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Young M, Enriquez-Marulanda A, Salih M, Shutran M, Budohoski K, Grandhi R, Taussky P, Ogilvy CS. Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device. Neurosurgery 2024; 94:271-277. [PMID: 37655903 DOI: 10.1227/neu.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.
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Affiliation(s)
- Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Karol Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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Li W, Xiao Z, Zhao K, Yang S, Zhang Y, Li B, Zhou Y, Ma Y, Chai E. Efficacy of pipeline embolization device vs. traditional coils in embolization of intracranial aneurysms: A systematic review and meta-analysis. Front Neurol 2022; 13:978602. [PMID: 36247783 PMCID: PMC9558282 DOI: 10.3389/fneur.2022.978602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn recent years, the Pipeline embolization device (PED) has been widely used in the embolization of intracranial aneurysms, but there are some inconsistent findings on whether its efficacy and safety are superior to those of traditional coils embolization (coils alone, stent-assisted coils and balloon-assisted coils). The purpose of this meta-analysis was to evaluate the safety and efficacy of PED in intracranial aneurysm embolization by comparing with traditional coils.MethodsWe systematically searched PubMed, Embase, Web of Science, and The Cochrane Library databases for randomized controlled trials and observational studies (case-control studies and cohort studies) comparing the efficacy of PED with traditional coils in intracranial aneurysm embolization published before April 1, 2022. The endpoints observed in this meta-analysis were procedure-related intracranial hemorrhage, procedure-related intracranial ischemia, other procedure-related complications (e.g., aneurysm rupture, neurological impairment, etc.), retreatment rate, complete occlusion (100%) of the aneurysm at the last follow-up, and favorable functional outcome (MRS ≤ 2).ResultsA total of 10 studies with a total of 1,400 patients (PED group: 576 and Traditional coils: 824) were included in this meta-analysis. A comprehensive analysis of the included literature showed that the PED group had a higher rate of complete aneurysm occlusion [OR = 2.62, 95% Cl (1.94, 3.55), p < 0.00001] and Lower re-treatment rate [OR = 0.20, 95% Cl (0.12, 0.34 p < 0.00001)] compared with the traditional coil embolization group at the last follow-up. In terms of procedure-related intracranial hemorrhage [OR = 3.04, 95% Cl (1.08, 8.57), p = 0.04] and other procedure-related complications [OR = 2.91, 95% Cl (1.48, 5.57), p = 0.002], the incidence of PED was higher than that of the traditional coil embolization group. Moreover, in terms of favorable functional outcome [OR = 0.4, 95% Cl (0.22, 0.71), p = 0.002] of patients at the last follow-up, the PED group was lower than the traditional coil embolization group. There was no statistically significant between the two groups in terms of surgery-related intracranial ischemia complications [OR = 0.88, 95% Cl (0.47, 1.64), p = 0.68].ConclusionPED had higher rates of complete aneurysm occlusion and lower rates of aneurysm retreatment compared with traditional coils, but traditional coils was superior to the PED group in terms of procedure-related intracranial hemorrhage complication and other procedure-related complications (aneurysm rupture, neurological impairment), and favorable functional outcome (mRS ≤ 2). This result still needs to be further confirmed by additional large-sample, multicenter, prospective randomized controlled trials.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325673.
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Affiliation(s)
- Wei Li
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Zaixing Xiao
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Kaixuan Zhao
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Shijie Yang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yichuan Zhang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Bin Li
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yu Zhou
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yong Ma
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Erqing Chai
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- *Correspondence: Erqing Chai
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3
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Catapano JS, Koester SW, Srinivasan VM, Labib MA, Majmundar N, Nguyen CL, Rutledge C, Cole TS, Baranoski JF, Ducruet AF, Albuquerque FC, Spetzler RF, Lawton MT. A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms. J Neurosurg 2022; 136:1245-1250. [PMID: 34653974 DOI: 10.3171/2021.5.jns211149] [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: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. METHODS The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. RESULTS A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. CONCLUSIONS Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.
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Affiliation(s)
- Joshua S Catapano
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Visish M Srinivasan
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Mohamed A Labib
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Neil Majmundar
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Candice L Nguyen
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Caleb Rutledge
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Tyler S Cole
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Jacob F Baranoski
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Andrew F Ducruet
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Felipe C Albuquerque
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Robert F Spetzler
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Michael T Lawton
- 1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Raychev R, Sirakov S, Sirakov A, Saber H, Vinuela F, Jahan R, Nour M, Szeder V, Colby G, Duckwiler G, Tateshima S. Critical Angiographic and Sonographic Analysis of Intra Aneurysmal and Downstream Hemodynamic Changes After Flow Diversion. Front Neurol 2022; 13:813101. [PMID: 35356453 PMCID: PMC8960056 DOI: 10.3389/fneur.2022.813101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionSuccessful treatment of intracranial aneurysms after flow diversion (FD) is dependent on the flow modulating effect of the device. We aimed to investigate the intra-aneurysmal and parent vessel hemodynamic changes, as well as the incidence of silent emboli following treatment with various FD devices.MethodsWe evaluated the appearance of the eclipse sign in nine distinct phases of cerebral angiography before and immediately after FD placement in correlation with aneurysm occlusion. Angiographic and clinical data of consecutive procedures were analyzed retrospectively. Patients who had successful FD procedure without adjunctive coiling, visible eclipse sign on post embolization angiography, and reliable follow-up angiographic data were included in the analysis. Detailed analysis of hemodynamic data from transcranial doppler after FD was performed in selected patients, such as monitoring for silent emboli.ResultsAmong all patients (N = 65) who met inclusion criteria, complete aneurysm occlusion at 12 months was achieved in 89% (58/65). Eclipse sign prior to FD was observed in 42% (27/65) with unchanged appearance in 4.6% (3/65) of the treated patients. None of these three patients achieved complete aneurysm occlusion. Among all analyzed variables, such as aneurysm size, device type used, age, and appearance of the eclipse sign pre- and post-FD, the most reliable predictor of permanent aneurysm occlusion at 12 months was earlier, prolonged, and sustained eclipse sign visibility in more than three angiographic phases in comparison to the baseline (p < 0.001). Elevation in flow velocities within the ipsilateral vascular territory was noted in 70% (9/13), and bilaterally in 54% (7/13) of the treated patients. None of the patients had silent emboli.ConclusionsIntra-aneurysmal and parent vessel hemodynamic changes after FD can be reliably assessed by the cerebral angiography and transcranial doppler with important implications for the prediction of successful treatment.
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Affiliation(s)
- Radoslav Raychev
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
- *Correspondence: Radoslav Raychev
| | - Stanimir Sirakov
- Department of Radiology, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Alexander Sirakov
- Department of Radiology, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Hamidreza Saber
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Fernando Vinuela
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Reza Jahan
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - May Nour
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Viktor Szeder
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Geoffrey Colby
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, United States
| | - Gary Duckwiler
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Satoshi Tateshima
- Department of Radiology, University of California, Los Angeles, Los Angeles, CA, United States
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5
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Suzuki R, Takigawa T, Nariai Y, Hyodo A, Suzuki K. Comparison of Pipeline Embolization and Coil Embolization for the Treatment of Large Unruptured Paraclinoid Aneurysms. Neurol Med Chir (Tokyo) 2021; 62:97-104. [PMID: 34759071 PMCID: PMC8841233 DOI: 10.2176/nmc.oa.2021-0242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The efficacy of flow diversion (FD) in the treatment of paraclinoid aneurysms has been established. The pipeline embolization device (PED) is one of the most commonly used FD devices. Coil embolization is also useful for treating paraclinoid aneurysms. This study aimed to compare the efficacy and safety of PED treatment and coil embolization for large unruptured paraclinoid aneurysms. This was a single-center, retrospective study of large unruptured paraclinoid aneurysms treated endovascularly between 2009 and 2019 (coil embolization between 2009 and 2015, and PED between 2015 and 2019). Cases with a follow-up period of less than 1 year and recurrence after coil embolization were excluded. The treatment outcomes between coil embolization and PED were compared. We investigated 45 patients with 45 large unruptured paraclinoid aneurysms treated by endovascular surgery in our institution. Twenty-four patients were treated with coil embolization and 21 with PED. In the PED group, the device cost was significantly lower (2,770.4 ± 699.5 vs. 1941.2 ± 552.8 [1000 yen], P = 0.03), procedure duration was significantly shorter (155.4 ± 66.7 vs. 95.1 ± 35.4 min, P <0.01), and the numbers of re-treatments were lower than those in the coil embolization group (41.7 vs. 14.3%, P = 0.05). Both PED and coil embolization were effective and safe for large unruptured paraclinoid aneurysms, and their treatment results were similar. The PED is more beneficial because of its lower cost, shorter procedure duration, and fewer retreatments, and is therefore more useful for the treatment of large unruptured paraclinoid aneurysms.
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Affiliation(s)
- Ryotaro Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center
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6
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Wang T, Richard SA, Li J, Zhang C, Wang C, Lin S, He J, Xie X, You C. Outcomes of vascular wall malapposition following Pipeline Flex embolization device implantation for cerebral aneurysms: A retrospective study. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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7
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Wang T, Richard SA, Jiao H, Li J, Lin S, Zhang C, Wang C, Xie X, You C. Institutional experience of in-stent stenosis after pipeline flow diverter implantation: A retrospective analysis of 6 isolated cases out of 118 patients. Medicine (Baltimore) 2021; 100:e25149. [PMID: 33725998 PMCID: PMC7982244 DOI: 10.1097/md.0000000000025149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 02/22/2021] [Indexed: 02/05/2023] Open
Abstract
Pipeline embolization devices (PLEDs) are flow diverting stents that have exhibited be safe and efficient in the treatment of complex aneurysms. Nevertheless, in-stent stenosis (ISS) has been reported as one of the cardinal complications associated with PLED. The association of wall malapposition and ISS in patient treated with PLED has not been reported.A retrospective study was conducted to identify patients with ISS after implantation of PLED as treatment for intracranial aneurysms from April 25, 2018 to April 24, 2019. Incidence of ISS and its associated causes such as sharp change of the PLED, distal wall malapposition, inconsistent compliance between parent artery as well as the PLED occlusion due to intimal hyperplasia and vessel tortuosity. Assessment of conservative treatment and retreatment outcomes of ISS were documented.In all, 6 ISS cases were identified by 2 independent neurointerventionalists out of 118 aneurysm patients treated with PLED. Thus, the incidence rate of ISS in patients treated with PLED was as low as 5% at our institution compared to other studies. The follow-up time for detection of ISS ranged from 6 to 12 months after implantation. Several combinations of reasons such as sharp change of the PLED, distal wall malapposition, inconsistent compliance between parent arteries as well as PLED occlusion due to intimal hyperplasia and vessel tortuosity accounted for the causes of ISS during our analysis. Conservative treatment with a combination of antiplatelet during follow-ups did not resolve the ISS in our study probably due to associated underlying factors above.
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Affiliation(s)
- Ting Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
- Department of Medicine, Princefield University, P. O. Box MA 128, Ho-Volta Region, Ghana West Africa
| | - He Jiao
- Department of Radiology, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Junrao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Chaohua Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Xiaodong Xie
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, PR China
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8
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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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9
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Vakharia K, Waqas M, Shakir HJ, Chin F, Hartke JN, Shallwani H, Beecher JS, Siddiqui AH, Levy EI. Versatile use of catheter systems for deployment of the Pipeline embolization device: a comparison of biaxial and triaxial catheter systems. J Neurointerv Surg 2020; 12:585-590. [PMID: 31959632 DOI: 10.1136/neurintsurg-2019-015610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/10/2019] [Accepted: 12/15/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND A Pipeline embolization device (PED; Medtronic, Dublin, Ireland) can be deployed using either a biaxial or a triaxial catheter delivery system. OBJECTIVE To compare the use of these two catheter delivery systems for intracranial aneurysm treatment with the PED. METHODS A retrospective study of patients undergoing PED deployment with biaxial or triaxial catheter systems between 2014 and 2016 was conducted. Experienced neurointerventionalists performed the procedures. Patients who received multiple PEDs or adjunctive coils were excluded. The two groups were compared for PED deployment time, total fluoroscopy time, patient radiation exposure, complications, and cost. RESULTS Eighty-two patients with 89 intracranial aneurysms were treated with one PED each. In 49 cases, PEDs were deployed using biaxial access; triaxial access was used in 33 cases. Time (min) from guide catheter run to PED deployment was significantly shorter in the biaxial group (24.0±18.7 vs 38.4±31.1, P=0.006) as was fluoroscopy time (28.8±23.0 vs 50.3±27.1, P=0.001). Peak radiation skin exposure (mGy) in the biaxial group was less than in the triaxial group (1243.7±808.2 vs 2074.6±1505.6, P=0.003). No statistically significant differences were observed in transient and permanent complication rates or modified Rankin Scale scores at 30 days. The triaxial access system cost more than the biaxial access system (average $3285 vs $1790, respectively). Occlusion rates at last follow-up (mean 6 months) were similar between the two systems (average 88.1%: biaxial, 89.2%: triaxial). CONCLUSION Our results indicate near-equivalent safety and effectiveness between biaxial and triaxial approaches. Some reductions in cost and procedure time were noted with the biaxial system.
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Affiliation(s)
- Kunal Vakharia
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Hakeem J Shakir
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Felix Chin
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Joelle N Hartke
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Hussain Shallwani
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Jeffrey S Beecher
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA.,Departments of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA .,Departments of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
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10
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Lu P, Zhang Y, Niu H, Wang Y. Comparison of endovascular treatment for middle cerebral artery aneurysm with a low-profile visualized intraluminal support stent or pipeline embolization device. Exp Ther Med 2019; 18:2072-2078. [PMID: 31410163 PMCID: PMC6676140 DOI: 10.3892/etm.2019.7775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 04/12/2019] [Indexed: 11/10/2022] Open
Abstract
The aim of the present study was to evaluate the safety and effectiveness of low-profile visualized intraluminal support (LVIS) stent and the pipeline embolization device (PED) for middle cerebral artery (MCA) aneurysm treatment. Data of patients with MCA aneurysms who received endovascular treatment with LVIS stent or PED added to the hospital's database between August 2016 and March 2018 were retrospectively collected, and the clinical results and angiographic outcomes were evaluated. A total of 43 patients were included in the study, of whom 23 received LVIS stents and 20 received PED. The rate of complete occlusion was similar in the two groups at 6 months post-treatment (90.9 vs. 88.9%; P=0.832). Peri-operative complications were more frequent in the PED group; however, the LVIS group had more ischemic symptoms during the long-term follow-up. A larger aneurysm size (P=0.032) was associated with recanalization in the two groups. In conclusion, the LVIS stent and PED had acceptable rates of complete occlusion and aneurysm size was an independent predictor for recanalization. LVIS is more effective during the peri-operative period, while PED appears to have higher long-term safety.
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Affiliation(s)
- Peng Lu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Ye Zhang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Huanjiang Niu
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Yirong Wang
- Department of Neurosurgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
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11
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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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12
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Ravindra VM, Griauzde J, Scoville JP, Kilburg CJ, Wilkinson DA, Christensen C, Couldwell WT, Taussky P. Moderate Sedation for Pipeline Embolization of Posterior Circulation Disease: Technical Note from a Single Center. World Neurosurg 2018; 121:131-136. [PMID: 30273722 DOI: 10.1016/j.wneu.2018.09.167] [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: 03/26/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Flow diversion has been an important addition to endovascular neurosurgery, but its use in the posterior circulation remains controversial. Our goal is to describe the safety and efficacy of moderate sedation during flow diversion for posterior circulation lesions (aneurysms or dissecting pseudoaneurysms). METHODS The authors retrospectively reviewed the medical records of all patients who underwent placement of a Pipeline embolization device for a posterior circulation lesion using moderate sedation at a single institution from August 2012 through November 2017. Clinical data and outcomes were evaluated. RESULTS Fifteen consecutive patients were identified: 8 female, 7 male (mean age 52.2 ± 16.3 years, range 15-81). Eleven lesions were located in the vertebral artery, 1 in the posterior inferior cerebellar artery, 2 in the posterior cerebral artery, and 1 in the basilar artery. All patients underwent flow diversion with Pipeline embolization devices. One patient experienced an acute occlusion of the basilar artery during the procedure that required revascularization. Mean fluoroscopy time was 35.6 ± 16.5 minutes (range 15.5-75). Mean follow-up time was 12.7 ± 8.8 months (range 3-36). No patient had new neurologic deficits in the perioperative or postoperative period. Conversion to general anesthesia was not required in any case. CONCLUSIONS Moderate sedation is safe and feasible in patients undergoing flow diversion for posterior circulation lesions. In addition, its use may allow for more rapid identification of procedural complications, facilitating emergent treatment and decreasing procedure-related morbidity.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Julius Griauzde
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P Scoville
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Craig J Kilburg
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Clint Christensen
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
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13
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Saber H, Kherallah RY, Hadied MO, Kazemlou S, Chamiraju P, Narayanan S. Antiplatelet therapy and the risk of ischemic and hemorrhagic complications associated with Pipeline embolization of cerebral aneurysms: a systematic review and pooled analysis. J Neurointerv Surg 2018; 11:362-366. [PMID: 30201813 DOI: 10.1136/neurintsurg-2018-014082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Pipeline embolization devices (PEDs) are increasingly used in the treatment of cerebral aneurysms. Yet, major ischemic or hemorrhagic complications after PED treatment associated with antiplatelet regimens are not well-established. OBJECTIVE To investigate the risk of ischemic and hemorrhagic complications associated with common antiplatelet regimens following PED treatment, and to examine whether platelet function testing (PFT) is associated with a lower risk of these complications. METHODS We searched Medline, Embase, and Cochrane from 2009 to 2017. Twenty-nine studies were included that had reported a uniform antiplatelet regimen protocol and had provided data on major ischemic and hemorrhagic complications following PED treatment. Random-effect meta-analysis was used to pool overall ischemic and hemorrhagic event rates across studies. The rate of these complications with respect to the antithrombotic regimen and PFT was assessed by χ2 proportional tests. RESULTS Overall, 2002 patients (age 55.9 years, 76% female) were included. A low-dose acetylsalicylic acid (ASA) regimen before and after PED treatment was associated with a higher rate of late ischemic complications than with high-dose ASA therapy (2.62 (95% CI 1.46 to 4.69) and 2.56 (1.41 to 4.64), respectively). Duration of post-procedure clopidogrel therapy <6 months was associated with greater rates of ischemic complications (1.56, 95% CI 1.11 to 2.20) than a clopidogrel regimen of ≥6 months. Performing PFT before PED treatment was not associated with the risk of ischemic complications (1.27, 95% CI 0.77 to 2.10). CONCLUSION High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.
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Affiliation(s)
- Hamidreza Saber
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Riyad Y Kherallah
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mohamad O Hadied
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | - Parthasarathi Chamiraju
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sandra Narayanan
- Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, USA.,Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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14
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Beydoun HA, Azarbaijani Y, Cheng H, Anderson-Smits C, Marinac-Dabic D. Predicting Successful Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Through Meta-Regression. World Neurosurg 2018; 114:e938-e958. [DOI: 10.1016/j.wneu.2018.03.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
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15
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Delayed Posttreatment Residual Flow into Aneurysm After Flow Diverter Placement. World Neurosurg 2018; 116:205-208. [PMID: 29852305 DOI: 10.1016/j.wneu.2018.05.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/18/2018] [Accepted: 05/18/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Inflow into an aneurysm sac immediately following flow diverter (FD) treatment is an assumed cause of delayed aneurysmal rupture. The significance of delayed posttreatment residual flow occurring months after FD treatment is unknown. CASE DESCRIPTION A 76-year-old woman with a large intracranial aneurysm measuring 23.0 × 18.1 mm in the cavernous segment of the right internal carotid artery was treated with placement of a single FD (Pipeline Embolization Device, Covidien, Irvine, California, USA). Postprocedure digital subtraction angiography (DSA) demonstrated flow stagnation inside the aneurysm dome. The patient was discharged 9 days post procedure without new neurologic deficits. A 6-month follow-up DSA demonstrated delayed posttreatment residual flow into the aneurysm sac. Although she was scheduled for additional FD placement because of concern for aneurysmal rupture, the operation was not conducted due to an interim motor vehicle accident. Oral treatment with aspirin (100 mg/day) and clopidogrel (75 mg/day) was continued during her recovery. DSA performed 12 months post procedure showed that the aneurysm had completely thrombosed. CONCLUSIONS Our findings suggest that delayed post-treatment residual flow into an aneurysm may form part of the normal clinical course post FD placement and may not preclude eventual thrombosis of the aneurysm. Larger studies are needed to determine whether more frequent follow-up DSAs after FD placement are necessary and whether all patients exhibiting delayed post-treatment residual flow into an aneurysm require additional FD placement or if watchful waiting is a more suitable course.
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16
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Adeeb N, Gupta R, Schneider AM, Leadon M, Enriquez A, Griessenauer CJ, Salem M, Alturki A, Schmalz P, Ogilvy CS, Thomas AJ, Moore JM. Defining a Clopidogrel Response Cut-Off Value Using Light Transmission Aggregometry Before Pipeline Embolization of Unruptured Intracranial Aneurysms. World Neurosurg 2018; 113:e146-e152. [DOI: 10.1016/j.wneu.2018.01.198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
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17
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Delgado Almandoz JE, Kayan Y, Tenreiro A, Wallace AN, Scholz JM, Fease JL, Milner AM, Mulder M, Uittenbogaard KM, Tenreiro-Picón O. Clinical and angiographic outcomes in patients with intracranial aneurysms treated with the pipeline embolization device: intra-procedural technical difficulties, major morbidity, and neurological mortality decrease significantly with increased operator experience in device deployment and patient management. Neuroradiology 2017; 59:1291-1299. [PMID: 28986614 DOI: 10.1007/s00234-017-1930-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/19/2017] [Indexed: 12/31/2022]
Abstract
PURPOSE Flow diversion constitutes a pivotal advancement in endovascular intracranial aneurysm treatment, but requires development of a new skill set. The aim of this study is to determine whether outcomes after treatment with the Pipeline Embolization Device improve with experience. METHODS We retrospectively reviewed all patients with intracranial aneurysms treated with Pipeline at two centers over a 4.5-year period. Baseline patient and aneurysm characteristics, complications, and angiographic outcomes were analyzed. RESULTS One hundred forty patients underwent 150 Pipeline procedures to treat 167 intracranial aneurysms during the study period, 109 women, mean age 55.4 years. One hundred twenty-six aneurysms were ICA, mean size 10.2 mm and mean neck 6.4 mm. Intra-procedural technical difficulties were higher during the first 75 procedures compared with the subsequent 75 (13.3 vs 2.7%; p = 0.03), as combined major morbidity and neurological mortality (14.7 vs 4%; p = 0.046). In multivariate regression analysis, increased operator experience with Pipeline remained an independent predictor of intra-procedural technical difficulties (p = 0.02, odds ratio (OR) 0.015, 95% CI 0.0004-0.55) and combined major morbidity and neurological mortality (p = 0.03, OR 0.16, 95% CI 0.03-0.84). At last follow-up, 123 aneurysms were completely occluded (81.5%, mean 24 months). In our cohort, age ≤ 53 years was an independent predictor of complete aneurysm occlusion at last follow-up (p = 0.001, OR 0.92, 95% CI 0.88-0.97). Five aneurysms were retreated (3.3%). CONCLUSION The Pipeline embolization device is an effective treatment for intracranial aneurysms. The risk of intra-procedural technical difficulties and combined major morbidity and neurological mortality decreases significantly with increased operator experience in Pipeline deployment and patient management.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA.
| | - Yasha Kayan
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Andrea Tenreiro
- Division of Interventional Neuroradiology, Clínica El Ávila, Caracas, Venezuela
| | - Adam N Wallace
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jill M Scholz
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Jennifer L Fease
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Anna M Milner
- Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA
| | - Maximilian Mulder
- Division of Critical Care Medicine, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Kyle M Uittenbogaard
- Division of Neurological Surgery, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
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18
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Kilburg C, Taussky P, Kalani MYS, Park MS. Novel use of flow diversion for the treatment of aneurysms associated with arteriovenous malformations. Neurosurg Focus 2017; 42:E7. [PMID: 28565984 DOI: 10.3171/2017.2.focus1755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The use of flow-diverting stents for intracranial aneurysms has become more prevalent, and flow diverters are now routinely used beyond their initial scope of approval at the proximal internal carotid artery. Although flow diversion for the treatment of cerebral aneurysms is becoming more commonplace, there have been no reports of its use to treat flow-related cerebral aneurysms associated with arteriovenous malformations (AVMs). The authors report the cases of 2 patients whose AVM-associated aneurysms were managed with flow diversion. A 40-year-old woman presented with a history of headaches that led to the identification of an unruptured Spetzler-Martin Grade V, right parietooccipital AVM associated with 3 aneurysms of the ipsilateral internal carotid artery. Initial attempts at balloon-assisted coil embolization of the aneurysms were unsuccessful. The patient underwent placement of a flow-diverting stent across the diseased vessel; a 6-month follow-up angiogram demonstrated complete occlusion of the aneurysms. In the second case, a 57-year-old man presented with new-onset seizures, and an unruptured Spetzler-Martin Grade V, right frontal AVM associated with an irregular, wide-necked anterior communicating artery aneurysm was identified. The patient underwent placement of a flow-diverting stent, and complete occlusion of the aneurysm was observed on a 7-month follow-up angiogram. These 2 cases illustrate the potential for use of flow diversion as a treatment strategy for feeding artery aneurysms associated with AVMs. Because of the need for dual antiplatelet medications after flow diversion in this patient population, however, this strategy should be used judiciously.
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Affiliation(s)
- Craig Kilburg
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - M Yashar S Kalani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Min S Park
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
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19
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Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
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Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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20
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Valle-Giler EP, Atallah E, Tjoumakaris S, Rosenwasser RH, Jabbour P. Transcirculation Pipeline embolization device deployment: a rescue technique. Neurosurg Focus 2017; 42:E13. [DOI: 10.3171/2017.2.focus16485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) has become a very important tool in the treatment of nonruptured cerebral aneurysms. However, a patient’s difficult anatomy or vascular stenosis may affect the device delivery. The purpose of this article was to describe an alternate technique for PED deployment when ipsilateral anatomy is not amenable for catheter navigation.A 44-year-old woman with a symptomatic 6-mm right superior hypophyseal artery aneurysm and a known history of right internal carotid artery dissection presented for PED treatment of her aneurysm. An angiogram showed persistence of the arterial dissection with luminal stenosis after 6 months of dual antiplatelet treatment. The contralateral internal carotid artery was catheterized and the PED was deployed via a transcirculation approach, using the anterior communicating artery. Transcirculation deployment of a PED is a viable option when ipsilateral anatomy is difficult or contraindicated for this treatment.
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21
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Innovations in Endovascular Treatment Strategies for Large Carotid Cavernous Aneurysms—The Safety and Efficacy of a Flow Diverter. J Stroke Cerebrovasc Dis 2017; 26:1071-1080. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.12.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/24/2016] [Indexed: 11/21/2022] Open
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22
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Zhou G, Su M, Yin YL, Li MH. Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus 2017; 42:E17. [DOI: 10.3171/2017.3.focus16450] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to review the literature on the use of flow-diverting devices (FDDs) to treat intracranial aneurysms (IAs) and to investigate the safety and complications related to FDD treatment for IAs by performing a meta-analysis of published studies.METHODSA systematic electronic database search was conducted using the Springer, EBSCO, PubMed, Medline, and Cochrane databases on all accessible articles published up to January 2016, with no restriction on the publication year. Abstracts, full-text manuscripts, and the reference lists of retrieved articles were analyzed. Random-effects meta-analysis was used to pool the complication rates across studies.RESULTSSixty studies were included, which involved retrospectively collected data on 3125 patients. The use of FDDs was associated with an overall complication rate of 17.0% (95% confidence interval [CI] 13.6%–20.5%) and a low mortality rate of 2.8% (95% CI 1.2%–4.4%). The neurological morbidity rate was 4.5% (95% CI 3.2%–5.8%). No significant difference in the complication or mortality rate was observed between 2 commonly used devices (the Pipeline embolization device and the Silk flow-diverter device). A significantly higher overall complication rate was found in the case of ruptured IAs than in unruptured IA (odds ratio 2.3, 95% CI 1.2–4.3).CONCLUSIONSThe use of FDDs in the treatment of IAs yielded satisfactory results with regard to complications and the mortality rate. The risk of complications should be considered when deciding on treatment with FDDs. Further studies on the mechanism underlying the occurrence of adverse events are required.
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Affiliation(s)
- Geng Zhou
- 1Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai
| | - Ming Su
- 2Shandong Academy of Chinese Medicine, Lixia, Jinan; and
| | - Yan-Ling Yin
- 3Department of Anesthesiology, The Military General Hospital of Beijing PLA, Beijing, China
| | - Ming-Hua Li
- 1Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai
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23
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Potts MB, Shapiro M, Zumofen DW, Raz E, Nossek E, DeSousa KG, Becske T, Riina HA, Nelson PK. Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation. J Neurosurg 2017; 127:1333-1341. [PMID: 28059658 DOI: 10.3171/2016.9.jns152638] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO). METHODS The authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded. RESULTS Among 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented "delayed" PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy. CONCLUSIONS In this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large-necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.
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Affiliation(s)
- Matthew B Potts
- 1Departments of Neurological Surgery and Radiology, Division of Cerebrovascular/Neurointerventional Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Daniel W Zumofen
- 5Departments of Neurological Surgery and Radiology, Universitätsspital Basel, Switzerland
| | | | - Erez Nossek
- 6Department of Neurosurgery, Maimonides Medical Center, Brooklyn, New York; and
| | | | - Tibor Becske
- 7Department of Neurology, Rochester General Hospital, Rochester, New York
| | - Howard A Riina
- Departments of2Radiology.,4Neurological Surgery, Bernard and Irene Schwartz Neurointerventional Radiology Section, New York University Langone School of Medicine, New York, New York
| | - Peter K Nelson
- Departments of2Radiology.,4Neurological Surgery, Bernard and Irene Schwartz Neurointerventional Radiology Section, New York University Langone School of Medicine, New York, New York
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Gupta R, Moore JM, Griessenauer CJ, Adeeb N, Patel AS, Youn R, Poliskey K, Thomas AJ, Ogilvy CS. Assessment of Dual-Antiplatelet Regimen for Pipeline Embolization Device Placement: A Survey of Major Academic Neurovascular Centers in the United States. World Neurosurg 2016; 96:285-292. [DOI: 10.1016/j.wneu.2016.09.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/04/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
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Zanaty M, Daou B, Chalouhi N, Starke RM, Samaniego E, Derdeyn C, Jabbour P, Hasan D. Same-Day Discharge After Treatment with the Pipeline Embolization Device Using Monitored Anesthesia Care. World Neurosurg 2016; 96:31-35. [PMID: 27565476 DOI: 10.1016/j.wneu.2016.08.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The Pipeline Embolization Device (PED) has been used and shown to be safe under monitored anesthesia care (MAC). We present the results of the first study, to our knowledge, assessing the safety and feasibility of same-day discharge in patients undergoing treatment with the PED, using MAC. METHODS A total of 130 patients with 143 cerebral aneurysms (CAs) were identified. Patients were treated under MAC with the PED. All of the patients were counseled preoperatively about the elective nature of the procedure and the same-day discharge. RESULTS The mean age of the participants was 60.7 ± 12.12 years. Men constituted 27.69% (36/130) of the population. The number of procedures was 138. All of our patients elected to return home the same day, whereas only 6.15% (8/130) of them changed their mind in the postoperative setting and elected to stay overnight out of convenience (late discharge, patient preference, or living alone at home). Overall discharge home on the same day occurred after 90.6% of procedures (125/138) and in 91.53% (119/130) of the patients. All same-day discharges took place within 4-6 hours after the procedures. The rate of major complications was 0.75% (1/134). The mortality rate was 0%. CONCLUSIONS PED treatment under MAC is feasible and safe. This has brought forth an era of outpatient treatment of CAs where patients are discharged home 6 hours after the procedure.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Badih Daou
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Edgar Samaniego
- Department of Neurology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Colin Derdeyn
- Department of Radiology and Interventional Radiology, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, Iowa, USA.
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Daou B, Starke RM, Chalouhi N, Barros G, Tjoumakaris S, Rosenwasser RH, Jabbour P. P2Y12 Reaction Units: Effect on Hemorrhagic and Thromboembolic Complications in Patients With Cerebral Aneurysms Treated With the Pipeline Embolization Device. Neurosurgery 2016; 78:27-33. [PMID: 26571145 DOI: 10.1227/neu.0000000000000978] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The main concern with the use of the pipeline embolization device (PED) in treating cerebral aneurysms is the risk of hemorrhagic and thromboembolic complications. OBJECTIVE To investigate if P2Y12 reaction unit (PRU) values are associated with hemorrhagic and thromboembolic complications after treatment with the PED and to find an optimal range of preprocedural PRU values. METHODS Two hundred thirty-one patients with 248 cerebral aneurysms treated with the PED were retrospectively identified. Patients were started on dual-antiplatelet treatment at least 10 days before the intervention. PRU values were checked. Univariate and multivariate logistic regression were performed. Youden Indices were calculated to determine cutoffs for optimal PRU values. RESULTS Mean patient age was 57 years. Mean last preprocedural PRU was 132 (range: 1-382). The combined rate of major hemorrhagic complications (4%) and major thromboembolic complications (5.6%) was 9.6%. Analysis using Youden indices suggested an optimal PRU range of 70 to 150 with higher odds of complications outside this range (P = .01, odds ratio [OR] = 3 [1.2-7.5]). PRU <60 was a significant predictor of hemorrhagic complications (P = .04, OR = 2.45 [1.01-5.9]) and PRU >240 was a significant predictor of any thromboembolic complication (P = .04, OR = 3.6 [1.04-12]) and cerebral thromboembolic complications (P = .02, OR = 4 [1.2-14]). CONCLUSION Target preoperative PRU values should be between 60 and 240 and ideally between 70 and 150. Values below this range and above it carry higher odds of hemorrhagic and thromboembolic complications, respectively.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Raper DMS, Ding D, Peterson EC, Crowley RW, Liu KC, Chalouhi N, Hasan DM, Dumont AS, Jabbour P, Starke RM. Cavernous carotid aneurysms: a new treatment paradigm in the era of flow diversion. Expert Rev Neurother 2016; 17:155-163. [DOI: 10.1080/14737175.2016.1212661] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Daniel M. S. Raper
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eric C. Peterson
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
| | | | - Kenneth C. Liu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - David M. Hasan
- Department of Neurological Surgery, University of Iowa, Iowa City, IA, USA
| | - Aaron S. Dumont
- Department of Neurological Surgery, Tulane University, New Orleans, LA, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Miller School of Medicine, University of Miami Hospital, Jackson Memorial Hospital, Miami Children’s Hospital, Miami, FL, USA
- Department of Radiology, University of Miami Miller School of Medicine, University of Miami Hospital and Jackson Memorial Hospital, Miami, FL, USA
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Kim SO, Chung YG, Won YS, Rho MH. Delayed Ischemic Stroke after Flow Diversion of Large Posterior Communicating Artery Aneurysm. J Cerebrovasc Endovasc Neurosurg 2016; 18:19-26. [PMID: 27114962 PMCID: PMC4842904 DOI: 10.7461/jcen.2016.18.1.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/21/2015] [Accepted: 03/09/2016] [Indexed: 11/23/2022] Open
Abstract
For securing large, giant, and wide-neck aneurysms, conventional coil embolization has substantial limitations, such as incomplete occlusion, recanalization, and a high recurrence rate. To overcome these limitations, a novel paradigm was suggested and, as a result, flow-diverting device was developed. The flow-diverting device is an innovative and effective technique to allow securing of large, giant, and wide-neck aneurysms. In numerous studies, the flow-diverting device has shown better outcomes than coil embolization. However, the flow-diverting device has also some risks, including rupture of aneurysm, intracerebral hemorrhage, and ischemic stroke. In addition, with more experience, unexpected complications are also reported.5)7) In the present case, we experienced a delayed ischemic stroke at 27 days after endovascular treatment. The patient had multiple aneurysms and, among them, we treated a large posterior communicating artery aneurysm using Pipeline™ Embolization Device. The patient was tolerable for 25 days, but then suddenly presented intermittent right hemiparesis. In the initial diffusion magnetic resonance imaging (MRI), there was no acute lesion; however, in the follow-up MRI, an acute ischemic stroke was found in the territory of anterior choroidal artery which was covered by Pipeline Embolization Device. We suspect that neo-intimal overgrowth or a tiny thrombus have led to this delayed complication. Through our case, we learned that the neurosurgeon should be aware of the possibility of delayed ischemic stroke after flow diversion, as well as, long-term close observation and follow-up angiography are necessary even in the event of no acute complications.
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Affiliation(s)
- Si On Kim
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Yeon Gu Chung
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Yu Sam Won
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Myung Ho Rho
- Department of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
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Park MS, Kilburg C, Taussky P, Albuquerque FC, Kallmes DF, Levy EI, Jabbour P, Szikora I, Boccardi E, Hanel RA, Bonafé A, McDougall CG. Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry. AJNR Am J Neuroradiol 2016; 37:1127-31. [PMID: 26767709 DOI: 10.3174/ajnr.a4678] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/18/2015] [Indexed: 12/18/2022]
Abstract
Flow diversion to treat cerebral aneurysms has revolutionized neurointerventional surgery. Because the addition of coils potentially increases the time and complexity of endovascular procedures, we sought to determine whether adjunctive coil use is associated with an increase in complications. Patients in the International Retrospective Study of Pipeline Embolization Device registry were divided into those treated with the Pipeline Embolization Device alone (n = 689 patients; n = 797 aneurysms; mean aneurysm size, 10.3 ± 7.6 mm) versus those treated with the Pipeline Embolization Device and concurrent coil embolization (n = 104 patients; n = 109 aneurysms; mean aneurysm size, 13.6 ± 7.8 mm). Patient demographics and aneurysm characteristics were examined. Rates of neurologic morbidity and mortality were compared between groups. The Pipeline Embolization Device with versus without coiling required a significantly longer procedure time (135.8 ± 63.9 versus 96.7 ± 46.2 min; P < .0001) and resulted in higher neurological morbidity (12.5% versus 7.8%; P = .13). These data suggest that either strategy represents an acceptable risk profile in the treatment of complex cerebral aneurysms and warrants further investigation.
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Affiliation(s)
- M S Park
- From the Department of Neurosurgery (M.S.P., C.K., P.T.), University of Utah Health Care, Salt Lake City, Utah
| | - C Kilburg
- From the Department of Neurosurgery (M.S.P., C.K., P.T.), University of Utah Health Care, Salt Lake City, Utah
| | - P Taussky
- From the Department of Neurosurgery (M.S.P., C.K., P.T.), University of Utah Health Care, Salt Lake City, Utah
| | - F C Albuquerque
- Department of Neurosurgery (F.C.A., C.G.M.), Barrow Neurological Institute, Phoenix, Arizona
| | - D F Kallmes
- Department of Radiology (D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - E I Levy
- Department of Neurosurgery (E.I.L.), University of Buffalo, Buffalo, New York
| | - P Jabbour
- Department of Neurosurgery (P.J.), Thomas Jefferson University, Philadelphia, Pennsylvania
| | - I Szikora
- Department of Neurointerventions (I.S.), National Institute of Neurosciences, Budapest, Hungary
| | - E Boccardi
- Department of Neuroradiology (E.B.), Ospedale Niguarda Ca' Granda, Milan, Italy
| | - R A Hanel
- Department of Neurosurgery (R.A.H.), Baptist Health, Jacksonville, Florida
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui de Chauliac, Montpellier, France
| | - C G McDougall
- Department of Neurosurgery (F.C.A., C.G.M.), Barrow Neurological Institute, Phoenix, Arizona
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Rescue microsurgery with bypass and stent removal following Pipeline treatment of a giant internal carotid artery terminus aneurysm. Acta Neurochir (Wien) 2015; 157:2071-5. [PMID: 26429702 DOI: 10.1007/s00701-015-2593-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
Abstract
We report the microsurgical rescue and removal of a Pipeline stent embolization of a giant internal carotid artery terminus aneurysm. After the initial placement of a Pipeline Embolization Device (PED), it migrated proximally to the cavernous carotid with the distal end free in the middle of the aneurysm, resulting in only partial aneurysm neck coverage. The patient underwent microsurgical rescue with trapping, bypass, and opening of the aneurysm with PED removal. The vessel remained patent in the proximal segment previously covered by the Pipeline stent. Microsurgical rescue for definitive aneurysm treatment with PED removal can be safe and effective for aneurysms unsuccessfully treated with PED.
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31
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Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Hasan D, Khoury J, Rosenwasser RH, Jabbour P. Pipeline Embolization Device in the Treatment of Recurrent Previously Stented Cerebral Aneurysms. AJNR Am J Neuroradiol 2015; 37:849-55. [PMID: 26611991 DOI: 10.3174/ajnr.a4613] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 09/16/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The use of the Pipeline Embolization Device in the management of recurrent previously stented cerebral aneurysms is controversial. The aim of this study was to evaluate the efficacy and safety of the Pipeline Embolization Device in the treatment of recurrent, previously stented aneurysms. MATERIALS AND METHODS Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline Embolization Device with no prior stent placement (group 2). Occlusion at the latest follow-up angiogram, recurrence and retreatment rates, clinical outcome, complications, and morbidity and mortality observed after treatment with the Pipeline Embolization Device were analyzed. RESULTS Patient characteristics were similar between the 2 groups. The mean time from stent placement to recurrence was 25 months. Pipeline Embolization Device treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2 (P = .036). The retreatment rate in group 1 was 11.1% versus 7.1% in group 2 (P = .62). The rate of good clinical outcome at the latest follow-up in group 1 was 81% versus 93.2% in group 2 (P = .1). Complications were observed in 14.3% of patients in group 1 and 9.5% of patients in group 2 (P = .684). CONCLUSIONS The use of the Pipeline Embolization Device in the management of previously stented aneurysms is less effective than the use of this device in nonstented aneurysms. Prior stent placement can worsen the safety and efficacy profile of this device.
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Affiliation(s)
- B Daou
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - R M Starke
- Department of Neurological Surgery (R.M.S.), University of Virginia School of Medicine, Charlottesville, Virginia
| | - N Chalouhi
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - S Tjoumakaris
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - D Hasan
- Department of Neurosurgery (D.H.), University of Iowa, Iowa City, Iowa
| | - J Khoury
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - R H Rosenwasser
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - P Jabbour
- From the Department of Neurosurgery (B.D., N.C., S.T., J.K., R.H.R., P.J.), Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Raychev R, Tateshima S, Vinuela F, Sayre J, Jahan R, Gonzalez N, Szeder V, Duckwiler G. Predictors of thrombotic complications and mass effect exacerbation after pipeline embolization: The significance of adenosine diphosphate inhibition, fluoroscopy time, and aneurysm size. Interv Neuroradiol 2015; 22:34-41. [PMID: 26537850 DOI: 10.1177/1591019915609125] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/03/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The mechanisms leading to delayed rupture, distal emboli and intraparenchymal hemorrhage in relation to pipeline embolization device (PED) placement remain debatable and poorly understood. The aim of this study was to identify clinical and procedural predictors of these perioperative complications. METHODS We conducted a retrospective review of consecutive patients who underwent PED placement. We utilized a non-commercial platelet aggregation method measuring adenosine diphosphate (ADP)% inhibition for evaluation of clopidogrel response. To our knowledge, this is the first study to test ADP in neurovascular procedures. Multivariable regression analysis was used to identify the strongest predictor of three separate outcomes: (1) thrombotic complications, (2) hemorrhagic complications, and (3) aneurysm mass effect exacerbation RESULTS Permanent complication-related morbidity and mortality at 3 months was 6% (3/48). No specific predictors of hemorrhagic complications were identified. In the univariate analysis, the strongest predictors of thrombotic complications were: ADP% inhibition<49 (p=0.01), aneurysm size (p=0.04) and fluoroscopy time (p=0.002). In the final multivariate analysis, among all baseline variables, fluoroscopy time exceeding 52 min was the only factor associated with thrombotic complications (p=0.007). Aneurysm size≥18 mm was the single predictor of mass effect exacerbation (p=0.039). CONCLUSIONS Procedural complexity, reflected by fluoroscopy time, is the strongest predictor of thrombotic complications in this study. ADP% inhibition is a reliable method of testing clopidogrel response in neurovascular procedures and values of <50% may predict thrombotic complications. Interval mass effect exacerbation after PED placement may be anticipated in large aneurysms exceeding 18 mm.
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Zanaty M, Chalouhi N, Jabbour P, Starke RM, Hasan D. The unusual angiographic course of intracranial pseudoaneurysms. Asian J Neurosurg 2015; 10:327-30. [PMID: 26425168 PMCID: PMC4558815 DOI: 10.4103/1793-5482.162721] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Although rare, traumatic intracranial pseudoaneurysms remain one of the most difficult vascular lesions to diagnose and treat. A 55-year-old male patient underwent endoscopic endonasal transphenoidal resection for a pituitary macroadenoma. The operation was complicated by an arterial bleed. The initial angiogram revealed pseudoaneurysm of the anterior choroidal artery. Although the pseudoaneurysm completely disappeared on the second angiogram, it was surprisingly found to have enlarged on the third angiogram. The lesion was successfully treated with flow-diversion using a pipeline embolization device. The present case demonstrates that the natural history of iatrogenic pseudoaneurysms may be unpredictable and misleading. Traumatic pseudoaneurysms should, therefore, be carefully followed when conservative treatment is elected or when the lesion seems to have spontaneously regressed. Flow-diversion seems to be a reasonable treatment option.
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Affiliation(s)
- Mario Zanaty
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - David Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Durst CR, Starke RM, Clopton D, Hixson HR, Schmitt PJ, Gingras JM, Ding D, Liu KC, Crowley RW, Jensen ME, Evans AJ, Gaughen J. Endovascular treatment of ophthalmic artery aneurysms: ophthalmic artery patency following flow diversion versus coil embolization. J Neurointerv Surg 2015; 8:919-22. [PMID: 26354944 DOI: 10.1136/neurintsurg-2015-011887] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/20/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The Pipeline Embolization Device (PED) has been shown to effectively treat complex internal carotid artery aneurysms while maintaining patency of covered side branches. The purpose of this retrospective matched cohort study is to evaluate the effect of flow diversion on the patency of the ophthalmic artery when treating ophthalmic artery aneurysms. METHODS A retrospective review of our prospectively collected institutional database identified 19 ophthalmic artery aneurysms treated with a PED. These were matched according to aneurysm diameter in a 1:2 fashion to ophthalmic artery aneurysms treated via coil embolization, although it is important to note that there was a statistically significance difference in the neck diameter between the two groups (p=0.045). Clinical and angiographic outcomes were recorded and analyzed. RESULTS On follow-up angiography, decreased flow through the ophthalmic artery was observed in 26% of the PED cohort and 0% of the coil embolization cohort (p=0.003). No ophthalmologic complications were noted in either cohort. Complete occlusion at 12 months was more common following PED treatment than coil embolization (74% vs 47%; p=0.089), although lower than reported in previous trials. This may be due to inflow into the ophthalmic artery keeping the aneurysm patent. Retreatments were more common following coil embolization than PED (24% vs 11%), but this was not significant (p=0.304). Permanent morbidity rates were not significantly different between the PED (11%) and coil embolization (3%) cohorts (p=0.255). CONCLUSIONS Our results suggest that ophthalmic artery aneurysms may be adequately and safely treated with either the PED or coil embolization. However, treatment with the PED carries a higher risk of impeding flow to the ophthalmic artery, although this did not result in clinical sequelae in the current study.
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Affiliation(s)
- Christopher R Durst
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert M Starke
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David Clopton
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - H Robert Hixson
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Paul J Schmitt
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jean M Gingras
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth C Liu
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - R Webster Crowley
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mary E Jensen
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Avery J Evans
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John Gaughen
- Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
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Di Maria F, Pistocchi S, Clarençon F, Bartolini B, Blanc R, Biondi A, Redjem H, Chiras J, Sourour N, Piotin M. Flow Diversion versus Standard Endovascular Techniques for the Treatment of Unruptured Carotid-Ophthalmic Aneurysms. AJNR Am J Neuroradiol 2015; 36:2325-30. [PMID: 26272972 DOI: 10.3174/ajnr.a4437] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 04/17/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Over the past few years, flow diversion has been increasingly adopted for the treatment of intracranial aneurysms, especially in the paraclinoid and paraophthalmic carotid segment. We compared clinical and angiographic outcomes and complication rates in 2 groups of patients with unruptured carotid-ophthalmic aneurysms treated for 7 years by either standard coil-based techniques or flow diversion. MATERIALS AND METHODS From February 2006 to December 2013, 162 unruptured carotid-ophthalmic aneurysms were treated endovascularly in 138 patients. Sixty-seven aneurysms were treated by coil-based techniques in 61 patients. Flow diverters were deployed in 95 unruptured aneurysms (77 patients), with additional coiling in 27 patients. Complication rates, clinical outcome, and immediate and long-term angiographic results were retrospectively analyzed. RESULTS No procedure-related deaths occurred. Four procedure-related thromboembolic events (6.6%) leading to permanent morbidity in 1 case (1.6%) occurred in the coiling group. Neurologic complications were observed in 6 patients (7.8%) in the flow-diversion group, resulting in 3.9% permanent morbidity. No statistically significant difference was found between complication (P = .9) and morbidity rates (P = .6). In the coiling group (median follow-up, 31.5 ± 24.5 months), recanalization occurred at 1 year in 23/50 (54%) aneurysms and 27/55 aneurysms (50.9%) at the latest follow-up, leading to retreatment in 6 patients (9%). In the flow-diversion group (mean follow-up, 13.5 ± 10.8 months), 85.3% (35/41) of all aneurysms were occluded after 12 months, and 74.6% (50/67) on latest follow-up. The retreatment rate was 2.1%. Occlusion rates between the 2 groups differed significantly at 12 months (P < .001) and at the latest follow-up (P < .005). CONCLUSIONS Our retrospective analysis shows better long-term occlusion of carotid-ophthalmic aneurysms after use of flow diverters compared with standard coil-based techniques, without significant differences in permanent morbidity.
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Affiliation(s)
- F Di Maria
- From the Department of Neuroradiology (F.D.M., F.C., H.R., J.C., N.S.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - S Pistocchi
- Department of Neuroradiology (S.P., B.B., R.B., H.R., M.P.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - F Clarençon
- From the Department of Neuroradiology (F.D.M., F.C., H.R., J.C., N.S.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - B Bartolini
- Department of Neuroradiology (S.P., B.B., R.B., H.R., M.P.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - R Blanc
- Department of Neuroradiology (S.P., B.B., R.B., H.R., M.P.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - A Biondi
- Department of Neuroradiology (A.B.), Centre Hospitalier J. Minjoz, Besançon, France
| | - H Redjem
- From the Department of Neuroradiology (F.D.M., F.C., H.R., J.C., N.S.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France Department of Neuroradiology (S.P., B.B., R.B., H.R., M.P.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - J Chiras
- From the Department of Neuroradiology (F.D.M., F.C., H.R., J.C., N.S.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - N Sourour
- From the Department of Neuroradiology (F.D.M., F.C., H.R., J.C., N.S.), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - M Piotin
- Department of Neuroradiology (S.P., B.B., R.B., H.R., M.P.), Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
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Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Khoury J, Hasan D, Rosenwasser RH, Jabbour PM. The Use of the Pipeline Embolization Device in the Management of Recurrent Previously Coiled Cerebral Aneurysms. Neurosurgery 2015; 77:692-7; discission 697. [DOI: 10.1227/neu.0000000000000901] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The biggest downside of cerebral aneurysm coiling is the high rates of recurrence and retreatments. With the increasing number of aneurysm recurrences after failed coiling procedures, the best retreatment strategy remains unknown.
OBJECTIVE:
To assess the efficacy and safety of the Pipeline Embolization Device (PED) in the treatment of recurrent previously coiled aneurysms.
METHODS:
Thirty-three patients who underwent treatment with the PED of a recurrent previously coiled aneurysm were retrospectively identified. Efficacy was assessed in terms of angiographic occlusion at the latest cerebral angiogram, recurrence and retreatment rates after PED placement, and clinical outcome at the latest follow-up. Safety was assessed by looking at the complications, morbidity, and mortality after PED treatment.
RESULTS:
The mean patient age was 53 years. The mean percent recurrence from coiling to PED placement was 34%. The mean time from coiling to PED placement was 40 months. PED treatment resulted in complete aneurysm occlusion in 76.7% of patients and near-complete aneurysm occlusion (≥90%) in 10%, for a total rate of complete and near-complete aneurysm occlusion of 86.7%. All patients, including those with incomplete aneurysm occlusion, had a significant reduction in aneurysm size. Two aneurysms required another retreatment after PED placement (6.2%). Ninety-seven percent of patients had a good clinical outcome. Complications were observed in 1 patient (3%), who suffered an intracerebral hemorrhage. There were no mortalities.
CONCLUSION:
The use of the PED in the management of recurrent, previously coiled aneurysms is safe and effective in achieving aneurysm occlusion.
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Affiliation(s)
- Badih Daou
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jean Khoury
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa City, Iowa
| | | | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Nossek E, Chalif DJ, Chakraborty S, Lombardo K, Black KS, Setton A. Concurrent use of the Pipeline Embolization Device and coils for intracranial aneurysms: technique, safety, and efficacy. J Neurosurg 2015; 122:904-11. [PMID: 25658781 DOI: 10.3171/2014.12.jns141259] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The use of the Pipeline Embolization Device (PED) as a sole endovascular modality has been described for the treatment of brain aneurysms. The benefit of using coils concurrently with a limited number of PEDs is not well documented. The authors describe their experience with this technique as well as their midterm clinical and angiographic results. METHODS This is a retrospective review of patients treated between 2011 and 2014. The authors placed a minimal number of PEDs with the addition of coils using a "jailed" microcatheter technique. A partially dense coil mass was obtained. Immediate and midterm clinical and angiographic results are reviewed. RESULTS The authors treated 27 patients harboring 28 aneurysms using this technique. The mean aneurysm size was 11.9 mm, and the mean neck size was 5.4 mm. A mean of 1.48 PEDs were placed per patient, and a mean of 1.33 PEDs per aneurysm were placed. The Raymond score immediately after PED placement was 2 or 3 in 82.1% of the patients. There were no intraprocedural or postprocedural complications. All PEDs were successfully deployed. No clinical or technical adverse effects related to the coil mass were observed. There were no clinical or radiographic signs of ischemia in this group. At follow-up imaging, complete aneurysm occlusion was demonstrated on the first MR angiogram (3-5 months) in all patients who reached this milestone. Follow-up digital subtraction angiography (5-13 months) confirmed complete occlusion in all patients who reached this milestone. All patients maintained their baseline clinical status. CONCLUSIONS The deployment of PEDs with concurrent partially dense coiling is safe and efficacious. This technique achieved early complete occlusion and endovascular reconstruction of the parent vessel, without inducing mass effect. Favorable midterm clinical results were observed in all patients.
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Affiliation(s)
| | | | | | - Kim Lombardo
- 2Radiology, Hofstra North Shore–Long Island Jewish School of Medicine, and North Shore–Long Island Jewish Health System, Manhasset, New York
| | - Karen S. Black
- 2Radiology, Hofstra North Shore–Long Island Jewish School of Medicine, and North Shore–Long Island Jewish Health System, Manhasset, New York
| | - Avi Setton
- Departments of 1Neurosurgery and
- 2Radiology, Hofstra North Shore–Long Island Jewish School of Medicine, and North Shore–Long Island Jewish Health System, Manhasset, New York
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Skukalek SL, Winkler AM, Kang J, Dion JE, Cawley CM, Webb A, Dannenbaum MJ, Schuette AJ, Asbury B, Tong FC. Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis. J Neurointerv Surg 2014; 8:58-65. [DOI: 10.1136/neurintsurg-2014-011145] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 10/13/2014] [Indexed: 11/03/2022]
Abstract
PurposeThe pipeline embolization device (PED) necessitates dual antiplatelet therapy (APT) to decrease thrombotic complications while possibly increasing bleeding risks. The role of APT dose, duration, and response in patients with hemorrhagic and thromboembolic events warrants further analysis.MethodsA PubMed and Google Scholar search from 2009 to 2014 was performed using the following search terms individually or in combination: pipeline embolization device, aneurysm(s), and flow diversion, excluding other flow diverters. Review of the bibliographies of the retrieved articles yielded 19 single and multicenter studies. A statistical meta-analysis between aspirin (ASA) dose (low dose ≤160 mg, high dose ≥300 mg), loading doses of APT agents, post-PED APT regimens, and platelet function testing (PFT) with hemorrhagic or thrombotic complications was performed.ResultsASA therapy for ≤6 months post-PED was associated with increased hemorrhagic events. High dose ASA ≤6 months post-PED was associated with fewer thrombotic events compared with low dose ASA. Post-PED clopidogrel for ≤6 months demonstrated an increased incidence of symptomatic thrombotic events. Loading doses of ASA plus clopidogrel demonstrated a decreased incidence of permanent symptomatic hemorrhagic events. PFT did not show a statistically significant relationship with symptomatic hemorrhagic or thrombotic complications.ConclusionsHigh dose ASA >6 months is associated with fewer permanent thrombotic and hemorrhagic events. Clopidogrel therapy ≤6 months is associated with higher rates of thrombotic events. Loading doses of ASA and clopidogrel were associated with a decreased incidence of hemorrhagic events. PFT did not have any significant association with symptomatic events.
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Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafé A, Cekirge S, Fiorella D, Jabbour P, Levy E, McDougall C, Siddiqui A, Szikora I, Woo H, Albuquerque F, Bozorgchami H, Dashti SR, Delgado Almandoz JE, Kelly ME, Turner R, Woodward BK, Brinjikji W, Lanzino G, Lylyk P. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 2014; 36:108-15. [PMID: 25355814 DOI: 10.3174/ajnr.a4111] [Citation(s) in RCA: 408] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine neurologic complication rates following Pipeline Embolization Device placement for intracranial aneurysm treatment in a real-world setting. MATERIALS AND METHODS We retrospectively evaluated all patients with intracranial aneurysms treated with the Pipeline Embolization Device between July 2008 and February 2013 in 17 centers worldwide. We defined 4 subgroups: internal carotid artery aneurysms of ≥10 mm, ICA aneurysms of <10 mm, other anterior circulation aneurysms, and posterior circulation aneurysms. Neurologic complications included spontaneous rupture, intracranial hemorrhage, ischemic stroke, permanent cranial neuropathy, and mortality. Comparisons were made with t tests or ANOVAs for continuous variables and the Pearson χ(2) or Fisher exact test for categoric variables. RESULTS In total, 793 patients with 906 aneurysms were included. The neurologic morbidity and mortality rate was 8.4% (67/793), highest in the posterior circulation group (16.4%, 9/55) and lowest in the ICA <10-mm group (4.8%, 14/294) (P = .01). The spontaneous rupture rate was 0.6% (5/793). The intracranial hemorrhage rate was 2.4% (19/793). Ischemic stroke rates were 4.7% (37/793), highest in patients with posterior circulation aneurysms (7.3%, 4/55) and lowest in the ICA <10-mm group (2.7%, 8/294) (P = .16). Neurologic mortality was 3.8% (30/793), highest in the posterior circulation group (10.9%, 6/55) and lowest in the anterior circulation ICA <10-mm group (1.4%, 4/294) (P < .01). CONCLUSIONS Aneurysm treatment with the Pipeline Embolization Device is associated with the lowest complication rates when used to treat small ICA aneurysms. Procedure-related morbidity and mortality are higher in the treatment of posterior circulation and giant aneurysms.
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Affiliation(s)
- D F Kallmes
- From the Department of Radiology (D.F.K., W.B., G.L.), Mayo Clinic, Rochester, Minnesota
| | - R Hanel
- Department of Neurosurgery (R.H.), Mayo Clinic, Jacksonville, Florida
| | - D Lopes
- Department of Neurological Surgery (D.L.), Rush University Medical Center, Chicago, Illinois
| | - E Boccardi
- Department of Neuroradiology (E.B.), Niguarda CA' Granda Hospital, Milan, Italy
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui de Chauliac, Montpellier, France
| | - S Cekirge
- Department of Radiology (S.C.), Hacettepe University Hospitals, Ankara, Turkey
| | - D Fiorella
- Department of Neurological Surgery (D.F., H.W.), Stony Brook University Medical Center, Stony Brook, New York
| | - P Jabbour
- Department of Neurosurgery (P.J.), Thomas Jefferson University, Philadelphia, Pennsylvania
| | - E Levy
- Department of Neurosurgery (E.L., A.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - C McDougall
- Department of Neurosurgery (C.M., F.A.), Barrow Neurological Associates, Phoenix, Arizona
| | - A Siddiqui
- Department of Neurosurgery (E.L., A.S.), University at Buffalo, State University of New York, Buffalo, New York
| | - I Szikora
- National Institute of Neurosciences (I.S.), Budapest, Hungary
| | - H Woo
- Department of Neurological Surgery (D.F., H.W.), Stony Brook University Medical Center, Stony Brook, New York
| | - F Albuquerque
- Department of Neurosurgery (C.M., F.A.), Barrow Neurological Associates, Phoenix, Arizona
| | - H Bozorgchami
- Department of Neurology (H.B.), Oregon Health and Science University, Portland, Oregon
| | - S R Dashti
- Norton Neuroscience Institute (S.R.D.), Louisville, Kentucky
| | - J E Delgado Almandoz
- Department of Radiology (J.E.D.A.), Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - M E Kelly
- Division of Neurosurgery, Department of Surgery (M.E.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - R Turner
- Department of Neurosciences (R.T.), Medical University of South Carolina, Charleston, South Carolina
| | - B K Woodward
- Vista Radiology PC (B.K.W.), Knoxville, Tennessee
| | - W Brinjikji
- From the Department of Radiology (D.F.K., W.B., G.L.), Mayo Clinic, Rochester, Minnesota
| | - G Lanzino
- From the Department of Radiology (D.F.K., W.B., G.L.), Mayo Clinic, Rochester, Minnesota
| | - P Lylyk
- Department of Neuroscience (P.L.), Equipo de Neurocirugía Endovascular Radiología Intervencionista, Buenos Aires, Argentina
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Intra-aneurysmal thrombus modification after flow-diversion. J Clin Neurosci 2014; 22:105-10. [PMID: 25192591 DOI: 10.1016/j.jocn.2014.05.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 05/28/2014] [Indexed: 11/22/2022]
Abstract
Flow diversion has been successfully used to treat large and giant intracranial aneurysms that present with mass effect. We conducted a retrospective review, evaluating the modification of thrombi in this aneurysm type after treatment with the Pipeline Embolization Device (ev3 Endovascular, Plymouth, MN, USA) and the effects of these modifications on symptoms. Eight patients, seven of whom were female, harbored eight partially thrombosed large or giant aneurysms. Five of the eight aneurysms presented with symptomatic mass effect. At 1 year follow-up, complete occlusion occurred in 75% (6/8) of patients. On average, the longest thrombus diameter measured 22.31 mm before treatment and 14.05 mm 1 year afterwards. Seven of the eight thrombi regressed, as did their aneurysms. All six patients with shrunken thrombi had tremendous symptom improvement and became asymptomatic in the following year. The current findings seem to reflect the size variation of the intra-aneurysmal thrombus rather than the size of the aneurysm itself.
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Chalouhi N, Bovenzi CD, Thakkar V, Dressler J, Jabbour P, Starke RM, Teufack S, Gonzalez LF, Dalyai R, Dumont AS, Rosenwasser R, Tjoumakaris S. Long-term catheter angiography after aneurysm coil therapy: results of 209 patients and predictors of delayed recurrence and retreatment. J Neurosurg 2014; 121:1102-6. [PMID: 25192480 DOI: 10.3171/2014.7.jns132433] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. The need for long-term imaging follow-up was recently investigated. This study assessed the diagnostic yield of long-term digital subtraction angiography (DSA) follow-up and determined predictors of delayed aneurysm recurrence and retreatment. METHODS Inclusion criteria were as follows: 1) available short-term and long-term (> 36 months) follow-up DSA images, and 2) no or only minor aneurysm recurrence (not requiring further intervention, i.e., < 20%) documented on short-term follow-up DSA images. RESULTS Of 209 patients included in the study, 88 (42%) presented with subarachnoid hemorrhage. On shortterm follow-up DSA images, 158 (75%) aneurysms showed no recurrence, and 51 (25%) showed minor recurrence (< 20%, not retreated). On long-term follow-up DSA images, 124 (59%) aneurysms showed no recurrence, and 85 (41%) aneurysms showed recurrence, of which 55 (26%) required retreatment. In multivariate analysis, the predictors of recurrence on long-term follow-up DSA images were as follows: 1) larger aneurysm size (p = 0.001), 2) male sex (p = 0.006), 3) conventional coil therapy (p = 0.05), 4) aneurysm location (p = 0.01), and 5) a minor recurrence on short-term follow-up DSA images (p = 0.007). Ruptured aneurysm status was not a predictive factor. The sensitivity of short-term follow-up DSA studies was only 40.0% for detecting delayed aneurysm recurrence and 45.5% for detecting delayed recurrence requiring further treatment. CONCLUSIONS The results of this study highlight the importance of long-term angiographic follow-up after coil therapy for ruptured and unruptured intracranial aneurysms. Predictors of delayed recurrence and retreatment include large aneurysms, recurrence on short-term follow-up DSA images (even minor), male sex, and conventional coil therapy.
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Affiliation(s)
- Nohra Chalouhi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Cory D. Bovenzi
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Vismay Thakkar
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Jeremy Dressler
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert M. Starke
- 2Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Sonia Teufack
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - L. Fernando Gonzalez
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Richard Dalyai
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Aaron S. Dumont
- 3Department of Neurological Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Robert Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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Chalouhi N, Zanaty M, Jabbour PM, Starke RM, Tjoumakaris SI, Rosenwasser RH, Gonzalez LF. Intracerebral hemorrhage after pipeline embolization: Management of antiplatelet agents and the case for point-of-care testing—Case reports and review of literature. Clin Neurol Neurosurg 2014; 124:21-4. [DOI: 10.1016/j.clineuro.2014.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/28/2014] [Accepted: 06/14/2014] [Indexed: 10/25/2022]
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Brasiliense LB, Hanel RA. Pipeline Embolization Device: Lessons Learned After 1000 Aneurysms. World Neurosurg 2014; 82:248-50. [DOI: 10.1016/j.wneu.2014.06.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Zanaty M, Chalouhi N, Starke RM, Barros G, Saigh MP, Schwartz EW, Ajiboye N, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P. Flow Diversion Versus Conventional Treatment for Carotid Cavernous Aneurysms. Stroke 2014; 45:2656-61. [DOI: 10.1161/strokeaha.114.006247] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mario Zanaty
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Nohra Chalouhi
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Robert M. Starke
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Guilherme Barros
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Mark Philip Saigh
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Eric Winthrop Schwartz
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Norman Ajiboye
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Stavropoula I. Tjoumakaris
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - David Hasan
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Robert H. Rosenwasser
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
| | - Pascal Jabbour
- From the Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA (M.Z., N.C., G.B., M.P.S., E.W.S., N.A., S.I.T., R.H.R., P.J.); Department of Neurosurgery, University of Virginia, Charlottesville (R.M.S.); and Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City (D.H.)
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Tanweer O, Raz E, Brunswick A, Zumofen D, Shapiro M, Riina HA, Fouladvand M, Becske T, Nelson PK. Cavernous carotid aneurysms in the era of flow diversion: a need to revisit treatment paradigms. AJNR Am J Neuroradiol 2014; 35:2334-40. [PMID: 25147199 DOI: 10.3174/ajnr.a4081] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Recent techniques of endoluminal reconstruction with flow-diverting stents have not been incorporated into treatment algorithms for cavernous carotid aneurysms. This study examines the authors' institutional experience and a systematic review of the literature for outcomes and complications using the Pipeline Embolization Device in unruptured cavernous carotid aneurysms. MATERIALS AND METHODS A retrospective search for cavernous carotid aneurysms from a prospectively collected data base of aneurysms treated with the Pipeline Embolization Device at our institution was performed. Baseline demographic, clinical, and laboratory values; intrainterventional data; and data at all follow-up visits were collected. A systematic review of the literature for complication data was performed with inquiries sent when clarification of data was needed. RESULTS Forty-three cavernous carotid aneurysms were included in the study. Our mean radiographic follow-up was 2.05 years. On last follow-up, 88.4% of the aneurysms treated had complete or near-complete occlusion. Aneurysm complete or near-complete occlusion rates at 6 months, 12 months, and 36 months were 81.4%, 89.7%, and 100%, respectively. Of patients with neuro-ophthalmologic deficits on presentation, 84.2% had improvement in their visual symptoms. Overall, we had a 0% mortality rate and a 2.3% major neurologic complication rate. Our systematic review of the literature yielded 227 cavernous carotid aneurysms treated with the Pipeline Embolization Device with mortality and morbidity rates of 0.4% and 3.1%, respectively. CONCLUSIONS Endoluminal reconstruction with flow diversion for large unruptured cavernous carotid aneurysms can yield high efficacy with low complications. Further long-term data will be helpful in assessing the durability of the cure; however, we advocate a revisiting of current management paradigms for cavernous carotid aneurysms.
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Affiliation(s)
- O Tanweer
- From the Departments of Neurosurgery (O.T., A.B., D.Z., P.K.N.)
| | - E Raz
- Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.)
| | - A Brunswick
- From the Departments of Neurosurgery (O.T., A.B., D.Z., P.K.N.)
| | - D Zumofen
- From the Departments of Neurosurgery (O.T., A.B., D.Z., P.K.N.) Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.)
| | - M Shapiro
- Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.)
| | - H A Riina
- Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.)
| | - M Fouladvand
- Neurology (M.F., T.B., P.K.N.), New York University School of Medicine, New York, New York
| | - T Becske
- Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.) Neurology (M.F., T.B., P.K.N.), New York University School of Medicine, New York, New York
| | - P K Nelson
- From the Departments of Neurosurgery (O.T., A.B., D.Z., P.K.N.) Radiology (E.R., D.Z., M.S., H.A.R., T.B., P.K.N.) Neurology (M.F., T.B., P.K.N.), New York University School of Medicine, New York, New York.
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Chitale R, Zanaty M, Chalouhi N, Jabbour P, Rosenwasser RH, Tjoumakaris S. Immediate aneurysm rupture after pipeline embolization: a new complication of flow diversion. Clin Neurol Neurosurg 2014; 124:188-91. [PMID: 25087041 DOI: 10.1016/j.clineuro.2014.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 07/04/2014] [Accepted: 07/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Rohan Chitale
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Mario Zanaty
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, USA
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Albuquerque FC, Park MS, Abla AA, Crowley RW, Ducruet AF, McDougall CG. A reappraisal of the Pipeline embolization device for the treatment of posterior circulation aneurysms. J Neurointerv Surg 2014; 7:641-5. [DOI: 10.1136/neurintsurg-2014-011340] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 07/25/2014] [Indexed: 11/04/2022]
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Rodriguez JN, Hwang W, Horn J, Landsman TL, Boyle A, Wierzbicki MA, Hasan SM, Follmer D, Bryant J, Small W, Maitland DJ. Design and biocompatibility of endovascular aneurysm filling devices. J Biomed Mater Res A 2014; 103:1577-94. [PMID: 25044644 DOI: 10.1002/jbm.a.35271] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/01/2014] [Accepted: 06/12/2014] [Indexed: 12/13/2022]
Abstract
The rupture of an intracranial aneurysm, which can result in severe mental disabilities or death, affects approximately 30,000 people in the United States annually. The traditional surgical method of treating these arterial malformations involves a full craniotomy procedure, wherein a clip is placed around the aneurysm neck. In recent decades, research and device development have focused on new endovascular treatment methods to occlude the aneurysm void space. These methods, some of which are currently in clinical use, utilize metal, polymeric, or hybrid devices delivered via catheter to the aneurysm site. In this review, we present several such devices, including those that have been approved for clinical use, and some that are currently in development. We present several design requirements for a successful aneurysm filling device and discuss the success or failure of current and past technologies. We also present novel polymeric-based aneurysm filling methods that are currently being tested in animal models that could result in superior healing.
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Affiliation(s)
- Jennifer N Rodriguez
- Department of Biomedical Engineering, Texas A&M University, 3120 TAMU, College Station, Texas, 77843
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Rosenwasser RH, Chalouhi N, Tjoumakaris S, Jabbour P. Open vs Endovascular Approach to Intracranial Aneurysms. Neurosurgery 2014; 61 Suppl 1:121-9. [DOI: 10.1227/neu.0000000000000377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Robert H. Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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50
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Gandhi CD, Bulsara KR, Fifi J, Kass-Hout T, Grant RA, Delgado Almandoz JE, English J, Meyers PM, Abruzzo T, Prestigiacomo CJ, Powers CJ, Lee SK, Albani B, Do HM, Eskey CJ, Patsalides A, Hetts S, Hussain MS, Ansari SA, Hirsch JA, Kelly M, Rasmussen P, Mack W, Pride GL, Alexander MJ, Jayaraman MV. Platelet function inhibitors and platelet function testing in neurointerventional procedures: Table 1. J Neurointerv Surg 2014; 6:567-77. [DOI: 10.1136/neurintsurg-2014-011357] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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