suite B-400, 200 Lothrop St., Pittsburgh, PA, 15213, USA.,Cooper Neurological Institute, Cooper University Medical Center, Camden, NJ, USA
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, Freitas RK, de Oliveira RS, Colli BO, Dos Santos AC, Abud DG. Treatment of distal unruptured intracranial aneurysms using a surface-modified flow diverter under prasugrel monotherapy: a pilot safety trial. J Neurointerv Surg 2021; 13:647-651. [PMID: 33632882 DOI: 10.1136/neurintsurg-2020-017262] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/25/2021] [Accepted: 01/28/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Flow diverters (FDs) are effective in the treatment of carotid aneurysms. Compared with carotid aneurysms, the treatment of distal intracranial aneurysms with FDs has been associated with a relatively high incidence of complications. Low thrombogenic modified-surface FDs may reduce ischemic complications and allow for the use of a single antiplatelet medication. The aim of this study was to assess the safety and efficacy of the p48 MW HPC Flow Modulation Device (Phenox GmbH, Bochum, Germany) to treat distal intracranial aneurysms used in combination with prasugrel monotherapy. METHODS This was a single-center, prospective, pivotal, open, single-arm study. Patients were included in this study from December 2019 to September 2020. The primary endpoints were the incidence of any neurologic deficit after treatment until 1 month of follow-up, defined as National Institutes of Health Stroke Scale (NIHSS) ≥1, and the incidence of acute ischemic lesions in magnetic resonance imagin (MRI) images 48 hours after treatment. The secondary endpoint was the rate of complete occlusion of the aneurysms at the 1-month follow-up. RESULTS Twenty-one patients harboring 27 distal aneurysms of the anterior circulation were included. Mean age was 57.8 (SD 9.7) years, and 16 patients were female (80%). No patient had neurologic symptoms at the 1-month follow-up. Four patients (20%) had asymptomatic acute brain ischemic lesions on MRI. Complete aneurysm occlusion occurred in 9/27 (33.3%) aneurysms at the 1-month follow-up. CONCLUSION In this pilot safety trial, treatment of distal intracranial aneurysms with p48 MW HPC under monotherapy with prasugrel appeared to be safe.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil.,Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze Freitas
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Ricardo Santos de Oliveira
- Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Benedicto Oscar Colli
- Division of Neurosurgery, Department of Surgery, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Antônio Carlos Dos Santos
- Division of Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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Rosengart A, Collins MK, Hendrix P, Uber R, Sartori M, Jain A, Mao J, Goren O, Schirmer CM, Griessenauer CJ. P 2Y 12 inhibitors in neuroendovascular surgery: An opportunity for precision medicine. Interv Neuroradiol 2021; 27:682-694. [PMID: 33541183 DOI: 10.1177/1591019921991394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT), primarily the combination of aspirin with a P2Y12 inhibitor, in patients undergoing intravascular stent or flow diverter placement remains the primary strategy to reduce device-related thromboembolic complications. However, selection, timing, and dosing of DAPT is critical and can be challenging given the existing significant inter- and intraindividual response variations to P2Y12 inhibitors. METHODS Assessment of indexed, peer-reviewed literature from 2000 to 2020 in interventional cardiology and neuroendovascular therapeutics with critical, peer-reviewed appraisal and extraction of evidence and strategies to utilize DAPT in cardio- and neurovascular patients with endoluminal devices. RESULTS Both geno- and phenotyping for DAPT are rapidly and conveniently available as point-of-care testing at a favorable cost-benefit ratio. Furthermore, systematic inclusion of a quantifying clinical risk score combined with an operator-linked, technical risk assessment for potential adverse events allows a more precise and individualized approach to new P2Y12 inhibitor therapy. CONCLUSIONS The latest evidence, primarily obtained from cardiovascular intervention trials, supports that combining patient pharmacogenetics with drug response monitoring, as part of an individually tailored, precision medicine approach, is both predictive and cost-effective in achieving and maintaining individual target platelet inhibition levels. Indirect evidence supports that this gain in optimizing drug responses translates to reducing main adverse events and overall treatment costs in patients undergoing DAPT after intracranial stent or flow diverting treatment.
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Affiliation(s)
- Axel Rosengart
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Malie K Collins
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Philipp Hendrix
- Department of Neurosurgery, Saarland University Medical Center and Saarland University, Faculty of Medicine, Homburg/Saar, Germany
| | | | | | - Abhi Jain
- Department of Radiology, Einstein Medical Center, Philadelphia, PA, USA
| | - Jennifer Mao
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, de Freitas RK, Abud DG. Aspirin monotherapy in the treatment of distal intracranial aneurysms with a surface modified flow diverter: a pilot study. J Neurointerv Surg 2021; 13:336-341. [PMID: 33514613 DOI: 10.1136/neurintsurg-2020-017024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Flow diverters (FDs) result in high occlusion rates of aneurysms located distally to the carotid artery. However, the complications reported are not negligible. New modified surface FDs have low thrombogenic properties that may reduce ischemic complications related to the treatment. In addition, a modified surface FD may allow for the use of a single antiplatelet medication to reduce hemorrhagic risk during the procedure. The aim of this study was to assess the safety and efficacy of the p48 MW HPC (phenox, Bochum, Germany) to treat distal intracranial aneurysms under the use of aspirin monotherapy. METHODS The primary endpoint was the incidence of any neurologic deficit after treatment after 6 months of follow-up. The secondary endpoint was the rate of the complete occlusion of the aneurysms at the 6-month follow-up. Enrollment of 20 patients was planned, but after inclusion of seven patients the study was stopped due to safety issues. RESULTS Seven patients with eight aneurysms were included. Among the seven patients, three (42.8%) had ischemic complications on the second day after FD deployment. Two patients experienced complete recovery at discharge (National Institutes of Health Stroke Scale (NIHSS) score=0), while one patient maintained mild dysarthria at discharge (NIHSS score=1) which improved after 6 months (NIHSS score=0). All three patients had no new symptoms during the 6-month follow-up. Complete aneurysm occlusion occurred in six (75%) of the eight aneurysms at the 6-month follow-up. CONCLUSIONS Antiplatelet monotherapy with aspirin for the treatment of distal intracranial aneurysms with this modified surface FD resulted in a significant incidence of ischemic complications after treatment.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil.,Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze de Freitas
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
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Limbucci N, Leone G, Renieri L, Nappini S, Cagnazzo F, Laiso A, Muto M, Mangiafico S. Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas. Neurosurgery 2020; 86:S85-S94. [PMID: 31838532 PMCID: PMC6911737 DOI: 10.1093/neuros/nyz334] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.
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Affiliation(s)
- Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Giuseppe Leone
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.,Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Federico Cagnazzo
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Mario Muto
- Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
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Bonney PA, Connor M, Fujii T, Singh P, Koch MJ, Stapleton CJ, Mack WJ, Walcott BP. Failure of Flow Diverter Therapy: Predictors and Management Strategies. Neurosurgery 2020; 86:S64-S73. [PMID: 31838530 DOI: 10.1093/neuros/nyz305] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/15/2019] [Indexed: 11/14/2022] Open
Abstract
Flow diversion is a safe and effective treatment for many types of brain aneurysms. Even so, there remain some aneurysms that persist despite initial treatment. In studies with the longest follow-up (5 yr), at least 5% of aneurysms persist with this treatment modality. As the cumulative experience and clinical indications for flow diversion continue to expand, the anatomic and functional characteristics that are associated with aneurysm persistence are increasingly described. Identification of these factors preoperatively can help to guide initial treatment decisions, enhance monitoring protocols in the follow-up period, and establish best practices for re-treatment when necessary. Herein, we review published clinical series and provide examples to highlight variables implicated in aneurysm persistence after treatment with flow diversion.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Michelle Connor
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tatsuhiro Fujii
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Parampreet Singh
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - William J Mack
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.,University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Telles JPM, Solla DJF, Yamaki VN, Rabelo NN, da Silva SA, Caldas JGP, Teixeira MJ, Junior JR, Figueiredo EG. Comparison of surgical and endovascular treatments for fusiform intracranial aneurysms: systematic review and individual patient data meta-analysis. Neurosurg Rev 2020; 44:2405-2414. [PMID: 33205313 DOI: 10.1007/s10143-020-01440-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/14/2020] [Accepted: 11/12/2020] [Indexed: 12/29/2022]
Abstract
Fusiform intracranial aneurysms (FIA) are associated with significant morbidity and mortality. We carried out a systematic review and meta-analysis of individual participant data with propensity score adjustment to compare the functional and angiographic outcomes between surgical and endovascular approaches to FIA. We conducted a systematic review for articles on the treatment of FIA with individual patient-level detailing. Data from patients treated for FIA in our institution from 2010 to 2018 were also collected. The primary studied outcome was morbidity, and secondary outcomes were angiographic results and retreatment. Propensity score-adjusted mixed-effects logistic regression models evaluated treatment options, stratified by anatomical location. Compiling original and published data, there were 312 cases, of which 79 (25.3%) had open surgery, and 233 (74.5%) were treated with endovascular procedures. There were no differences between treatment groups, for neither cavernous ICA (OR 1.04, 95% CI 0.05-23.6) nor supraclinoid aneurysms (OR 7.82, 95% CI 0.65-94.4). Both size (OR 1.11, 95% CI 1.03-1.19) and initial mRS (OR 2.0, 95% CI 1.2-3.3) were risk factors for morbidity, independent of location. Neither age nor rupture status influenced the odds of posterior morbidity. Unfavorable angiographic outcomes were more common in the endovascular group for supraclinoid and vertebrobasilar aneurysms (χ2, P < 0.01). There were no differences between morbidity of surgical and endovascular treatments for FIA, regardless of aneurysm location. Size and initial mRS were correlated with functional outcomes, whereas age and rupture status were not. Microsurgery seems to yield better long-term angiographic results compared to endovascular procedures.
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Affiliation(s)
- João Paulo Mota Telles
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Davi Jorge Fontoura Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Nagai Yamaki
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nicollas Nunes Rabelo
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Saul Almeida da Silva
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - José Guilherme Pereira Caldas
- Department of Interventional Neuroradiology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jefferson Rosi Junior
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Cimflova P, Özlük E, Korkmazer B, Ahmadov R, Akpek E, Kizilkilic O, Islak C, Kocer N. Long-term safety and efficacy of distal aneurysm treatment with flow diversion in the M2 segment of the middle cerebral artery and beyond. J Neurointerv Surg 2020; 13:631-636. [PMID: 33082291 DOI: 10.1136/neurintsurg-2020-016790] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Indications for flow diversion stent (FDS) treatment are expanding. However, there is still a lack of evidence for the long-term outcome in distally located aneurysms in the M2 segment of the middle cerebral artery (MCA) and beyond. METHODS Consecutive subjects (from June 2013 to August 2020) with MCA aneurysms in the M2 segment or beyond treated with FDS were reviewed retrospectively. The primary endpoints for clinical safety were the absence of mortality, stroke event, re-rupture of the aneurysm, and worsening of clinical symptoms. The primary endpoint for treatment efficacy was complete/near-complete occlusion at follow-up after 12 months. RESULTS 23 patients were identified: 7 aneurysms were located in the M2 segment of the MCA, 4 in the M2-M3 bifurcation, 2 in M3, 3 in M3-4 branching, and 2 in M4; 5 aneurysms were located in M2 with extension into the M1-M2 bifurcation. 13 aneurysms were of fusiform morphology, 8 sacculofusiform, and 2 saccular. 16 aneurysms were of highly suspected dissecting etiology. The median diameter of the parent vessel was 2.1 mm proximally and 2 mm distally. The median time of the follow-up was 30 months (range 16 months to 6 years). Complete/near complete occlusion was observed in 14/20 patients (70%) and one stable remodeling (5%) was seen at 12 months. 22 patients (95.6%) had an excellent clinical outcome (mRS 0-1) at 6 months. Technical challenges associated with the deployment of FDS occurred in 8.7% of cases. Severe complications, intraparenchymal hemorrhage and re-rupture of the aneurysm occurred in 2 patients (8.7%). CONCLUSION Flow diversion of distally located aneurysms is technically feasible with low morbidity and mortality.
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Affiliation(s)
- Petra Cimflova
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University Brno, Brno, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Enes Özlük
- Department of Radiology, Acibadem Atakent Hospital, Istanbul, Turkey
| | - Bora Korkmazer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ramiz Ahmadov
- Department of Neurosurgery, Acibadem Atakent Hospital, Istanbul, Turkey
| | - Elif Akpek
- Department of Anaestesiology and Reanimation, Acibadem Universitesi Medical Faculty, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Civan Islak
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Naci Kocer
- Department of Neuroradiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Ravina K, Strickland BA, Rennert RC, Chien M, Mack WJ, Amar AP, Russin JJ. A3-A3 Anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: Experience With in Situ Bypass and Lessons Learned From Pseudoaneurysm Cases. Oper Neurosurg (Hagerstown) 2020; 17:247-260. [PMID: 30462326 DOI: 10.1093/ons/opy334] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 09/27/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND A3-A3 side-to-side bypass is an intracranial-to-intracranial (IC-IC) revascularization option when aneurysm treatment involves occlusion of one anterior cerebral artery (ACA). OBJECTIVE To describe applications of A3-A3 side-to-side bypass in the management of ACA true and pseudoaneurysms along with a review of pertinent literature. METHODS Six consecutive patients undergoing an A3-A3 bypass as part of their aneurysm management, representing a single-surgeon experience in a 2-yr period, were included in this retrospective review of a prospectively collected database. RESULTS Three male and three female patients with a median (range) age of 41.5 (11-69) years representing four ruptured and two unruptured aneurysms were included. Two of the aneurysms were communicating while four were postcommunicating from which three were pseudoaneurysms. Complete aneurysm obliteration was achieved in 5/6 cases. Bypass patency was evaluated in all cases intra- and postoperatively. Good outcomes (modified Rankin Scale score ≤ 2) at follow-up were observed in 4/6 patients. An improvement in mRS scores at the most recent follow-up as compared to preoperative status was achieved in three while scores remained the same in two patients. Ischemic complications related to aneurysm treatment were observed in two patients, both of which achieved good functional recovery upon follow-up. One patient deceased postoperatively due to progression of vasospasm-related infarcts. CONCLUSION A3-A3 bypass in the management of true as well as pseudoaneurysms of the ACA can achieve good postoperative outcomes in selected patients. Prompt diagnosis and aggressive surgical treatment needs to be pursued if a vessel injury with pseudoaneurysm formation is suspected.
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Affiliation(s)
- Kristine Ravina
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Robert C Rennert
- Department of Neurosurgery, University of California at San Diego, San Diego, California
| | - Mark Chien
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Arun P Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jonathan J Russin
- Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California.,Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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Cagnazzo F, Lefevre PH, Derraz I, Dargazanli C, Gascou G, di Carlo DT, Perrini P, Ahmed R, Hak JF, Riquelme C, Bonafe A, Costalat V. Flow-Diversion Treatment for Unruptured Nonsaccular Intracranial Aneurysms of the Posterior and Distal Anterior Circulation: A Meta-Analysis. AJNR Am J Neuroradiol 2020; 41:134-139. [PMID: 31924605 DOI: 10.3174/ajnr.a6352] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/14/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Treatment management and outcomes of unruptured nonsaccular aneurysms are different compared with their saccular counterparts. PURPOSE Our aim was to analyze the outcomes after flow diversion among nonsaccular unruptured lesions. DATA SOURCES A systematic search of 3 data bases (2005-2019) was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. STUDY SELECTION We included studies reporting flow diversion for nonsaccular unruptured aneurysms of the posterior and distal anterior circulations. Anterior circulation lesions were included if located distal to the petrocavernous and supraclinoid ICA (MCA, A1, anterior communicating artery, A2). Giant dolichoectatic holobasilar lesions were excluded because of their poor treatment outcomes. DATA ANALYSIS Aneurysm occlusion and complication rates were calculated (random effects meta-analysis). DATA SYNTHESIS We included 15 studies (213 aneurysms). The long-term adequate occlusion rate was 85.3% (137/168; 95% CI, 78.2%-92.4%; I2 = 42.3%). Treatment-related complications were 17.4% (41/213; 95% CI, 12.45%-22.4%; I2 = 0%). Overall, 15% (37/213; 95% CI, 10%-20%; I2 = 0%) were ischemic events. Procedure-related morbidity was 8% (20/213; 95% CI, 5%-12%; I2 = 0%). Fusiform or dissecting types had comparable adequate occlusion (116/146 = 83%; 95% CI, 74%-92%; I2 = 48% versus 33/36 = 89%; 95% CI, 80%-98%; I2 = 0%; P = .31) and complication rates (35/162 = 17%; 95% CI, 10%-25%; I2 = 24% versus 11/51 = 19%; 95% CI, 10%-31%; I2 = 0%; P = .72). Aneurysm size (>10 versus ≤10 mm) was independently associated with a higher rate of complications (OR = 6.6; 95% CI, 1.3-15; P = .02). The rate of ischemic events after discontinuation of the antiplatelet therapy was 5% (5/93; 95% CI, 2%-9%; I2 = 0%). LIMITATIONS Small and retrospective studies were available for this meta-analysis. CONCLUSIONS Unruptured nonsaccular aneurysms located in the posterior and distal anterior circulations can be effectively treated with flow diversion. Nevertheless, treatment-related complications are not negligible, with about 15% ischemic events and 8% morbidity. Larger size (>10 mm) significantly increases the risk of procedure-related adverse events.
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Affiliation(s)
- F Cagnazzo
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - P-H Lefevre
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - I Derraz
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - C Dargazanli
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - G Gascou
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - D T di Carlo
- Department of Neurosurgery (D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - P Perrini
- Department of Neurosurgery (D.T.d.C., P.P.), University of Pisa, Pisa, Italy
| | - R Ahmed
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - J F Hak
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - C Riquelme
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - A Bonafe
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
| | - V Costalat
- From the Neuroradiology Department (F.C., P.-H.L., I.D., C.D., G.G., R.A., J.F.H., C.R., A.B., V.C.), CHU Gui De Chauliac, Montpellier, France
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Dmytriw AA, Phan K, Salem MM, Adeeb N, Moore JM, Griessenauer CJ, Foreman PM, Shallwani H, Shakir H, Siddiqui AH, Levy EI, Davies JM, Harrigan MR, Thomas AJ, Ogilvy CS. The Pipeline Embolization Device: Changes in Practice and Reduction of Complications in the Treatment of Anterior Circulation Aneurysms in a Multicenter Cohort. Neurosurgery 2020; 86:266-271. [PMID: 30860254 DOI: 10.1093/neuros/nyz059] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. OBJECTIVE To assess aneurysm occlusion and complication rates over time. METHODS Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. RESULTS A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). CONCLUSION We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.
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Affiliation(s)
- Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Kevin Phan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nimer Adeeb
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Geisinger School of Medicine, Danville, Pennsylvania
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Hussain Shallwani
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Hakeem Shakir
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Tsuchiya N, Fujiwara H, Takahashi H, Ogura R, Yoshimura J, Fujii Y. Overlapping Stents and Coil Embolization of Ruptured Anterior Cerebral Artery Dissecting Aneurysms in the Acute Phase. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:435-440. [PMID: 37502660 PMCID: PMC10370535 DOI: 10.5797/jnet.cr.2019-0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/17/2020] [Indexed: 07/29/2023]
Abstract
Objective To report a case of ruptured anterior cerebral artery dissection treated with stent-assisted coil embolization with overlapping stents. Case Presentation A 51-year-old woman developed subarachnoid hemorrhage the day after transient left hemiparesis. Angiography revealed a ruptured anterior cerebral artery dissecting aneurysm. We conducted stent-assisted coil embolization with the overlapping stent technique on the day after the hemorrhage. She recovered steadily without rebleeding. Six months after embolization, no recurrence was found on angiography. Conclusion Although an acceptable result was achieved in this case, the safety and efficacy of this procedure are unconfirmed. A larger number of cases should be accumulated.
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Affiliation(s)
- Naoto Tsuchiya
- Department of Neurosurgery, Nagano Red Cross Hospital, Nagano, Nagano, Japan
| | - Hidemoto Fujiwara
- Department of Neurosurgery, Nagano Red Cross Hospital, Nagano, Nagano, Japan
| | - Haruhiko Takahashi
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Niigata, Japan
| | - Ryousuke Ogura
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Niigata, Japan
| | - Junichi Yoshimura
- Department of Neurosurgery, Nagano Red Cross Hospital, Nagano, Nagano, Japan
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, University of Niigata, Niigata, Niigata, Japan
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Pressman E, De la Garza CA, Chin F, Fishbein J, Waqas M, Siddiqui A, Snyder K, Davies JM, Levy E, Kan P, Ren Z, Mokin M. Nuisance bleeding complications in patients with cerebral aneurysm treated with Pipeline embolization device. J Neurointerv Surg 2020; 13:247-250. [PMID: 32620576 DOI: 10.1136/neurintsurg-2020-016245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/15/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients with cerebral aneurysms treated with the Pipeline embolization device (PED) are maintained on dual antiplatelet therapy (DAPT) to prevent thromboembolic complications. Rates of minor, "nuisance" bleeding in these patients remain unknown. We sought to evaluate the frequency and factors associated with this bleeding and its effect on DAPT compliance. METHODS We performed a multicenter retrospective cohort study on consecutive cases of intracranial aneurysms treated with PED. Patient characteristics, aneurysm characteristics, and bleeding complications were analyzed. Severity of bleeding was defined according to a previously published classification defining nuisance bleeding as easy bruising, bleeding from small cuts, petechia, and ecchymosis. RESULTS 245 PED aneurysm procedures on 243 patients were retrospectively collected from three academic centers over a 4.25-year period. Sixty-seven patients (27%) had nuisance bleeds. Patients with a higher risk of nuisance bleeding were older (59.1±3.4 vs . 54.7±2.2, P=0.032). Patients with nuisance bleeds were more likely to have their DAPT regimen changed or dose lowered (29% vs 8.3%, P<0.001), were on DAPT for less time (10.0 months±2.60 vs. 14.6 months±1.95, P=0.005) and were more likely to have aneurysm occlusion at 6 months (P<0.001). Stepwise logistic regression found age predictive of a nuisance bleed (OR=1.033) CONCLUSIONS: Nuisance bleeding was a common complaint of PED-treated aneurysm patients maintained on DAPT. Increasing age and aneurysmal occlusion at 6 months were the only factors predictive of nuisance bleeds. Clinicians were more likely to adjust antiplatelet regimens or stop DAPT early given a nuisance bleed.
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Affiliation(s)
- Elliot Pressman
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Carlos A De la Garza
- Neurology, Baylor College of Medicine Department of Neurology, Houston, Texas, USA
| | - Felix Chin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jacob Fishbein
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kenneth Snyder
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Zeguang Ren
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA.,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
| | - Maxim Mokin
- University of South Florida Department of Neurosurgery and Brain Repair, Tampa, Florida, USA .,Neurosciences Group, Tampa General Hospital, Tampa, FL, USA
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Shin DS, Carroll CP, Elghareeb M, Hoh BL, Kim BT. The Evolution of Flow-Diverting Stents for Cerebral Aneurysms; Historical Review, Modern Application, Complications, and Future Direction. J Korean Neurosurg Soc 2020; 63:137-152. [PMID: 32120455 PMCID: PMC7054118 DOI: 10.3340/jkns.2020.0034] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
In spite of the developing endovascular era, large (15–25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.
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Affiliation(s)
- Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Christopher P Carroll
- Department of Brain & Spine Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA.,Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | | | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Setlur Nagesh SV, Vakharia K, Waqas M, Munich SA, Bednarek DR, Davies JM, Snyder KV, Mokin M, Rudin S, Levy EI, Siddiqui AH. Single-center experience of using high definition (Hi-Def) imaging during neurointervention treatment of intracranial aneurysms using flow diverters. J Neurointerv Surg 2020; 12:897-901. [PMID: 32046993 DOI: 10.1136/neurintsurg-2019-015551] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/19/2019] [Accepted: 01/05/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND A new dual resolution imaging x-ray detector system (Canon Medical Systems Corporation, Tochigi, Japan) has a standard resolution 194 µm pixel conventional flat-panel detector (FPD) mode and a high-resolution 76 µm high-definition (Hi-Def) mode in a single unit. The Hi-Def mode enhances the visualization of the intravascular devices. OBJECTIVE We report the clinical experience and physician evaluation of this new detector system with Hi-Def mode for the treatment of intracranial aneurysms using a Pipeline embolization device (PED). METHODS During intervention at our institute, under large field of view (FOV) regular resolution FPD mode imaging, the catheter systems and devices were first guided to the proximity of the treatment area. Final placement and deployment of the PED was performed under Hi-Def mode guidance. A post-procedure 9-question physician survey was conducted to qualitatively assess the impact of Hi-Def mode visualization on physicians' intraoperative decision-making. One-sample t-test was performed on the responses from the survey. Dose values reported by the x-ray unit were also recorded. RESULTS Twenty-five cases were included in our study. The survey results indicated that, for each of the nine questions, the physicians in all cases indicated that the Hi-Def mode improved visualization compared with the FPD mode. For the 25 cases, the mean cumulative entrance air kerma was 2.35 Gy, the mean dose area product (DAP) was 173.71 Gy.cm2, and the mean x-ray exposure time was 39.30 min. CONCLUSIONS The Hi-Def mode improves visualization of flow diverters and may help in achieving more accurate placement and deployment of devices.
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Affiliation(s)
- Swetadri Vasan Setlur Nagesh
- Canon Stroke and Vascular Research Center, UB Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
| | - Stephan A Munich
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
| | - Daniel R Bednarek
- Canon Stroke and Vascular Research Center, UB Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, New York, United States
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, United States
| | - Stephen Rudin
- Canon Stroke and Vascular Research Center, UB Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Biomedical Engineering, University at Buffalo, Buffalo, New York, United States.,Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, New York, United States.,Department of Electrical Engineering, University at Buffalo, Buffalo, New York, United States
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, UB Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, UB Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA .,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, United States.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, United States
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Srivatsan A, Kan P. Commentary: Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, Carotid Cavernous Fistulas. Neurosurgery 2020; 86:E227-E228. [PMID: 31844902 DOI: 10.1093/neuros/nyz450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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OĞUZ Ş, TABAKCI ÖN, UYSAL E, BULUT E, DİNÇ H. Pipeline Flex Embolization Device (PED Flex) for the treatment of intracranial
aneurysms: Periprocedural outcomes and first-year angiographic results. Turk J Med Sci 2019; 49:1640-1646. [PMID: 31655536 PMCID: PMC7518671 DOI: 10.3906/sag-1906-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/18/2019] [Indexed: 11/03/2022] Open
Abstract
Background/aim The Pipeline Flex Embolization Device (PED Flex) is a new updated version of the PED classic that incorporates a new delivery system to allow facilitation of stent deployment, resheathing, and removal of the capture coil. This study evaluated the PED Flex in terms of the technical aspects of the procedure and first-year follow-up results. Materials and methods This retrospective study involved prospectively collected data from May 2015 to August 2017. The primary endpoint was technical aspects of the procedure, and the secondary endpoint was first-year follow-up results. Results Forty-nine patients with 59 target intracranial aneurysms were enrolled. Patients’ mean age was 52 years (range 21−71 years), and 31 (63.0%) were female. All aneurysms except for three were unruptured. The mean aneurysm diameter was 8 mm. Forty-seven patients with 56 aneurysms were successfully treated. Due to advancement, repositioning, and migration problems, 8 (13.1%) stents were not deployed and discharged. The total aneurysm occlusion rate was 77.0%. The mortality rate was 4.3%. Conclusion Our experience shows that the applicability and safety of the renewed delivery system provided by PED Flex for improving device apposition and opening has been proven with one-year angiographic and clinical follow-up results.
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Affiliation(s)
- Şükrü OĞUZ
- Department of Radiology, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
| | - Ömer Naci TABAKCI
- Department of Radiology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbulTurkey
| | - Ender UYSAL
- Department of Radiology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbulTurkey
| | - Eser BULUT
- Department of Radiology, Kanuni Training and Research Hospital, TrabzonTurkey
| | - Hasan DİNÇ
- Department of Radiology, Faculty of Medicine, Karadeniz Technical University, TrabzonTurkey
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Cherian J, Srinivasan V, Froehler MT, Grossberg JA, Cawley CM, Hanel RA, Puri A, Dumont T, Ducruet AF, Albuquerque F, Arthur A, Cheema A, Spiotta A, Anadani M, Lopes D, Saied A, Kim L, Kelly CM, Chen PR, Mocco J, De Leacy R, Powers CJ, Grandhi R, Fargen KM, Chen SR, Johnson JN, Lam S, Kan P. Flow Diversion for Treatment of Intracranial Aneurysms in Pediatric Patients: Multicenter Case Series. Neurosurgery 2019; 87:53-62. [DOI: 10.1093/neuros/nyz380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/02/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Though the Pipeline Embolization Device (Medtronic) is approved for use in adults 22 yr and older, the high efficacy and long-term durability of the device is attractive for treatment of intracranial aneurysms in younger patients who often have aneurysms less amenable to traditional endovascular treatments.
OBJECTIVE
To report technical, angiographic, and clinical outcomes in patients aged 21 or below undergoing flow-diversion treatment for intracranial aneurysms.
METHODS
Retrospective review across 16 institutions identified 39 patients aged 21 or below undergoing 46 treatment sessions with Pipeline Embolization Device placement between 2012 and 2018. A total of 50 intracranial aneurysms were treated. Details regarding patient demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed in a multicenter database.
RESULTS
A total of 70% of patients were male. Nonsaccular morphology was seen in half of identified aneurysms. Six aneurysms were giant, and five patients were treated acutely after ruptured presentation. Eight patients were younger than 10 yr of age. Complete aneurysm occlusion was seen in 74% of treated aneurysms. Three aneurysms (6%) were retreated. A total of 83% of patients had a modified Rankin Scale scores of ≤2 at last clinical follow-up. There were 2 early mortalities (4.3%) in the immediate postprocedure period because of rerupture of a treated ruptured aneurysm. No recanalization of a previously occluded aneurysm was observed.
CONCLUSION
Flow-diversion treatment is a safe and effective treatment for intracranial aneurysms in patients younger than 22 yr. Rates of complete aneurysm occlusion and adverse events are comparable for rates seen in older patients.
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Affiliation(s)
- Jacob Cherian
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Ricardo A Hanel
- Department of Neurosurgery, Jacksonville Baptist, Jacksonville, Florida
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Andrew F Ducruet
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Felipe Albuquerque
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adam Arthur
- Department of Neurosurgery, Semmes Murphy, Memphis, Tennessee
| | - Ahmed Cheema
- Department of Neurosurgery, Semmes Murphy, Memphis, Tennessee
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mohammad Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Demetrius Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Ahmed Saied
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
- Neurology Department, Mansoura University, Mansoura, Egypt
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Cory M Kelly
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ciarán J Powers
- Department of Neurological Surgery, The Ohio State Wexner Medical Center, Columbus, Ohio
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Kyle M Fargen
- Department of Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina
| | - Stephen R Chen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Sandi Lam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Townsend RK, Wolfe SQ, Anadani M, Spiotta A, De Leacy R, Mocco J, Garner RM, Albuquerque FC, Ducruet AF, Kan P, Fargen KM. Endovascular management of acute postprocedural flow diverting stent thrombosis. J Neurointerv Surg 2019; 12:67-71. [DOI: 10.1136/neurintsurg-2019-014944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/12/2019] [Accepted: 08/15/2019] [Indexed: 11/03/2022]
Abstract
IntroductionPostprocedural thrombosis is a rare complication after flow diverting stent (FD) implantation for aneurysm treatment with few reported cases in the literature. Management strategies and outcomes associated with this complication have not been reported.MethodsA multicenter retrospective series of cases of acute postprocedural FD thrombosis were compiled and prevalence was calculated based on procedural volumes over a 7 year period. Acute postprocedural FD thrombosis was defined as the development of neurologic deficit with angiographic imaging demonstrating acute thrombus within the index FD stent at least 2 hours following completion of the implantation procedure.ResultsA total of 10 cases of postprocedural thrombosis were identified at five participating centers among a total of 768 patients treated (prevalence 1.3%). Thrombosis occurred a median of 5.5 days after implantation (range 0–83 days). 9/10 patients underwent emergent angiography with intent to perform endovascular reperfusion. A variety of different endovascular treatments were used, including aspiration thrombectomy, retrievable stent thrombectomy, balloon angioplasty, and intra-arterial thrombolytic infusion, without any procedural complications. There were no instances of FD migration, stent kinking, or aneurysm rupture. 90% of patients achieved Thrombolysis in Cerebral Infarction 2B or greater revascularization. Favorable clinical outcomes (modified Rankin Scale score of 0–2) at 3 months were achieved in 88% of patients.ConclusionAcute postprocedural thrombosis of an FD is a rare complication that occurs in approximately 1–2% of patients after aneurysm treatment. Patients presenting with acute postprocedural FD thrombosis should be aggressively managed using large vessel occlusion thrombectomy techniques, as good angiographic and clinical outcomes are possible.
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Wallace AN, Grossberg JA, Almandoz JED, Kamran M, Roy AK, Kayan Y, Austin MJ, Howard BM, Moran CJ, Cawley CM, Cross DT, Dion JE, Kansagra AP, Osbun JW. Endovascular Treatment of Posterior Cerebral Artery Aneurysms With Flow Diversion: Case Series and Systematic Review. Neurosurgery 2019. [PMID: 29528441 DOI: 10.1093/neuros/nyx561] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Flow diversion of posterior cerebral artery (PCA) aneurysms has not been widely reported, possibly owing to concerns regarding parent vessel size and branch vessel coverage. OBJECTIVE To examine the safety and effectiveness of PCA aneurysm flow diverter treatment. METHODS Retrospective review of PCA aneurysms treated with the Pipeline Embolization Device (PED; Medtronic Inc, Dublin, Ireland) at 3 neurovascular centers, including periprocedural complications and clinical and angiographic outcomes. Systematic review of the literature identified published reports of PCA aneurysms treated with flow diversion. Rates of aneurysm occlusion and complications were calculated, and outcomes of saccular and fusiform aneurysm treatments were compared. RESULTS Ten PCA aneurysms in 9 patients were treated with the PED. There were 2 intraprocedural thromboembolic events (20%), including 1 symptomatic infarction and 1 delayed PED thrombosis. Eight of 10 patients returned to or improved from their baseline functional status. Complete aneurysm occlusion with parent vessel preservation was achieved in 75% (6/8) of cases at mean follow-up of 16.7 mo. Eleven of 12 (92%) major branch vessels covered by a PED remained patent. Including the present study, systematic review of 15 studies found a complete aneurysm occlusion rate of 88% (30/34) and complication rate of 26% (10/38), including 5 symptomatic ischemic strokes (13%; 5/38). Fusiform aneurysms more frequently completely occluded compared with saccular aneurysms (100% vs 70%; P = .03) but were associated with a higher complication rate (43% vs 9%; P = .06). CONCLUSION The safety and effectiveness profile of flow diverter treatment of PCA aneurysms may be acceptable in select cases.
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Affiliation(s)
- Adam N Wallace
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.,Department of Radiology, University of Iowa, Iowa City, Iowa
| | | | - Josser E Delgado Almandoz
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Mudassar Kamran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
| | - Anil K Roy
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Yasha Kayan
- Division of Neurointerventional Radi-ology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Matthew J Austin
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri
| | | | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Jacques E Dion
- Department of Radiology, Emory University, Atlanta, Georgia
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri.,Department of Neurology, Washington University, St. Louis, Missouri
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, Missouri.,Department of Neurosurgery, Washington University, St. Louis, Missouri.,Department of Neurology, Washington University, St. Louis, Missouri
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Lessons Learned from Endovascular Coil Embolization of Pericallosal Artery Aneurysms and Adoption of Flow Diversion: A Retrospective Cohort Assessment of the Efficacy of Coiling and Flow Diversion. World Neurosurg 2019; 129:e444-e451. [DOI: 10.1016/j.wneu.2019.05.181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 11/20/2022]
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49
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Sivasankar R, Shrivastava M, Limaye US. Experience with FRED junior flow diverter in treatment of cerebral aneurysms at or distal to the circle of Willis. J Clin Neurosci 2019; 69:166-169. [PMID: 31451376 DOI: 10.1016/j.jocn.2019.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 06/14/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
This retrospective study was aimed at assessing our results of endovascular management using the FRED junior flow diverter in cerebral aneurysms at or distal to the circle of Willis. 12 patients with 15 small cerebral vessel aneurysms at or distal to the circle of Willis underwent endovascular treatment using the FRED junior flow diverter at two tertiary care centres in Mumbai, India. 12 of the 15 aneurysms were unruptured, one was treated in an acutely ruptured setting, while two, which had presented with SAH were initially treated with balloon assisted coiling and later treated in a staged manner with a flow diverter. Technical success was 100% in all 15 deployments. Deployments were made across angles ranging from 45° to 180°. There was no stroke/TIA/death in any of the cases, which were unruptured. The O'Kelly-Marotta (OKM) staging was used to analyze angiographic follow up (at least one post procedure angiogram) which was available in 8 patients (10 aneurysms). OKM D & C was seen in 80% of the aneurysms on follow up angiograms. The treatment of small vessel cerebral aneurysms at or distal to the Circle of Willis using a dedicated flow diverter (FRED Jr.) is both technically feasible and highly efficacious.
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Affiliation(s)
- Rajeev Sivasankar
- Dept of Imaging & Interventional Radiology, INHS Asvini, Colaba, Mumbai, India.
| | - Manish Shrivastava
- Consultant Interventional Neuroradiology, Department of Imaging & Interventional Radiology, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Uday S Limaye
- Consultant Interventional Neuroradiology, Department of Imaging & Interventional Radiology, Lilavati Hospital, Mumbai, India
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50
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Podlasek A, Al Sultan AA, Assis Z, Kashani N, Goyal M, Almekhlafi MA. Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:148-155. [DOI: 10.1136/neurintsurg-2019-014996] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 05/30/2019] [Accepted: 06/02/2019] [Indexed: 01/15/2023]
Abstract
BackgroundThromboembolic complications are not uncommon in patients undergoing neurointerventional procedures. The use of flow diverting stents is associated with higher risks of these complications despite current dual antiplatelet regimens.ObjectiveTo explore contemporary evidence on the safety of emerging dual antiplatelet regimens in flow diverting stenting procedures.MethodsWe performed a systematic review and meta-analysis to identify relevant articles in electronic databases, and relevant references. Studies reporting the complications and mortality of flow diverting stenting procedures using acetyl salicylic acid (ASA) + ticagrelor or ASA + prasugrel compared with ASA + clopidogrel were included.ResultsOf 452 potentially relevant studies, we identified 49 studies (2526 patients) which reported the safety of ticagrelor or prasugrel for pooled analysis, and five studies (1005 patients) for meta-analysis. The pooled overall mortality in all studies was 2.14%, ischemic complications 6.89%, and hemorrhagic complications 3.68%. The use of ticagrelor or prasugrel was associated with a lower risk of mortality compared with clopidogrel (RR=4.57, 95% CI 1.23 to 16.99; p=0.02). Considering ischemic events, ASA + clopidogrel was as safe as ASA + prasugrel (RR=0.55, 95% CI 0.11 to 2.74; p=0.47) and ASA + ticagrelor (RR=0.74, 95% CI 0.32 to 1.74; p=0.49). ASA +ticagrelor was not associated with a higher risk of hemorrhagic complications (RR=0.92, 95% CI 0.27 to 3.16; p=0.89).ConclusionsEvidence suggests that dual antiplatelet regimens including ticagrelor or prasugrel are safe for patients undergoing flow diversion procedures. Regimens using ticagrelor were associated with better survival than those using clopidogrel in the included studies.
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