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Zoppo CT, Mocco J, Manning NW, Bogdanov AA, Gounis MJ. Surface modification of neurovascular stents: from bench to patient. J Neurointerv Surg 2024; 16:908-913. [PMID: 37793794 DOI: 10.1136/jnis-2023-020620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
Flow-diverting stents (FDs) for the treatment of cerebrovascular aneurysms are revolutionary. However, these devices require systemic dual antiplatelet therapy (DAPT) to reduce thromboembolic complications. Given the risk of ischemic complications as well as morbidity and contraindications associated with DAPT, demonstrating safety and efficacy for FDs either without DAPT or reducing the duration of DAPT is a priority. The former may be achieved by surface modifications that decrease device thrombogenicity, and the latter by using coatings that expedite endothelial growth. Biomimetics, commonly achieved by grafting hydrophilic and non-interacting polymers to surfaces, can mask the device surface with nature-derived coatings from circulating factors that normally activate coagulation and inflammation. One strategy is to mimic the surfaces of innocuous circulatory system components. Phosphorylcholine and glycan coatings are naturally inspired and present on the surface of all eukaryotic cell membranes. Another strategy involves linking synthetic biocompatible polymer brushes to the surface of a device that disrupts normal interaction with circulating proteins and cells. Finally, drug immobilization can also impart antithrombotic effects that counteract normal foreign body reactions in the circulatory system without systemic effects. Heparin coatings have been explored since the 1960s and used on a variety of blood contacting surfaces. This concept is now being explored for neurovascular devices. Coatings that improve endothelialization are not as clinically mature as anti-thrombogenic coatings. Coronary stents have used an anti-CD34 antibody coating to capture circulating endothelial progenitor cells on the surface, potentially accelerating endothelial integration. Similarly, coatings with CD31 analogs are being explored for neurovascular implants.
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Affiliation(s)
- Christopher T Zoppo
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - J Mocco
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathan W Manning
- The MIRI Centre, Ingham Institute for Applied Medical Science, Sydney, New South Wales, Australia
- Department of Interventional Radiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Alexei A Bogdanov
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Senol YC, Orscelik A, Bilgin C, Kobeissi H, Ghozy S, Arul S, Kallmes DF, Kadirvel R. Pipeline versus non-pipeline flow diverter treatment for M1 aneurysms: A systematic review and meta-analysis. Neuroradiol J 2024:19714009241260805. [PMID: 39033417 DOI: 10.1177/19714009241260805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The flow diversion treatment of aneurysms located distal to the Circle of Willis has recently increased in frequency. We conducted a systematic review and meta-analysis of the clinical and radiological outcomes of flow diverter (FD) embolization in treating M1 aneurysms. METHODS PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to May 2024 using the Nested Knowledge platform. We included studies assessing the long-term clinical and radiological outcomes for M1 aneurysms. Results of FDs classified as Pipeline Embolization Devices (PED) versus other types of FDs. Angiographic occlusion rates, ischemic and hemorrhagic complications, and favorable clinic outcomes were included. All data were analyzed using R software version 4.2.2. RESULTS Thirteen studies with 112 total patients (58 patients for PED and 54 patients for other FD devices) were included in our meta-analysis. The overall adequate (complete + near-complete) occlusion rates were 85.1%. The complete occlusion rate was higher with PED than with other FD devices (72.9% PED and 41.6% for non-PED FDs, respectively, p-value <.01). The ischemic complications were 9.9% and 9.0% for the PED and non-PED groups, respectively (p-value = .89). The overall modified Rankin Scale 0-2 was 100% for the non-PED and 97.1% for the PED group (p-value = .51). In-stent stenosis rate was 7.5% for PED devices compared to 2.6% in the non-PED group (p-value = .35). CONCLUSIONS This relatively small meta-analysis showed high rates of adequate and complete occlusion in FD treatment of M1 segment aneurysms, with favorable safety profiles. PEDs were associated with higher rates of complete aneurysm occlusion compared to other types of FDs.
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Affiliation(s)
- Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Ramirez-Velandia F, Enriquez-Marulanda A, Young M, Orrego-González E, Filo J, Fodor TB, Sconzo D, Shutran M, Ogilvy CS, Taussky P. Thromboembolic Events After the Coverage of Anterior Cerebral Artery with Flow Diversion: A Single Institution Series and Systematic Review. World Neurosurg 2024; 187:e1040-e1053. [PMID: 38754548 DOI: 10.1016/j.wneu.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | | | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eduardo Orrego-González
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Young M, Fodor TB, Sconzo D, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. Thromboembolic Events in the Posterior Circulation After Flow Diversion-A Closer Look at Coverage of the Posterior Cerebral Artery. World Neurosurg 2024; 187:e920-e928. [PMID: 38734173 DOI: 10.1016/j.wneu.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). METHODS This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. CONCLUSIONS The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Amoukhteh M, Hassankhani A, Jannatdoust P, Valizadeh P, Ghozy S, Bilgin C, Kallmes DF. Comparative meta-analysis of endovascular strategies for intracranial dissecting aneurysms: Flow diverters versus stents with or without coiling. Interv Neuroradiol 2024:15910199241262070. [PMID: 38873695 DOI: 10.1177/15910199241262070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Intracranial dissecting aneurysms present a challenging subset linked to considerable morbidity and mortality, necessitating effective therapeutic strategies to prevent complications. Traditional treatments face technical limitations, while emerging endovascular modalities like stent-assisted coiling, multiple stenting, and flow-diverting devices (FDDs) offer promise in reducing periprocedural risks and enhancing patient outcomes. The aim of this study is to compare the safety and efficacy outcomes of endovascular treatment for intracranial dissecting aneurysms using FDDs versus stents (with or without coiling). METHODS A systematic review and meta-analysis were conducted following established guidelines. The search included PubMed, Scopus, Web of Science, and Embase databases up to July 30, 2023. Eligible studies reporting outcomes of interest in both FDD and stent-treated groups were included, and the data was extracted and analyzed using STATA software. RESULTS Six studies were analyzed, involving 131 patients in the FDD group and 199 patients in the stent group. The pooled rates for favorable functional outcomes (86.8% vs. 86%), mortality (3.9% vs. 6%), adequate occlusion (79.7% vs. 86.3%), aneurysm recurrence (1.3% vs. 13.3%), in-stent stenosis/thrombosis (7% vs. 6.9%), ischemic events/infarctions (6.7% vs. 7.8%), retreatment (7% vs. 8.6%), and technical success (100% vs. 98.7%) were comparable in individuals treated with FDDs and stents (p > 0.05 in all cases). Additionally, complete occlusion rates were not significantly different between FDD (62.7%) and stent-treated patients (75.2%) (p = 0.06). However, after excluding one study in a leave-one-out analysis of the random effects meta-analysis, a significant difference in the pooled rates of this outcome was observed between the FDD (59.2%) and stent (75.2%) groups (p = 0.034). CONCLUSION FDDs present a promising approach for the treatment of intracranial dissecting aneurysms, yielding outcomes that are roughly comparable to stent-based methods. However, the absence of randomized trials and data limitations highlight the need for further research to enhance treatment strategies.
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Affiliation(s)
- Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | | | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Mosteiro A, Pedrosa L, Codes M, Reyes L, Werner M, Amaro S, Enseñat J, Rodríguez-Hernández A, Aalbers M, Boogaarts J, Torné R. Microsurgical and endovascular treatment of large and giant aneurysms of the anterior circulation: A systematic review. BRAIN & SPINE 2024; 4:102838. [PMID: 39071454 PMCID: PMC11279635 DOI: 10.1016/j.bas.2024.102838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 07/30/2024]
Abstract
Introduction Large and Giant intracranial aneurysms (LGIAs) have become the paradigm for which endovascular techniques do not provide satisfactory results. Yet, microsurgery is followed by non-negligible rates of morbimortality. This scenario may have changed since the introduction of flow-diversion devices. Research question Contemporary and standardised revision on microsurgical and endovascular results, with emphasis on anterior circulation LGIAs. Materials and methods A systematic literature search was conducted in two databases (PubMed and Embase) on treatment outcomes of LGIAs of the anterior circulation, after the introduction of flow-diverters 2008/01/01, till 2023/05/20. Small case series (<5 cases), series including >15% of posterior circulation aneurysms, and studies not reporting clinical and/or angiographic outcomes were excluded. Results 44 relevant studies (observational cohorts) were identified, including 2923 LGIAs predominantly from anterior circulation. Mean follow-up 22 (±20) months. 1494 (51%) LGIAs were treated endovascularly and 1427 (49%) microsurgically. According to the random effects model, pooled rates of favourable clinical outcomes were 85.8% (CI 95% 82.6-88.4), complete occlusion 69.4% (CI 95% 63.7-7.46), complications 19.6% (CI 95%16-23.9) and mortality 5.6% (CI 95% 4.4-7.1). Focusing on type of treatment, occlusion rates are higher with microsurgical (842/993, 85% vs 874/1,299, 67%), although good outcomes are slightly more frequent with endovascular (1045/1,135, 92% vs 1120/1,294, 87%). Discussion and conclusions According to contemporary data about occlusion rates, functional outcomes, and complications, primary or secondary treatment of LGIAs of the anterior circulation seems justified. Microsurgical occlusion rates are higher in LGIAs. An expert consensus on reporting complications and management strategies is warranted.
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Affiliation(s)
- Alejandra Mosteiro
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Leire Pedrosa
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | - Marta Codes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Luís Reyes
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Mariano Werner
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sergio Amaro
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Comprehensive Stroke Unit, Neurology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Joaquim Enseñat
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
| | | | - Marlien Aalbers
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Jeroen Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Gelderland, the Netherlands
| | - Ramon Torné
- Department of Neurosurgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
- IDIBAPS Biomedical Research Institute, Barcelona, Spain
- Interventional Neuroradiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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Senol YC, Orscelik A, Bilgin C, Kobeissi H, Ghozy S, Arul S, Kallmes DF, Kadirvel R. Safety and efficacy profile of off-label use of the Pipeline Embolization Device: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107586. [PMID: 38242183 PMCID: PMC10939757 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE The off-label utilization of the Pipeline Embolization Device (PED) is a common practice in numerous medical centers globally. Therefore, we conducted a systematic review and meta-analysis to evaluate the overall outcomes of this off-label usage of PEDs. METHODS PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to February 2023 using the Nested Knowledge platform to identify studies assessing the off-label use of PEDs. Any use of PED outside of the FDA-approved indication granted in 2018 is considered off-label use. Overall angiographic occlusion rates, ischemic and hemorrhagic complications, mortality, retreatment rates, and favorable clinic outcomes were included. Statistical analyses were performed to compare the overall outcome rates of anterior cerebral artery(ACA) vs. middle cerebral artery(MCA) and anterior vs posterior circulation subgroups. RESULTS We included 26 studies involving a total of 1,408 patients. The overall rate of complete occlusion was 80.3 % (95 % CI= 76.0-84.1). Subgroup analysis demonstrated a statistically significant difference in the rate of complete occlusion between anterior circulation (78.9 %) and posterior circulation (69.2 %) (p value=0.02). The rate of good clinical outcomes was 92.8 % (95 % CI= 88.8-95.4). The mortality rate was 1.4 % (95 % CI= 0.5-2.7). The overall rate of ischemic complications was 9.5 % (95 % CI= 7.7-11.6), with a comparable difference between anterior circulation (7.7 %) and posterior circulation (12.8 %) (p value=0.07). There was no statistically significant difference in MCA vs ACA subgroups in all parameters. CONCLUSIONS Off-label use of PEDs can be a safe and effective treatment option for intracranial aneurysms. However, there is a need for more prospective, high-quality, non-industry-funded registry studies and randomized trials to test the efficacy and safety of off-label usage of PEDs and to expand its indications.
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Affiliation(s)
- Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Atakan Orscelik
- Department of Neurosurgery, Medical University of South Carolina, SC, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Santhosh Arul
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Ramanathan Kadirvel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Rodríguez-Fernández C, Ruiz-Garcia P, Garcia-Sanchez MJ, Manrique-Zegarra M, Toledano-Illán C, Escartin J, Vences MA, Rubio LA, Luttich A, Pumar JM. Technical success, procedural safety, and efficacy of the Silk Vista Baby in the treatment of cerebral aneurysms over a mid-to-long-term follow-up. Front Neurol 2024; 15:1369443. [PMID: 38638309 PMCID: PMC11025534 DOI: 10.3389/fneur.2024.1369443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
Background Long-term follow-up of cerebral aneurysms treated with the Silk Vista Baby (SVB) flow diverter is lacking. This study aimed to assess the technical success, procedural safety, and efficacy of the SVB (Balt, Montmorency, France) for the treatment of intracranial aneurysms in small cerebral vessels over a mid-to long-term follow-up. Methods We retrospectively analyzed a prospectively maintained database of patients treated with the SVB between September 2018 and June 2021. Data regarding patient demographics, aneurysm characteristics, and technical procedures were also collected. Angiographic and clinical findings were recorded during the procedure and over a period of at least 12 months. Results Angiographic and clinical follow-up data were available for 50 patients/50 aneurysms. The procedural complication rate was 8%. At 12 months, the final results showed a technical success rate of 100%, the re rupture rate was 0%, neuromorbidity and mortality rates of 4 and 0%, respectively, and an almost complete occlusion rate of 94%. Conclusion Treatment of complex intracranial aneurysms with the SVB was safe and effective. Long-term results showed high rates of adequate and stable occlusions.
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Affiliation(s)
| | - Pedro Ruiz-Garcia
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
| | | | - Martiel Manrique-Zegarra
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
| | - Carlos Toledano-Illán
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
| | - Jorge Escartin
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
| | - Miguel Angel Vences
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
- School of Medicine, Universidad César Vallejo, Piura, Peru
| | - Luis Angel Rubio
- Interventional Neuroradiology Department, Hospital Universitario Fundación Jiménez Diaz, Madrid, Spain
| | - Alex Luttich
- Interventional Neuroradiology Department, Hospital Universitario Donostia, San Sebastian, Spain
| | - José Manuel Pumar
- Chair of Interventional Neuroradiology, University of Santiago de Compostela, Santiago de Compostela, Spain
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Hosseini EM, Zafarshamspour S, Ghasemi-Rad M, Benndorf G, Rasekhi A, Rafieossadat R. Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature. Childs Nerv Syst 2024; 40:345-357. [PMID: 37750891 DOI: 10.1007/s00381-023-06161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.
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Affiliation(s)
| | - Saber Zafarshamspour
- Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Goetz Benndorf
- Department of Radiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza Rasekhi
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Rafieossadat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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Al-Smadi AS, Ali R, Kappel AD, Intikhab O, Rajah GB, Luqman A. Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes. J Neuroophthalmol 2023; 43:541-546. [PMID: 37166977 DOI: 10.1097/wno.0000000000001867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). METHODS A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. RESULTS Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. CONCLUSIONS The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Neuroradiology (ASA-S, OI), The University of Chicago, Chicago, Illinois; Departments of Radiology (RA) and Neurosurgery (ADK, GBR, AL), School of Medicine, Wayne State University, Detroit, Michigan; and Department of Neurosurgery (GBR), Munson Medical Center, Traverse City, Michigan
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11
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Ling Y, Liu J, Zhou L, Xiang X, Wang P. Retreatment with a pipeline embolization device for recanalized aneurysms following stent-assisted coiling embolization. Front Neurol 2023; 14:1267258. [PMID: 38020632 PMCID: PMC10655097 DOI: 10.3389/fneur.2023.1267258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose Flow diverters have emerged as viable alternatives for the retreatment of recanalized aneurysms following stent-assisted coiling embolization. In this study, we aim to present our experience of retreatment for such aneurysms using the pipeline embolization device (PED). Materials and methods This case series presents a retrospective single-center analysis of patients with recanalized aneurysms who underwent retreatment using the PED between July 2019 and April 2023, subsequent to stent-assisted coiling embolization. Results The study includes five female patients, whose relevant clinical data were recorded. All patients had aneurysms located in the internal carotid artery, comprising two blood blister-like aneurysms and two giant aneurysms. Prior to the retreatment, two LVIS stents, two enterprise stents, and one solitaire stent were implanted. Among the five patients, one experienced a fatal post-operative subarachnoid hemorrhage, while two patients achieved complete embolization, and another patient achieved near-complete embolization during the last follow-up. Furthermore, one patient faced challenges during the placement of the PED and was unable to achieve successful deployment. We propose four overlapping relationships between a newly implanted PED and a previously deployed stent: (1) PED covering only the proximal end of the previous stent, (2) PED covering only the distal end of the previous stent, (3) PED covering both the proximal and distal ends of the previous stent, and (4) PED deployed within the previous stent. Antiplatelet therapy at our center involved daily dual therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) for at least 5 days before PED placement. Intra-arterial bolus administration of tirofiban (5 mcg/kg) was administered during or immediately after PED deployment, followed by a maintenance dose of 0.08 mcg/kg/min IV infusion for at least 24-48 h if necessary. Postprocedural dual antiplatelet therapy included clopidogrel (75 mg/day) for 6 months and aspirin (100 mg/day) for 12 months. Conclusion The findings of this study support the efficacy of the PED for the retreatment of recanalized aneurysms following stent-assisted coiling embolization.
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Affiliation(s)
| | | | | | | | - Peiming Wang
- Department of Neurointervention, Guangdong Sanjiu Brain Hospital, Guangzhou, China
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12
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Han M, Tong X, Wang Z, Liu A. Parent artery occlusion after pipeline embolization device implantation of intracranial saccular and fusiform aneurysms. J Neurointerv Surg 2023; 15:1090-1094. [PMID: 36328477 DOI: 10.1136/jnis-2022-019273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Studies reporting parent artery occlusion (PAO) after pipeline embolization device (PED) implantation are limited. The aim of this study was to investigate the incidence rate and risk factors of PAO after PED implantation. METHODS In this retrospective study, we enrolled consecutive patients with intracranial saccular and fusiform aneurysms treated with PED implantation at our institution. Multivariate logistic regression analysis was subsequently performed to determine the risk factors for PAO. RESULTS A total of 588 saccular and fusiform aneurysms were finally enrolled in the study. PAO was found in 14 (2.38%) aneurysms. The aneurysm complete occlusion rate was 79.6%. Compared with the non-PAO group, aneurysms in the PAO group were larger in size (20.08 vs 9.61 mm; p<0.001), had a greater neck diameter (9.92 vs 6.15 mm; p=0.001), and had higher frequencies of adjunctive coils (64.3% vs 35.7%; p=0.028). In the multivariate logistic analysis, aneurysm size (OR 1.12, 95% CI 1.02 to 1.24; p=0.016) and the presence of poor wall apposition after balloon angioplasty (OR 7.74, 95% CI 1.28 to 46.82; p=0.026) were associated with PAO occurrence after adjusting for confounding factors. CONCLUSIONS In this study, the incidence rate of PAO following PED implantation was 2.38% in intracranial saccular and fusiform aneurysms. Aneurysm size and residual presence of poor wall apposition after balloon angioplasty were risk factors for PAO. Further research is required to better understand the mechanisms of PAO.
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Affiliation(s)
- Mingyang Han
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhifei Wang
- Department of Neurosurgery, Central South University Third Xiangya Hospital, Changsha, Hunan, China
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Wang Y, Yang X, Zhu W, Wang X, Yao Y, Lu W, Yang G, Qin L, Liu J, Li M. Verification of software-based preoperative simulation of flow diverters in clinical cases. Interv Neuroradiol 2023; 29:510-519. [PMID: 35505598 PMCID: PMC10549721 DOI: 10.1177/15910199221097264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/24/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The authors sought to verify the use of a preoperative simulation software for the treatment of intracranial aneurysms using flow diverters (FDs) based on three-dimensional rotational angiography (3DRA) data. METHODS Based on 3DRA data, the preoperative simulation software (UKNOW) was used to simulate the deployment of virtual FDs. The length and dimensions of virtual and real devices were compared. The deployment plan recommended by the UKNOW software was preliminarily used to complete implantations in the real world. During the experiment, experienced neurointerventional experts were responsible for supervising and judging information such as the length, dimension, and deployment location of the FDs. RESULTS This study retrospectively analyzed the data of 29 patients who received FD treatment. There was no statistical difference between the length of the real device and the virtual device (p = 0.6). The dimensions of FDs recommended by the software were consistent with the dimensions used in 24 out of the 29 real cases. In four of the remaining five cases, neurointerventional experts found that the FD dimensions recommended by the software were superior to those were actually used. Thus, the accuracy rate for FD dimension recommendations by the UKNOW software was 96.6% (28/29). Procedures performed in five cases using deployment plans recommended by the UKNOW software all achieved good postoperative results; the deployment positions of the device were reasonable, and all devices showed good wall adherence. CONCLUSIONS UKNOW software could accurately simulate the length and deployment position of the real FDs and provide suitable device dimensions.
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Affiliation(s)
- Yixuan Wang
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinlan Wang
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
| | - Yangyang Yao
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Wangsheng Lu
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Guangming Yang
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Lan Qin
- UnionStrong (Beijing) Technology Co. Ltd, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Miao Li
- Department of Neurosurgery, The China-Japan Union Hospital, Jilin University, Changchun, China
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Jin H, Lv J, Meng X, Liu X, He H, Li Y. Pipeline versus Tubridge in the treatment of unruptured posterior circulation aneurysms. Chin Neurosurg J 2023; 9:22. [PMID: 37542351 PMCID: PMC10401889 DOI: 10.1186/s41016-023-00337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND To compare the safety and efficacy of pipeline embolization device (PED) and Tubridge flow diverter (TFD) for unruptured posterior circulation aneurysms. METHODS Posterior aneurysm patients treated with PED or TFD between January, 2019, and December, 2021, were retrospectively reviewed. Patients' demographics, aneurysm characteristics, treatment details, complications, and follow-up information were collected. The procedural-related complications and angiographic and clinical outcome were compared. RESULTS A total of 107 patients were involved; PED was applied for 55 patients and TFD for 52 patients. A total of 9 (8.4%) procedural-related complications occurred, including 4 (7.3%) in PED group and 5 (9.6%) in TFD group. During a mean of 10.3-month angiographic follow-up for 81 patients, complete occlusion was achieved in 35 (85.4%) patients in PED group and 30 (75.0%) in TFD group. The occlusion rate of PED group is slightly higher than that of TFD group. A mean of 25.0-month clinical follow-up for 107 patients showed that favorable clinical outcome was achieved in 53 (96.4%) patients in PED group and 50 (96.2%) patients in TFD group, respectively. No statistical difference was found in terms of procedural-related complications (p = 0.737), occlusion rate (p = 0.241), and favorable clinical outcome (0.954) between groups. CONCLUSIONS The current study found no difference in complication, occlusion, and clinical outcome between PED and TFD for unruptured PCAs.
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Affiliation(s)
- Hengwei Jin
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, No.119, South 4Th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jian Lv
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, No.119, South 4Th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xiangyu Meng
- Neurosurgery Department, The First Hospital of Hebei Medical University, Donggang Road 89, Shijiazhuang, Hebei Province, China
| | - Xinke Liu
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, No.119, South 4Th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Hongwei He
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, No.119, South 4Th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Youxiang Li
- Department of Neurosurgery, Beijing Tiantan Hospital and Beijing Neurosurgical Institute, Capital Medical University, No.119, South 4Th Ring West Road, Fengtai District, Beijing, 100070, China.
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Oh HS, Bae JW, Hong CE, Kim KM, Yoo DH, Kang HS, Cho YD. Stent-Assisted Coil Embolization Versus Flow-Diverting Stent in Unruptured Vertebral Artery Dissecting Aneurysms: Efficacy and Safety Comparison. Neurosurgery 2023; 93:120-127. [PMID: 36757195 DOI: 10.1227/neu.0000000000002384] [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: 08/01/2022] [Accepted: 12/04/2022] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Reconstructive strategies for unruptured vertebral artery dissecting aneurysms (VADAs) have increasingly relied on newly developed endovascular devices. However, their clinical performance metrics are seldom reported. OBJECTIVE To compare stent-assisted coil embolization (SACE) and flow-diverting stent (FDS) deployment as treatments for unruptured VADAs, focusing on efficacy and safety. METHODS A total of 72 VADAs were submitted to SACE (n = 48) or FDS (n = 24) between April 2009 and September 2021. We reviewed medical records and radiological data to assess efficacy and safety outcomes by method, building an inverse probability of treatment-weighted (IPTW) logistic regression model and conducting survival analyses. RESULTS Ultimately, 24 aneurysms (33.3%) showed signs of recanalization (major, 14; minor, 10) at 6-month follow-up. Initially determined 6-month rates of overall (SACE, 31.2%; FDS, 41.7%) and major (SACE, 20.8%; FDS, 16.7%) recanalization did not differ significantly by modality; but in the IPTW logistic regression model, adjusted for aneurysm morphology, major recanalization at 6 months was lower for the FDS (vs SACE) subset (odds ratio = 0.196; P = .027). Likewise, the cumulative rate of major recanalization was more favorable for the FDS (vs SACE) subset (hazard ratio = 0.291; P = .048) in IPTW Cox proportional hazards model adjusted for aneurysm morphology. Modality-based assessments of procedural and delayed complications were similar. CONCLUSION Both reconstructive VADA interventions are safe and effective by adjusting treatment modality depending on the angioanatomic configuration. However, follow-up data after treatment proved more favorable for FDS deployment than for SACE in limiting major recanalization. Case-controlled studies of more sizeable cohorts are needed for corroboration.
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Affiliation(s)
- Han San Oh
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
| | - Chang-Eui Hong
- Department of Neurosurgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Kang Min Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Theocharidou A, Spanou A, Alexandratou M, Michas V, Lamprou V, Psoma E, Finitsis S. An off-label use of flow-diverter stent as a successful treatment of a postoperative middle cerebral artery pseudoaneurysm. Radiol Case Rep 2023; 18:2219-2223. [PMID: 37123043 PMCID: PMC10139864 DOI: 10.1016/j.radcr.2023.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/24/2023] [Accepted: 03/07/2023] [Indexed: 05/02/2023] Open
Abstract
A pseudoaneurysm or false aneurysm is the result of the disruption of the vessel wall and the formation of a hematoma in communication with the vascular lumen, restrained by perivascular connective tissue. Intracranial pseudoaneurysms represent a rare entity mainly because of trauma, iatrogenic causes, infectious disease, radiation exposure, connective tissue disease and sometimes spontaneous occurrence. We present a 35-year-old female patient with a history of multiple low-grade glioma debulking surgeries. During the last procedure, laceration of the left middle cerebral artery (MCA) occurred with diffuse subarachnoid hemorrhage. Imaging studies showed the formation of a pseudoaneurysm of the left MCA which was successfully treated with the implantation of a flow diverter across the lesion neck and excellent mid- to long- term results. Flow diverter implantation may be a promising technique for the therapeutic management of cerebral pseudoaneurysms.
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Kashkoush A, El-Abtah ME, Achey R, Hussain MS, Toth G, Moore NZ, Bain M. Flow Diversion as Destination Treatment of Intracranial Mycotic Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2023; 24:492-498. [PMID: 36715979 DOI: 10.1227/ons.0000000000000593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/21/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Mycotic aneurysms represent a rare type of intracranial aneurysm. Treatment options usually consist of coiling, clipping, or liquid embolization. Data regarding outcomes after flow diversion of mycotic aneurysms are sparse. OBJECTIVE To present a single-center case series regarding our experience with FD as definitive treatment for ruptured mycotic aneurysms initially treated with coil embolization. METHODS We retrospectively reviewed a prospectively maintained database of all cerebrovascular procedures performed at a single institution between 2017 and 2021 for cases that used FD for the management of intracranial mycotic aneurysms. Prospectively collected data included patient demographics, medical history, rupture status, aneurysm morphology, aneurysm location, and periprocedural complications. The main outcomes included neurological examination and radiographic occlusion rate on cerebral digital subtraction angiography. RESULTS Three patients with 4 ruptured mycotic aneurysms that were initially treated with coil embolization were identified that required retreatment. The aneurysms were located along the middle cerebral artery bifurcation (n = 2), posterior cerebral artery P1/2 junction (n = 1), and basilar artery apex (n = 1), which all demonstrated recurrence after initial coil embolization. Successful retreatment using flow diverting stents was performed in all 3 patients. At the last angiographic follow-up, all aneurysms demonstrated complete occlusion. No patients suffered new periprocedural complications or neurological deficits after FD. CONCLUSION Flow-diverting stents may be an effective treatment option for intracranial mycotic aneurysms that are refractory to previous endovascular coiling. Future studies are warranted to establish the associated long-term safety and clinical efficacy.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Rebecca Achey
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Z Moore
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA.,Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Tatit RT, Ogilvy CS, Shutran MS, Tawk RG, Yasuda TA, Baccin CE. Plasticity of the adult circle of Willis in response to flow diversion stents. Surg Neurol Int 2023; 14:49. [PMID: 36895205 PMCID: PMC9990810 DOI: 10.25259/sni_1139_2022] [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: 12/18/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
Background We present five patients with remodeling of the adult circle of Willis in response to flow diverter stents (FDSs) at the anterior communicating artery (AComA) and the posterior communicating artery (PComA). The observed changes provide a paradigm of how flow change can institute anatomic changes in the adult circle of Willis vasculature. Case Description In the first two cases, after placement of the FDS covering the AComA, there was an increase in size and flow of the contralateral A1-anterior cerebral artery which had previously been hypoplastic. In one of the cases, this led to the filling of the aneurysm and required placement of coils within the lesion which was curative. In case three, the FDS effect led to asymptomatic occlusion of the PComA and associated aneurysm without change of the ipsilateral P1-segement of posterior-cerebral-artery (P1-PCA) caliber. In the fourth case, the FDS covering an aneurysm with a fetal PCA arising from its neck resulted in significant reduction of the aneurysm size, persistent flow and caliber of the fetal PCA, and the hypoplastic ipsilateral P1-PCA. Finally, in the fifth case, after FDS occlusion of the PComA and aneurysm there was increasement in diameter of the ipsilateral P1-PCA that was previously hypoplastic. Conclusion The use of FDS can affect vessels covered by the device and other arteries of the circle of Willis adjacent to the FDS. The phenomena illustrated in the hypoplastic branches appear to be a compensatory response to the hemodynamic changes induced by the divertor and to the altered flow in the circle of Willis.
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Affiliation(s)
- Rafael Trindade Tatit
- Department of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max S Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Thomas A Yasuda
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Baccin
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Lauzier DC, Huguenard AL, Srienc AI, Cler SJ, Osbun JW, Chatterjee AR, Vellimana AK, Kansagra AP, Derdeyn CP, Cross DT, Moran CJ. A review of technological innovations leading to modern endovascular brain aneurysm treatment. Front Neurol 2023; 14:1156887. [PMID: 37114225 PMCID: PMC10126349 DOI: 10.3389/fneur.2023.1156887] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Tools and techniques utilized in endovascular brain aneurysm treatment have undergone rapid evolution in recent decades. These technique and device-level innovations have allowed for treatment of highly complex intracranial aneurysms and improved patient outcomes. We review the major innovations within neurointervention that have led to the current state of brain aneurysm treatment.
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Affiliation(s)
- David C. Lauzier
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- *Correspondence: David C. Lauzier ;
| | - Anna L. Huguenard
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Anja I. Srienc
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Samuel J. Cler
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Joshua W. Osbun
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Arindam R. Chatterjee
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Ananth K. Vellimana
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Akash P. Kansagra
- Department of Neurointerventional Surgery, California Center of Neurointerventional Surgery, San Diego, CA, United States
| | - Colin P. Derdeyn
- Department of Radiology, University of Iowa School of Medicine, Iowa City, IA, United States
| | - Dewitte T. Cross
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Christopher J. Moran
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
- Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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20
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Gozal YM, Abou-Al-Shaar H, Alzhrani G, Taussky P, Couldwell WT. Complications of Endovascular and Open Aneurysm Surgery in the Era of Flow Diversion. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:85-94. [PMID: 37548727 DOI: 10.1007/978-3-030-12887-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
The techniques used for treatment of intracranial aneurysms have progressed dramatically over the decades. The introduction of modern endovascular techniques and the continued refinement of progressively less invasive neurosurgical approaches have contributed to steadily improving clinical outcomes. Moreover, innovations such as flow-diverting stents have achieved dramatic success and have gained rapid widespread adoption. Particularly in lesions for which the application of conventional treatment techniques is difficult, flow diversion technology has revolutionized aneurysm management. This review provides a discussion on the morbidity and mortality encountered in the treatment of intracranial aneurysms in the modern era. Common adverse events faced in the management of these lesions with open surgery and various endovascular techniques are highlighted.
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Affiliation(s)
- Yair M Gozal
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gmaan Alzhrani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
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Brunasso L, Casamassima N, Abrignani S, Sturiale CL, Incandela F, Giammalva GR, Iacopino DG, Maugeri R, Craparo G. Flow diversion for indirect carotid-cavernous fistula: Still an off-label indication? Surg Neurol Int 2023; 14:65. [PMID: 36895234 PMCID: PMC9990788 DOI: 10.25259/sni_1113_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/03/2023] [Indexed: 03/11/2023] Open
Abstract
Background Flow diversion (FD) is an established treatment for large or giant wide-necked unruptured intracranial aneurysms. In the past few years, the use of flow diverter devices was extended to several other "off-label" indications, including solitary or adjunctive treatment to coil embolization for direct (Barrow A type) carotid cavernous fistulas (CCFs). The use of liquid embolic agents still represents the first-line treatment for indirect CCFs. Typically, the ipsilateral inferior petrosal sinus or superior ophthalmic vein (SOV) is the preferred transvenous routes to access CCFs. In some cases, vessel tortuosity or different features make the endovascular access challenging, thus requiring different approaches and strategies. The aim of the study is to discuss rational and technical aspect in treating indirect CCFs referring to the most up-to-date literature. An alternative experience-based endovascular strategy with FD is described. Methods We report the case of a 54-year-old woman diagnosed with indirect CCF and treated with flow diverter stent. Results After multiple unsuccessful attempts at transarterial right SOV catheterization, a right indirect CCF fed by a single trunk at the ophthalmic origin from the internal carotid artery (ICA) was treated by ICA stand-alone FD. Blood flow was redirect and successfully reduced through the fistula, with immediately postprocedure improvement of the patient's clinical status (ipsilateral proptosis and chemosis). Ten-months radiological follow-up showed the complete obliteration of the fistula. No adjunctive endovascular treatment was performed. Conclusion FD appears a reasonable alternative stand-alone endovascular strategy also for selected difficult-to-access indirect CCFs, when all conventional routes are judged unfeasible. Further investigations will be necessary to better define and support this potential lesson-learned application.
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Affiliation(s)
- Lara Brunasso
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Nicola Casamassima
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Sergio Abrignani
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Palermo, Italy
| | - Francesca Incandela
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
| | - Giuseppe Roberto Giammalva
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Rosario Maugeri
- Neurosurgical Clinic, Azienda Ospedaliera Universitaria Policlinico (AOUP) "Paolo Giaccone", Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo
| | - Giuseppe Craparo
- Department of Neuroradiology, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Civico Hospital, Palermo
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22
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Zhang H, Ren J, Wang J, Lv X. The off-label uses of pipeline embolization device for complex cerebral aneurysms: Mid-term follow-up in a single center. Interv Neuroradiol 2022:15910199221148800. [PMID: 36583531 DOI: 10.1177/15910199221148800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To describe the off-label uses of pipeline embolization device for a variety of types of aneurysms including ruptured aneurysms, posterior circulation aneurysms, small aneurysms, distal aneurysms, and recurrent aneurysms. METHODS Clinical and angiographic data of patients who underwent pipeline embolization device treatment on off-label use at our center were retrospectively reviewed. For categorical variables, Fisher's exact test was used, and a two-sample Wilcoxon rank-sum test was used for patients' age to analyze the correlation with outcomes. RESULTS In this study, 121 aneurysms in 107 patients received off-label pipeline embolization device treatments. The overall rate of complete aneurysm occlusion was 77.8% (28/36 in 35 patients) for posterior circulation aneurysms and 95.3% (81/85 in 72 patients) for anterior circulation aneurysms. The posterior circulation aneurysms have a lower rate of aneurysm occlusion (p = 0.0372). The small aneurysms have a higher rate of aneurysm occlusion (p = 0.0104). The patient's sex, age, and aneurismal size were associated with ischemic stroke complications (p = 0.0397, 0.0166, and 0.0178). In posterior circulation aneurysm patients, only two basilar apex aneurysms underwent pipeline embolization device treatment, both of whom died of thrombotic complications. There was no difference in mortality between posterior circulation aneurysm patients (8.6%, 3/35) and anterior circulation aneurysm patients (1.4%, 1/72) (p = 0.1015). Patients of older age have a higher risk of death rate (p = 0.0053). CONCLUSIONS The off-label use of pipeline embolization device is often performed in clinical practice and can achieve efficacy in complex aneurysms. The off-label use of pipeline embolization device was found to carry an increased rate of mortality in older patients. Excluding basilar apex aneurysms, the pipeline embolization device is as safe as anterior circulation aneurysms in the treatment of posterior circulation aneurysms elsewhere.
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Affiliation(s)
- Huachen Zhang
- Department of Neurosurgery, 589702Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiyang Ren
- Center for Statistical Science and Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - Jiangdian Wang
- Center for Statistical Science and Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - Xianli Lv
- Department of Neurosurgery, 589702Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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23
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Ma C, Zhu H, Liang S, Liang F, Han J, Jia Z, Zhang Y, Jiang C. Pipeline for the treatment of distal cerebral circulation aneurysms: A multicenter study focusing on periprocedural Complications. Interv Neuroradiol 2022; 28:708-718. [PMID: 34913765 PMCID: PMC9706258 DOI: 10.1177/15910199211063703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/11/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIM Distal cerebral circulation aneurysms (DCCAs) remain treatment challenges for neurointervention. The off-label use of the pipeline embolization device (PED) for these aneurysms remains controversial. This study aimed to evaluate the safety and efficacy of PED for DCCAs in a multicenter cohort of patients. METHODS Between March 2016 and June 2021, we retrospectively analyzed the neurointerventional data on the clinical and radiological records of all patients undergoing PED treatment of DCCAs at three medical centers. RESULTS A total of 53 consecutive patients with 53 DCCAs were treated with PED. The mean aneurysm size was 12.3 ± 5.7 mm. In total, 75.4% (40/53) were fusiform and 24.5% (13/53) were saccular. Of these, 17.0% (9/53) were recurrent aneurysms that were previously treated with endovascular or microsurgical approaches. The technical success rate was 100%, among which 81.1% (43/53) procedures were completed with a single PED, and the rest (10/53, 18.8%) required telescoping with two devices. Angiographic follow-up data were available for 51 patients, with a median follow-up time of 12 months. At the latest follow-up, 46/51 (90.2%) aneurysms showed complete obliteration, and 4/51 (7.8%) showed reduced filling. Periprocedural complications such as hemorrhage were observed in two patients with MCA aneurysms (3.8%, 2/53), and ischemic events occurred in six patients (11.3%, 6/53). The overall mortality and morbidity rates were 7% (4/53). CONCLUSIONS PED is a viable option for treating DCCAs, especially for recurrent aneurysms. Coverage of bifurcation branches and perforator may increase the risk of complications.
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Affiliation(s)
- Chao Ma
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital,
School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Jintao Han
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Zichang Jia
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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24
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Luo C, Jin L, Dong J, Fu Z, Liu E, Yin S, Jian L, Luo P, Liu B, Huang W, Zhou S. Clinical outcomes of pipeline embolization devices with shield technology for treating intracranial aneurysms. Front Neurol 2022; 13:971664. [PMID: 36452166 PMCID: PMC9702813 DOI: 10.3389/fneur.2022.971664] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/24/2022] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION As a common endovascular treatment for intracranial aneurysms, the pipeline embolization device (PED) is considered a standard treatment option, especially for large, giant, wide-necked, or dissecting aneurysms. A layer of phosphorylcholine biocompatible polymer added to the surface of the PED can substantially improve this technology. This PED with shield technology (pipeline shield) is relatively novel; its early technical success and safety have been reported. We conducted a systematic literature review with the aim of evaluating the efficacy and safety of the pipeline shield. METHODS We searched the PubMed, Embase, and Cochrane databases, following the preferred reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. RESULTS We selected five prospective and two retrospective studies for review. A total of 572 aneurysms were included; of these, 506 (88.5%) were unruptured. The antiplatelet regimens were heterogeneous. The rate of perioperative and postoperative complications was 11.1% [95% confidence interval (CI): 6.5-18.9%]. The adequate occlusion rate at 6 months was 73.9% (95% CI: 69.1-78.7%). The adequate occlusion rate of more than 12 months was 80.9% (95% CI: 75.1-86.1%). The mortality rate was 0.7% (95% CI: 0.2-1.5%). Subgroup analyses showed that aneurysm rupture status had no effect on aneurysm occlusion rate, patient morbidity, or mortality. CONCLUSION This review demonstrates the safety and efficacy of the pipeline shield for treating intracranial aneurysms. However, direct comparisons of the pipeline shield with other flow diverters are needed to better understand the relative safety and effectiveness of different devices.
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Affiliation(s)
- Chao Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lide Jin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Jigen Dong
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Zaixiang Fu
- Department of Neurosurgery, School of Medicine, Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Erheng Liu
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shi Yin
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Lipeng Jian
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Pengren Luo
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Bo Liu
- College of Clinical Medicine, Jilin University, Changchun, China
| | - Wei Huang
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
| | - Shuai Zhou
- Department of Neurosurgery, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, China
- Medical Faculty, Kunming University of Science and Technology, Kunming, China
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25
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Restrepo AF, Singer J. Commentary: The Pennsylvania Postmarket Multicenter Experience With Flow Redirection Endoluminal Device. Neurosurgery 2022; 91:e109-e110. [PMID: 36001777 DOI: 10.1227/neu.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Andres F Restrepo
- Neurosurgery Division, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.,Department of Neurosurgery, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Justin Singer
- Neurosurgery Division, Department of Clinical Neurosciences, Spectrum Health, Grand Rapids, Michigan, USA.,Department of Neurosurgery, College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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26
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Khorasanizadeh M, Shutran M, Schirmer CM, Salem MM, Ringer AJ, Grandhi R, Mitha AP, Levitt MR, Jankowitz BT, Taussky P, Thomas AJ, Moore JM, Ogilvy CS. North American multicenter experience with the Flow Redirection Endoluminal Device in the treatment of intracranial aneurysms. J Neurosurg 2022; 138:933-943. [PMID: 36087324 DOI: 10.3171/2022.7.jns221371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diverters have revolutionized the endovascular treatment of intracranial aneurysms. Here, the authors present the first large-scale North American multicenter experience using the Flow Redirection Endoluminal Device (FRED) in the treatment of cerebral aneurysms. METHODS Consecutive cerebral aneurysms treated with FRED at 7 North American centers between June 2020 and November 2021 were included. Data collected included patient demographic characteristics, aneurysm characteristics, periprocedural and long-term complications, modified Rankin Scale (mRS) scores, and radiological follow-up. RESULTS In total, 133 aneurysms in 116 patients were treated with 123 FRED deployment procedures and included in this study. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) saccular, and 123 (92.5%) located in anterior circulation. The mean (range) aneurysm maximal width and neck width sizes were 7.2 (1.5-42.5) mm and 4.1 (1.0-15.1) mm, respectively. Successful FRED deployment was achieved in 122 procedures (99.2%). Adjunctive coiling was used in 4 procedures (3.3%). Radiological follow-up was available for 101 aneurysms at a median duration of 7.0 months. At last follow-up, complete occlusion was observed in 55.4% of patients, residual neck in 8.9%, and filling aneurysm in 35.6%; among cases with radiological follow-up duration > 10 months, these values were 21/43 (48.8%), 3/43 (7.0%), and 19/43 (44.2%), respectively. On multivariate regression analysis, age (OR 0.93, p = 0.001) and aneurysm neck size (OR 0.83, p = 0.048) were negatively correlated with odds of complete occlusion at latest follow-up. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) cases, respectively. The FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 patients (8.6%). There was 1 death due to massive periprocedural internal carotid artery stroke, and 3.6% of the patients had an mRS score > 2 at the last follow-up (vs 0.9% at baseline). CONCLUSIONS As the first large-scale North American multicenter FRED experience, this study confirmed the ease of successful FRED deployment but suggested lower efficacy and a higher rate of complications than reported by previous European and South American studies on FRED and other flow-diverting devices. The authors recommend judicious use of this device until future studies can better elucidate the long-term outcomes of FRED treatment.
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Affiliation(s)
- MirHojjat Khorasanizadeh
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - Mohamed M Salem
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew J Ringer
- 4Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ramesh Grandhi
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Alim P Mitha
- 6Department of Clinical Neurosciences, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Michael R Levitt
- 7Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | - Brian T Jankowitz
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philipp Taussky
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Ajith J Thomas
- 8Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Justin M Moore
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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27
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Cler SJ, Lauzier DC, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. Comparative study of on-label versus off-label treatment of intracranial aneurysms with the Pipeline embolization device. J Neurosurg 2022; 137:685-690. [PMID: 35090133 DOI: 10.3171/2021.11.jns212481] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 11/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline embolization device (PED) is widely used for the treatment of intracranial aneurysms, including in off-label applications. In this work, the authors compared the real-world efficacy and safety of PED use in on-label and off-label aneurysm treatments. METHODS Clinical and angiographic data of patients who underwent PED placement at a high-volume academic medical center were retrospectively obtained. Treatments were classified as on-label if they fell within the applications approved by the United States Food and Drug Administration as of 2021. Recorded outcomes included aneurysm occlusion, procedural complications, ischemic events, in-stent stenosis, intracranial hemorrhage, postprocedural functional status, and death. RESULTS In total, 416 aneurysms in 330 patients were treated with PED, comprising 256 aneurysms that received on-label treatments and 160 that received off-label treatments. The overall rate of complete aneurysm occlusion was 76.4% for on-label aneurysms and 75.6% for off-label aneurysms (p = 0.898). The risk of ischemic stroke in patients who underwent off-label treatments was 15.2%, which was higher than the 4.2% rate in patients who underwent on-label treatment (p = 0.003). All other clinical complications, procedural complications, and long-term functional status were comparable between the on-label and off-label groups. CONCLUSIONS In real-world practice, off-label use of PED is common and can achieve similar efficacy as on-label use. However, in aggregate, off-label use was found to carry an increased rate of ischemic complications. With judicious attention to safety and individual patient characteristics, these results highlight the scale and general feasibility of off-label PED use by experts.
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Affiliation(s)
- Samuel J Cler
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - David C Lauzier
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Arindam R Chatterjee
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua W Osbun
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher J Moran
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
| | - Akash P Kansagra
- 1Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; and
- 3Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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28
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Sirakov A, Bhogal P, Sirakova K, Minkin K, Ninov K, Karakostov V, Sirakov S. Intrasaccular neck-bridging: A technical note on Nautilus-assisted coiling of wide-necked cerebral aneurysms. Feasibility study, immediate and early angiographic results. Interv Neuroradiol 2022; 28:746-755. [PMID: 35818746 DOI: 10.1177/15910199221113738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Various adjunctive devices have been reported to be helpful during the endovascular coiling of complex, wide-necked cerebral aneurysms. This study aimed to describe the utilization of a recently introduced intrasaccular neck-bridging implant specifically designed to facilitate coil embolization. METHODS We retrospectively reviewed eight consecutive patients who underwent treatment for intracranial aneurysms with the Nautilus intrasaccular bridging system between February 2022 to May 2022. We evaluated the angiographic appearances of treated aneurysms at the end of the procedure and early follow-up, the clinical status and complications. RESULTS Eight patients with eight cerebral aneurysms (3 men and 5 women, mean age 52.8 years (range 39-66) were analyzed. Five of the treated aneurysms were managed in an acute case scenario. There were no technical difficulties while executing the technique. No other procedural adverse events were documented. Immediate complete occlusion of the aneurysm was seen in 6 patients, neck remnant in 1 and stable aneurysm reperfusion in one case. Early radiological follow-up was available in five patients, and the observed occlusion rates were - RR class I in all radiologically screened aneurysms. CONCLUSION Nautilus-assisted coil embolization represents a rapid and safe solution for complex cerebral aneurysms. In our opinion this device symbolizes a significant step forward in treating intracranial aneurysms. We believe that the technique's actual value consists of the fact that the device is fully compatible with the modern low-profile microcatheter technology and does not involve the need for antiplatelet medications.
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Affiliation(s)
- A Sirakov
- Interventional Radiology Department, UH St Ivan Rilski, Sofia, Bulgaria
| | - P Bhogal
- Interventional Neuroradiology Department, 112001The Royal Hospital, London, UK
| | - K Sirakova
- Neurosurgery Department, 266309UH St Ivan Rilski, Sofia, Bulgaria
| | - K Minkin
- Neurosurgery Department, 266309UH St Ivan Rilski, Sofia, Bulgaria
| | - K Ninov
- Radiology Department, 58788UH Aleksandrovska, Sofia, Bulgaria
| | - V Karakostov
- Neurosurgery Department, 266309UH St Ivan Rilski, Sofia, Bulgaria
| | - S Sirakov
- Interventional Radiology Department, UH St Ivan Rilski, Sofia, Bulgaria
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29
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Ma C, Zhu H, Liang S, Liang F, Sun J, Zhang Y, Jiang C. Comparison of Pipeline Embolization Device and Traditional Endovascular Therapeutic Approaches in Distal Cerebral Circulation Aneurysms Using Propensity Score Matching Analysis. Front Neurol 2022; 13:755122. [PMID: 35665044 PMCID: PMC9157485 DOI: 10.3389/fneur.2022.755122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Coiling and stent-assisted coiling remain the first-line treatments for distal cerebral circulation aneurysms (DCCAs). The off-label use of the pipeline embolization device (PED) for these aneurysms has been explored recently but remains controversial. Objective To compare traditional endovascular therapeutic approaches (coiling and stent-assisted coiling) and PED for DCCAs in a multicenter cohort of patients. Methods A multicenter, retrospective cohort comparison study was conducted that included consecutive patients with unruptured DCCAs treated with either traditional endovascular therapeutic approaches or PED placement at three centers between 2016 and 2020. Propensity score matching analysis was applied to adjust for baseline risk factors between the PED and TET groups. Matching was based on age, sex, aneurysm size, location, morphology, adjunctive coiling, treatment history, and preoperative mRS score. Results In total, 209 patients with DCCAs treated with PED or traditional endovascular therapeutic approaches were identified. Thirty-seven patients underwent PED treatment, and 172 patients underwent traditional endovascular therapeutic approaches. After propensity score matching, 37 aneurysm pairs were matched, and the baseline characteristics of the patients were balanced between the groups. The complete occlusion rate between PED and traditional endovascular therapeutic approach in both matched cohorts (91.7 vs. 92.3%, p > 0.78) was similar. The rate of periprocedural treatment-related complications in both the PED and traditional endovascular therapeutic groups was 13.5%. Univariate analysis identified average parent vessel diameter as the only predictor of complete occlusion (p = 0.038). Conclusions PED is a viable option for treating DCCAs by providing occlusion and complication rates similar to those of traditional endovascular therapeutic approaches. A rigid patient selection procedure and proper planning should be undertaken to reduce treatment-related complications.
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Affiliation(s)
- Chao Ma
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jidian Sun
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Yupeng Zhang
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Chuhan Jiang
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30
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Fana M, Alsrouji O, Rehman M. Pipeline Embolization Stent for the Treatment of Giant Supraclinoid Aneurysms: A Case Series. Cureus 2022; 14:e23674. [PMID: 35510007 PMCID: PMC9060751 DOI: 10.7759/cureus.23674] [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] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
Cerebrovascular aneurysms of the supraclinoid region are a technical challenge and can be particularly difficult to treat when greater than 25 mm in diameter. Such giant aneurysms can be approached with various skull-based and endovascular surgical techniques, and the advent of the Pipeline embolization stent presents a new treatment modality. Previously used for the treatment of small aneurysms, the Pipeline embolization device (PED) is a flow diverter device that has more recently been investigated in its use for the treatment of giant aneurysms with few studies to date published about its procedural outcomes. Here, we highlight the case of three patients (two elderly and one middle-aged) presenting symptomatically with giant supraclinoid aneurysms of the cavernous internal carotid artery (ICA) and posterior communicating artery treated with the Pipeline stent and monitored on follow-up visits. We further review the most current case reports and the two clinical trials to date investigating the utility of the Pipeline stent in the treatment of large and giant cerebral aneurysms, highlighting the emerging evidence of its efficacy and long-term patient outcomes. We report successful resolution of symptoms and radiographic evidence of aneurysm size reduction on all patient follow-ups and suggest the Pipeline embolization device as a novel technique that can be utilized for the treatment of giant cerebrovascular aneurysms with emerging evidence of immediate and long-term success.
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery 2022; 90:700-707. [PMID: 35319533 DOI: 10.1227/neu.0000000000001891] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pipeline embolization device (PED; ev3/Covidien) has proven safe and effective for treating selected intracranial aneurysms. This device's versatility and popularity have driven increased interest in expanding the latest 2018 Food and Drug Administration-approved indications. OBJECTIVE To compare "off-label" and "on-label" PED treatment. METHODS Retrospective analysis of aneurysms treated with PED at a single center from 2013 to 2019. Comparisons were made based on the 2018 Food and Drug Administration-approved indications. RESULTS A total of 492 treated aneurysms were included (65.2% on-label and 34.8% off-label). Aneurysm complete and near-complete occlusion rate was nonsignificantly lower in the off-label group (80.9% vs 85.7%; P = .19). Off-label treatment had higher rate of poor functional outcomes (modified Rankin Scale [mRS] >2: 10.3% vs 3.5%; P = .002). Although pretreatment mRS was already higher in the off-label group (5.3% vs 0.3%; P < .001) and there were no differences in mRS worsening during follow-up (5.5% vs 2.9%; P = .15). We also found a trend to a higher rate of intracranial hemorrhagic complications in the off-label group (4.7% vs 1.6%; P = .05), but there were no differences in hemorrhages requiring surgical intervention (1.8% vs 1.3%; P = .65). There were no differences in retreatment, thromboembolic complications, and mortality rates. CONCLUSION Off-label PED treatment may be considered for select aneurysms, which are challenging to treat with other techniques. These cases have similar complete and near-complete occlusion rates compared with on-label cases. There are, however, higher risks of poor functional outcomes despite similar rates of thromboembolic and hemorrhagic complications. This is partly explained by the significantly higher pretreatment mRS score in the off-label group.
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Song J, Mao Y. Giant Aneurysm Management. Adv Tech Stand Neurosurg 2022; 44:133-160. [PMID: 35107677 DOI: 10.1007/978-3-030-87649-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.
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Affiliation(s)
- Jianping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.,Neurosurgical Institute of Fudan University, Shanghai, China.,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.,National Center for Neurological Disorders, Shanghai, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China. .,Neurosurgical Institute of Fudan University, Shanghai, China. .,Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China. .,National Center for Neurological Disorders, Shanghai, China.
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Stamatopoulos T, Anagnostou E, Plakas S, Papachristou K, Lagos P, Samelis A, Derakhshani S, Mitsos A. Treatment of carotid cavernous sinus fistulas with flow diverters. A case report and systematic review. Interv Neuroradiol 2022; 28:70-83. [PMID: 33966468 PMCID: PMC8905080 DOI: 10.1177/15910199211014701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Carotid cavernous fistulas (CCFs) are rare, usually follow head trauma or aneurysmal rupture. Recent treatment options include endovascular techniques such as flow diversion devices (FDDs). OBJECTIVE To present our case treated with FDD application with transarterial cavernous-sinus coiling and present a systematic review on the use and effectiveness of FDDs in CCF treatment. MATERIALS AND METHODS We present our case of CCF treatment with FDD. A search was also conducted in PubMed, EMBASE and Cochrane until November 2020. Reference lists were also cross-checked. RESULTS Including our case, thirty-eight patients were identified with a CCF that was treated with FDDs in sixteen studies. Twenty-two patients were females, nine were males and the rest unidentified. The mean age was 52,6 years (range 17-86, SD± 19.28). Thirty-six patients suffered from direct and two from indirect CCFs. Single FDD was used in four cases, single FDD with embolic materials in eleven cases, multiple overlapping FDDs were used in six cases and multiple overlapping FDDs with embolic materials were used in seventeen cases. Thirty-five patients (92,1%) had clinical improvement, immediate angiographic occlusion was seen in 44,7% of the cases, while long-term occlusion rate was 100% but with variable follow-up periods. One patient (2,6%) presented with a neurological deficit related to FDD deployment. CONCLUSION Targeted treatment of CCFs with single or overlapping FDDs with or without adjunct embolic agents offers a high success rate, both clinically and long-term angiographically compared to other endovascular methods alone. However, further research with multi-center prospective trials is warranted.
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Affiliation(s)
- Theodosios Stamatopoulos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece,Center of Orthopaedics and Regenerative Medicine (C.O.R.E.), Center for Interdisciplinary Research and Innovation (C.I.R.I.), Aristotle University Thessaloniki, Thessaloniki, Greece,Theodosios Stamatopoulos, Department of Neurosurgery, 401 General Military Hospital of Athens, Panagioti Kanellopoulou and Mesogeion Ave, Athens 11525, Greece.
| | - Evangelos Anagnostou
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Sotirios Plakas
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | | | - Panagiotis Lagos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Apostolos Samelis
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
| | - Shahram Derakhshani
- Department of Interventional and Therapeutic Neuroradiology, Queen's University Hospital, Essex Center for Neurological Sciences, London, UK
| | - Aristotelis Mitsos
- Department of Neurosurgery, 401 General Military Hospital of Athens, Athens, Greece
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Dabhi N, Sarathy D, Snyder MH, Kellogg RT, Park MS. Flow Diverter Devices for Treatment of Intracranial Aneurysms in Small Parent Vessels – A Systematic Review of Literature. World Neurosurg 2022; 162:183-194.e7. [DOI: 10.1016/j.wneu.2022.02.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/08/2022] [Indexed: 11/29/2022]
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Liu A, Rincon-Torroella J, Bender MT, McDougall CG, Tufaro AP, London NR, Coon AL, Reh DD, Gallia GL. Combined Pipeline Embolization Device with Endoscopic Endonasal Fascia Lata/Muscle Graft Repair as a Salvage Technique for Treatment of Iatrogenic Carotid Artery Pseudoaneurysm. J Neurol Surg Rep 2021; 82:e43-e48. [PMID: 34877246 PMCID: PMC8635816 DOI: 10.1055/s-0041-1735284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022] Open
Abstract
The incidence of internal carotid artery (ICA) injury associated with endoscopic endonasal approaches to the pituitary is less than 1%. While parent vessel sacrifice has historically been the choice of treatment, vessel-preserving endovascular techniques have been reported. Although flow diversion offers endoluminal reconstruction, its major limitation is the delay in obtaining complete occlusion. We describe the use of a combined Pipeline embolization device (PED) with endoscopic endonasal repair using a fascia lata/muscle graft to treat an iatrogenic ICA pseudoaneurysm and report long-term radiographic follow-up. Further investigation into the utility of directed endoscopic endonasal repair of iatrogenic pseudoaneurysms initially treated with PED is necessary, especially given the need of post-PED anticoagulation and the rate of permanent neurological deficit after ICA sacrifice.
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Affiliation(s)
- Ann Liu
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | | | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States
| | - Cameron G McDougall
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony P Tufaro
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Division of Plastic Surgery, Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Neurosurgery, Carondelet Neurological Institute, Tucson, Arizona, United States
| | - Douglas D Reh
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Greater Baltimore Medical Center, Baltimore, Maryland, United States
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, United States.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Hospital, Baltimore, Maryland, United States
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Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
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Zhong W, Kuang H, Zhang P, Yang X, Luo B, Maimaitili A, Zhao Y, Song D, Guan S, Zhang H, Wang Y, Wang D, Su W, Wang Y. Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study. Front Neurol 2021; 12:675917. [PMID: 34603179 PMCID: PMC8481592 DOI: 10.3389/fneur.2021.675917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling. Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed. Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050). Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.
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Affiliation(s)
- Weiying Zhong
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Hong Kuang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Department of Neurosurgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ping Zhang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Donghai Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Wandong Su
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
| | - Yunyan Wang
- Department of Neurosurgery, Institute of Brain and Brain-Inspired Science, Qilu Hospital of Shandong University, Shandong University, Jinan, China.,Shandong Key Laboratory of Brain Function Remodeling, Shandong University, Jinan, China
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Abdel-Tawab M, Abdeltawab AK, Abdelmonem M, Moubark MA, Taha MAH, Morsy A, Bessar AA, Ahmed Ebada M. Efficacy and safety of flow diverters in posterior circulation aneurysms and comparison with their efficacy in anterior circulation aneurysms: A systematic review and meta-analysis. Interv Neuroradiol 2021; 27:609-621. [PMID: 33752478 PMCID: PMC8493351 DOI: 10.1177/15910199211003017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 01/21/2021] [Accepted: 02/10/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We aimed to assess the efficacy and safety of flow-diverter stents (FDs) in the management of posterior circulation cerebral aneurysms and compare FD efficacy between anterior and posterior circulation aneurysms. METHODS We searched the PubMed, Scopus, Cochrane, and Web of Science databases for relevant studies through March 2020. Studies assessing FDs for posterior circulation aneurysms that included ≥20 treated aneurysms were included. Moreover, the studies compared FD efficacy between anterior and posterior circulation aneurysms were included. Data regarding angiographic aneurysmal occlusion, procedural complications, mortality, and morbidity were extracted and pooled in a random-effects meta-analysis model. RESULTS Fourteen studies with a total of 659 patients and 676 posterior circulation aneurysms were included. The pooled rate of aneurysmal occlusion at long-term angiographic follow-up was 78% [95% confidence interval (CI), 71-85]. The pooled rates of intraparenchymal hemorrhage, ischemia, and procedure-related mortality and neurological morbidity were 2%, 8%, 7%, and 6%, respectively. Complete occlusion occurred in 82.4% of the posterior circulation aneurysm subgroup and 77.5% of the anterior circulation aneurysm subgroup. The difference was not significant (relative risk 1.01; 95% CI, 0.86-1.19; p = 0.91). Regression analysis showed that elderly patients and females had higher morbidity. CONCLUSION Posterior circulation aneurysms can be effectively treated with FDs with comparable occlusion rates to those in anterior circulation aneurysms. However, periprocedural complications are not negligible.
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Affiliation(s)
- Mohamed Abdel-Tawab
- Department of Diagnostic and Interventional Radiology, Assiut University Hospitals, Assiut, Egypt
| | | | | | - Mahmoud A Moubark
- Department of Diagnostic and Interventional Radiology, Assiut University Hospitals, Assiut, Egypt
| | - Mohamed AH Taha
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Assiut, Egypt
| | - Abdalla Morsy
- Department of Neurosurgery, Assiut University Hospitals, Assiut, Egypt
| | - Ahmed Awad Bessar
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Department of Diagnostic and Interventional Radiology, Zagazig University, Zagazig, Egypt
| | - Mahmoud Ahmed Ebada
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Department of Radiology, National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
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Kang H, Luo B, Liu J, Wang A, Zhang H, Li T, Song D, Zhao Y, Guan S, Wang Y, Feng W, Wang Y, Shi H, Liu J, Yang X. A novel score for evaluating cerebral aneurysms treated with flow diversion: 4F-flow diversion predictive score. Ther Adv Neurol Disord 2021; 14:17562864211039336. [PMID: 34434256 PMCID: PMC8381420 DOI: 10.1177/17562864211039336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background and purpose Although grading scales for angiography outcomes following cerebral aneurysm treatment with flow diversion have been published, physicians have not widely adopted these scales in practice. The aim of this study is to propose and validate a novel Flow diversion Predictive Score (4F-FPS) grading scale based on previously established scales that is simple and reliable. Methods We retrospectively analyzed consecutive patients who underwent endovascular treatment for cerebral aneurysms with flow diversion between January 2014 and September 2019. The included patients were randomly divided into the derivation and validation group in a 70/30 ratio, respectively. Aneurysms were classified as incomplete or complete occlusion based on final angiography outcomes. 4F-FPS was derived to predict aneurysm occlusion from multivariate logistic regression analyses in the derivation group and validated with previously published grading scales in the validation group. Results Overall, 662 patients [mean age, 53.8 years; 72.5% (480/662) female] with 662 aneurysms treated with the PipelineTM flow diverter were included [69.9% (463/662) derivation group, 30.1% (199/662) validation group]. The incidence of aneurysm occlusion was 82.7%. 4F-FPS demonstrated significant discrimination in 10-fold cross validation [mean receiver operating characteristic (ROC) area, 0.862 ± 0.055] and calibration (Cox & Snell R 2, 0.251; Nagelkerke R 2, 0.413) in the derivation group. The ROC area of 4F-FPS score in both the derivation and validation groups is the largest compared with previously published grading scales/scores (p < 0.05), which shows better sensitivity and specificity. The 4F-FPS score showed excellent prediction, discrimination, and calibration properties. Conclusion The 4F-FPS score is a simple and reliable tool to predict angiography outcome after flow diversion treatment. If widely adopted, it may provide a common language to be used in future reporting of flow diversion results for clinical trials and daily practice. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT03831672.
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Affiliation(s)
- Huibin Kang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Zhengzhou University People's Hospital, Zhengzhou, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Fudan University, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yunyan Wang
- Qilu Hospital of Shandong University, Jinan, China
| | - Wenfeng Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Wang
- First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing 100050, China
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Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33973024 DOI: 10.1007/978-3-030-63453-7_3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery. METHODS The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies. RESULTS In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity. CONCLUSIONS Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.
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Porto GBF, Al Kasab S, Sattur MG, Almallouhi E, Lajthia O, Casey MA, Starke RM, Lanzino G, Ogilvy CS, Thomas AJ, Kim L, James RF, Levitt M, Spiotta AM. Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review. World Neurosurg 2021; 154:e421-e427. [PMID: 34284157 DOI: 10.1016/j.wneu.2021.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. METHODS A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up. RESULTS A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. CONCLUSION Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.
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Affiliation(s)
- Guilherme B F Porto
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mithun G Sattur
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Orgest Lajthia
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael A Casey
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert M Starke
- Department of Neurosurgery, Division of Neuroendovascular Surgery, University of Miami, Miami, Florida, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Robert F James
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Michael Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Lauzier DC, Cler SJ, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. The value of long-term angiographic follow-up following Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2021; 14:585-588. [PMID: 34210838 DOI: 10.1136/neurintsurg-2021-017745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is commonly performed, but the value of long-term angiographic follow-up has not been rigorously evaluated. Here we examine the prevalence of actionable findings of aneurysm recurrence and development of in-stent stenosis in a cohort of patients that underwent long-term angiographic follow-up at multiple time points. METHODS Angiographic data from eligible patients were retrospectively assessed for aneurysm occlusion, in-stent stenosis, and aneurysm regrowth or recurrence. Patients were included in this study if they underwent angiographic imaging at 6 months post-treatment and at least one later time point. RESULTS 100% (132/132) of aneurysms occluded at 6 months remained occluded at final follow-up. 85.7% (6/7), 56.3% (27/48), and 25% (6/24) of aneurysms with entry remnant, subtotal filling, and total filling, respectively, at 6 months were completely occluded at final follow-up. 98.7% (147/149) of PED constructs that demonstrated no stenosis at 6 months demonstrated no stenosis at final angiography, while 44.4% (8/18) of PED constructs demonstrating in-stent stenosis at 6 months had resolution of stenosis on final angiography. CONCLUSIONS Among patients who undergo treatment of intracranial aneurysms with PED, the value of long-term angiography in patients demonstrating complete aneurysm occlusion and no in-stent stenosis on 6 month post-treatment angiography is low.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Samuel J Cler
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Acerbi F, Vetrano IG, Falco J, Gioppo A, Ciuffi A, Ziliani V, Schiariti M, Broggi M, Faragò G, Ferroli P. In Situ Side-to-Side Pericallosal-Pericallosal Artery and Callosomarginal-Callosomarginal Artery Bypasses for Complex Distal Anterior Cerebral Artery Aneurysms: A Technical Note. Oper Neurosurg (Hagerstown) 2021; 19:E487-E495. [PMID: 32726426 DOI: 10.1093/ons/opaa236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/23/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite surgical and endovascular technical improvements over the last decades, the treatment of complex aneurysms of the distal anterior cerebral artery (ACA) is very challenging for both vascular neurosurgeons and interventional neuroradiologists. Furthermore, the interpersonal anatomic variability requires, most of the time, a tailored planning. OBJECTIVE To describe a novel technique of bypasses in the territory of ACA to protect the brain territory distal to the aneurysm. METHODS A 53-yr-old male with a large complex fusiform aneurysm of the left distal A2 segment of the ACA, involving the origin of the callosomarginal and pericallosal arteries, was judged not suitable for a single procedure (endovascular or neurosurgical). Two side-to-side bypasses were performed in a single surgery to connect the pericallosal and callosomarginal arteries of both sides, distally to the aneurysm. Subsequently, an endovascular embolization of the aneurysm was achieved with coils. RESULTS The patency of the microanastomoses, performed in the anterior interhemispheric fissure, was positively evaluated intraoperatively with indocyanine green and fluorescein videoangiography. The aneurysm sac, together with proximal A2 segment, was completely occluded with platinum coils. At the last follow-up, computed tomography angiography confirmed the patency of both bypasses, without any sign of aneurysm recanalization. The patients never complained of any focal neurological deficits or worsening of clinical status. CONCLUSION We present an elegant and innovative solution to completely protect the distal ACA territory in cases of complex aneurysm involving the origin of both callosomarginal and pericallosal arteries.
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Affiliation(s)
- Francesco Acerbi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Ignazio G Vetrano
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Jacopo Falco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andrea Gioppo
- Diagnostic Radiology and Interventional Neuroradiology Unit, Fondazione IRCCS "Istituto Neurologico Carlo Besta", Milan, Italy
| | - Andrea Ciuffi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Vanessa Ziliani
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco Schiariti
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Faragò
- Diagnostic Radiology and Interventional Neuroradiology Unit, Fondazione IRCCS "Istituto Neurologico Carlo Besta", Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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To YP, Lok CS, On TC, Fuk FK, Kei LS. Comparison of Treatment Modalities in Postirradiation Carotid Blowout Syndrome: A Multicenter Retrospective Review. World Neurosurg 2021; 152:e666-e672. [PMID: 34129983 DOI: 10.1016/j.wneu.2021.06.032] [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: 05/19/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Carotid blowout syndrome (CBS) is not uncommon in our locality, where head and neck cancers, especially nasopharyngeal carcinoma, are prevalent. Traditionally, CBS has resulted in high morbidity and mortality. The treatment paradigm has evolved from open surgery to endovascular interventions, and each treatment modality has its merits and drawbacks. In the present study, we investigated the outcomes of different treatment modalities for postirradiation CBS. METHODS We performed a 10-year multicenter retrospective review of the outcomes after endovascular trapping, flow diverters, and bypass surgery from 2009 to 2019. RESULTS A total of 53 patients with 60 blowouts were included in the present study. Of the 60 blowout cases, 25 were in the flow diverter group, 27 in the endovascular trapping group, and 8 in the bypass group. The mean survival was 32.2 months, with patient age affecting overall survival (P = 0.002). The stroke rate affected the 3- and 6-month functional outcomes (odds ratio, 7.388 and 6.353; P = 0.008 and P = 0.014, respectively). Of the 24 cases in the flow diverter group, 96% had achieved immediate hemostasis, with a rebleeding rate of 20% (P = 0.009). No rebleeding had occurred with endovascular trapping or bypass. The stroke rate in the endovascular trapping, flow diverter, and bypass groups was 25.9%, 20%, and 12.5%, respectively (P = 0.696). CONCLUSIONS Our results have shown that endovascular trapping is the first-line treatment of CBS. For patients with contraindications to endovascular trapping, the flow diverter is an alternative. For patients who have undergone flow diversion alone, definitive treatment such as bypass surgery might be indicated for selected patients to minimize the risk of rebleeding. After endovascular trapping, surgical bypass might be considered for selected patients with a higher risk of stroke.
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Affiliation(s)
- Yuen Pak To
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, People's Republic of China.
| | - Chu Sai Lok
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong Special Administrative Region, People's Republic of China
| | - Tsang Chun On
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, People's Republic of China
| | - Fok Kam Fuk
- Department of Neurosurgery, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, People's Republic of China
| | - Lam Siu Kei
- Department of Neurosurgery, Tuen Mun Hospital, Hong Kong Special Administrative Region, People's Republic of China
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Catapano JS, Ducruet AF, Cadigan MS, Farhadi DS, Majmundar N, Nguyen CL, Baranoski JF, Cole TS, Wilkinson DA, Fredrickson VL, Srinivasan VM, Albuquerque FC. Endovascular treatment of vertebral artery dissecting aneurysms : a 20-year institutional experience. J Neurointerv Surg 2021; 14:257-261. [PMID: 33906940 DOI: 10.1136/neurintsurg-2020-017089] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The ideal treatment for unruptured vertebral artery dissecting aneurysms (VADAs) and ruptured dominant VADAs remains controversial. We report our experience in the management and endovascular treatment of patients with VADAs. METHODS Patients treated endovascularly for intradural VADAs at a single institution from January 1, 1999, to December 31, 2019, were retrospectively reviewed. Primary neurological outcomes were assessed using modified Rankin Scale (mRS) scores, with mRS >2 considered a poor neurological outcome. Additionally, any worsening (increase) in the mRS score from the preoperative neurological examination was considered a poor outcome. RESULTS Ninety-one patients of mean (SD) age 53 (11.6) years (48 (53%) men) underwent endovascular treatment for VADAs. Fifty-four patients (59%) presented with ruptured VADAs and 44 VADAs (48%) involved the dominant vertebral artery. Forty-seven patients (51%) were treated with vessel sacrifice of the parent artery, 29 (32%) with flow diversion devices (FDDs), and 15 (17%) with stent-assisted coil embolization (stent/coil). Rates of procedural complications and retreatment were significantly higher with stent/coil treatment (complications 4/15; retreatment 6/15) than with vessel sacrifice (complications 1/47; retreatment 2/47) or FDD (complications 2/29; retreatment 4/29) (p=0.008 and p=0.002, respectively). Of 37 patients with unruptured VADAs treated, only two (5%) had mRS scores >2 on follow-up. CONCLUSION Endovascular FDD treatment of VADAs appears to be associated with lower retreatment and complication rates than stenting/coiling, although further study is required for confirmation. Endovascular treatment of unruptured VADAs was safe and was associated with favorable angiographic and neurological outcomes.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Megan S Cadigan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dara S Farhadi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Neil Majmundar
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Foreman PM, Ilyas A, Cress MC, Vachhani JA, Hirschl RA, Agee B, Griessenauer CJ. Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data. AJNR Am J Neuroradiol 2021; 42:720-725. [PMID: 33602746 DOI: 10.3174/ajnr.a7002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The Pipeline Embolization Device (PED) is a flow-diverting stent for the treatment of intracranial aneurysms and is used off-label for a subset of ruptured aneurysms not amenable to traditional treatment. PURPOSE Our aim was to evaluate the safety and efficacy of the PED for treatment of ruptured intracranial aneurysms. DATA SOURCES A systematic review of the MEDLINE, EMBASE, and Scopus data bases from January 2011 to March 2020 was performed for articles reporting treatment of ruptured intracranial aneurysms with the PED. STUDY SELECTION A total of 12 studies comprising 145 patients with 145 treated aneurysms were included for analysis. DATA ANALYSIS Individual patient data were collected. Nonparametric tests were used to compare differences among patients. Logistic regression was used to determine an association with outcome variables. DATA SYNTHESIS Mean aneurysm size was 5.9 mm, and most were blister (51.0%) or dissecting (26.9%) in morphology. Three (2.1%) aneurysms reruptured following PED placement. Univariate logistic regression identified larger aneurysm size as a significant predictor of aneurysm rerupture (P = .008). Of patients with radiographic follow-up, 87.5% had complete aneurysm occlusion. Symptomatic neurologic complications occurred in 16.5%. LIMITATIONS Analysis was limited by the quality of the included data, most of which were from small case series representing class III medical evidence. No study assessed outcome in a blinded or independently adjudicated manner. CONCLUSIONS Most ruptured aneurysms treated with the PED were blister or dissecting aneurysms. Treatment was associated with a rerupture rate of 2.1% and a complete occlusion rate of 87.5%.
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Affiliation(s)
- P M Foreman
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - A Ilyas
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M C Cress
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - J A Vachhani
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - R A Hirschl
- From the Neuroscience and Rehabilitation Institute (P.M.F., M.C.C., J.A.V., R.A.H.), Orlando Health, Orlando, Florida
| | - B Agee
- Department of Neurosurgery (A.I., B.A.), University of Alabama at Birmingham, Birmingham, Alabama
| | - C J Griessenauer
- Department of Neurosurgery (C.J.G.), Geisinger Health System, Danville, Pennsylvania
- Research Institute of Neurointervention (C.J.G.), Paracelsus Medical University, Salzburg, Austria
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Dmytriw AA, Kapadia A, Enriquez-Marulanda A, Parra-Fariñas C, Kühn AL, Nicholson PJ, Waqas M, Renieri L, Michelozzi C, Foreman PM, Phan K, Yang IH, Tutino VM, Ogilvy CS, Radovanovic I, Harrigan MR, Siddiqui AH, Levy EI, Limbucci N, Cognard C, Krings T, Pereira VM, Thomas AJ, Marotta TR, Griessenauer CJ. Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion. J Neurosurg 2021; 134:961-970. [PMID: 32217800 DOI: 10.3171/2020.1.jns193293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Coverage of the anterior spinal artery (ASA) ostia is a source of considerable consternation regarding flow diversion (FD) in vertebral artery (VA) aneurysms due to cord supply. The authors sought to assess the association between coverage of the ASA, posterior spinal artery (PSA), or lateral spinal artery (LSA) ostia when placing flow diverters in distal VAs and clinical outcomes, with emphasis on cord infarction. METHODS A multicenter retrospective study of 7 institutions in which VA aneurysms were treated with FD between 2011 and 2019 was performed. The authors evaluated the risk of ASA and PSA/LSA occlusion, associated thromboembolic complication, complications overall, aneurysm occlusion status, and functional outcome. RESULTS Sixty patients with 63 VA and posterior inferior cerebellar artery aneurysms treated with FD were identified. The median aneurysm diameter was 7 mm and fusiform type was the commonest morphology (42.9%). During a procedure, 1 (61.7%) or 2 (33.3%) flow diverters were placed. Complete occlusion was achieved in 71.9%. Symptomatic thromboembolic complications occurred in 7.4% of cases and intracranial hemorrhage in 10.0% of cases. The ASA and PSA/LSA were identified in 51 (80.9%) and 35 (55.6%) complications and covered by the flow diverter in 29 (56.9%) and 13 (37.1%) of the procedures, respectively. Patency after flow diverter coverage on last follow-up was 89.2% for ASA and 100% for PSA/LSA, not significantly different between covered and noncovered groups (p = 0.5 and p > 0.99, respectively). No complications arose from coverage. CONCLUSIONS FD aneurysm treatment in the posterior circulation with coverage of ASA or PSA/LSA was not associated with higher rates of occlusion of these branches or any instances of cord infarction.
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Affiliation(s)
- Adam A Dmytriw
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anish Kapadia
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Alejandro Enriquez-Marulanda
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carmen Parra-Fariñas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Anna Luisa Kühn
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Patrick J Nicholson
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Muhammad Waqas
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Leonardo Renieri
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | | | - Paul M Foreman
- 4Orlando Health, Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Kevin Phan
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - I-Hsiao Yang
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- 8Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Vincent M Tutino
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Christopher S Ogilvy
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Ivan Radovanovic
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mark R Harrigan
- 7Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Adnan H Siddiqui
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Elad I Levy
- 5Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Nicola Limbucci
- 6Department of Interventional Neuroradiology, University of Florence, Italy
| | - Christophe Cognard
- 9Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Timo Krings
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vitor Mendes Pereira
- 3Neurosurgery & Neuroradiology Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, Toronto
| | - Thomas R Marotta
- 2Department of Medical Imaging & Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- 10Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania; and
- 11Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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de Castro-Afonso LH, Nakiri GS, Abud TG, Monsignore LM, de Freitas RK, Abud DG. Aspirin monotherapy in the treatment of distal intracranial aneurysms with a surface modified flow diverter: a pilot study. J Neurointerv Surg 2021; 13:336-341. [PMID: 33514613 DOI: 10.1136/neurintsurg-2020-017024] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Flow diverters (FDs) result in high occlusion rates of aneurysms located distally to the carotid artery. However, the complications reported are not negligible. New modified surface FDs have low thrombogenic properties that may reduce ischemic complications related to the treatment. In addition, a modified surface FD may allow for the use of a single antiplatelet medication to reduce hemorrhagic risk during the procedure. The aim of this study was to assess the safety and efficacy of the p48 MW HPC (phenox, Bochum, Germany) to treat distal intracranial aneurysms under the use of aspirin monotherapy. METHODS The primary endpoint was the incidence of any neurologic deficit after treatment after 6 months of follow-up. The secondary endpoint was the rate of the complete occlusion of the aneurysms at the 6-month follow-up. Enrollment of 20 patients was planned, but after inclusion of seven patients the study was stopped due to safety issues. RESULTS Seven patients with eight aneurysms were included. Among the seven patients, three (42.8%) had ischemic complications on the second day after FD deployment. Two patients experienced complete recovery at discharge (National Institutes of Health Stroke Scale (NIHSS) score=0), while one patient maintained mild dysarthria at discharge (NIHSS score=1) which improved after 6 months (NIHSS score=0). All three patients had no new symptoms during the 6-month follow-up. Complete aneurysm occlusion occurred in six (75%) of the eight aneurysms at the 6-month follow-up. CONCLUSIONS Antiplatelet monotherapy with aspirin for the treatment of distal intracranial aneurysms with this modified surface FD resulted in a significant incidence of ischemic complications after treatment.
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Affiliation(s)
- Luis Henrique de Castro-Afonso
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Thiago Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil.,Interventional Neuroradiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Lucas Moretti Monsignore
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Rafael Kiyuze de Freitas
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
| | - Daniel Giansante Abud
- 1Division of Interventional Neuroradiology, Department of Medical Imaging, Hematology and Oncology, Universidade de Sao Paulo Faculdade de Medicina de Ribeirao Preto, Ribeirao Preto, São Paulo, Brazil
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Dinc H, Saatci I, Oguz S, Baltacioglu F, Yildiz A, Donmez H, Belet U, Onal B, Andic C, Koc O, Kocak O, Koroglu M, Cetin M, Cekirge HS. Long-term clinical and angiographic follow-up results of the dual-layer flow diverter device (FRED) for the treatment of intracranial aneurysms in a multicenter study. Neuroradiology 2021; 63:943-952. [PMID: 33392735 DOI: 10.1007/s00234-020-02627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Our aim was to determine the long-term safety and efficacy of the Flow Re-Direction Endoluminal Device (FRED) in this multicenter study with prospective design. MATERIALS-METHOD This study included 136 consecutive patients with 155 aneurysms treated between March 2013 and June 2016 in 10 centers. Twenty-two (16.2%) patients presented with rupture of the index aneurysm. Large/giant aneurysms comprised 1/3 of the cohort. Adjuvant coil use during the treatment was 15.5%. The effectiveness measure in the study was the percentage of aneurysms with stable occlusion at follow-up. RESULTS Vascular imaging follow-up was performed at least once in 131/136 (96.3%) patients with 148/155 (95.5%) aneurysms up to 75 months (mean: 37.3 months; median: 36 months according to latest follow-up), and 102/155(65.8%) aneurysms in 90/136 (66.2%) patients had ≥ 24-month control. According to the latest controls, the overall stable occlusion rate was 91.9% (95% CI, 87.5 to 96.3%). Three out of 148 aneurysms with follow-up were retreated (2%, 95% CI 0.0 to 4.3%). Adverse events were noted in 19/136 (14%, 95% CI, 9 to 21%) patients with a morbidity of 1.5% (95% CI, 0.0 to 3.5%). Mortality was 1/136 (0.7%, 95% CI, 0.02 to 2.2%) and was unrelated to aneurysm treatment. In-stent stenosis (ISS) was detected in 10/131 of the patients with follow-up (7.6%, 95% CI; 3.1 to 12.2%), only one being symptomatic. No adverse events have occurred in any of the patients with follow-up after 24 months, except the one resulting from ISS. CONCLUSION In the treatment of cerebral aneurysms which were candidates for flow diversion technique, this study showed long-term efficacy of FRED with good safety and occlusion rates.
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Affiliation(s)
- Hasan Dinc
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Isil Saatci
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey.
| | - Sukru Oguz
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Feyyaz Baltacioglu
- Radiology Department, School of Medicine, Marmara University, Istanbul, Turkey
| | - Altan Yildiz
- Radiology Department, School of Medicine, Mersin University, Mersin, Turkey
| | - Halil Donmez
- Radiology Department, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Umit Belet
- Radiology Department, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Baran Onal
- Radiology Department, School of Medicine, Gazi University, Ankara, Turkey
| | - Cagatay Andic
- Radiology Department, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Osman Koc
- Radiology Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Omer Kocak
- Radiology Department, Koru Hospitals, Ankara, Turkey
| | - Mert Koroglu
- Interventional Radiology Clinic, Medical Park VM Hospital, Samsun, Turkey
| | - Mustafa Cetin
- Radiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey
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Ide S, Kiyosue H, Tokuyama K, Hori Y, Sagara Y, Kubo T. Direct Carotid Cavernous Fistulas. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:583-592. [PMID: 37502141 PMCID: PMC10370662 DOI: 10.5797/jnet.ra.2020-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/01/2020] [Indexed: 07/29/2023]
Abstract
A direct carotid cavernous fistula (CCF) is an abnormal shunt between the internal carotid artery (ICA) and the cavernous sinus (CS). Traumatic CCF is the most common type, accounting for up to 75% of all CCFs. For the management of direct CCF, endovascular therapy has become the standard. For successful endovascular therapy, evaluation of the size and location of orifice of the CCF, venous drainage, and tolerance for ICA occlusion on cerebral angiography is necessary. Multi-planner reformatted images of 3D rotation angiography are useful to visualize the fistula and compartments of the CS precisely. Due to the limited commercial availability of detachable balloons, detachable coils have become a widely employed endovascular tool for the treatment of direct CCFs. The advantageous aspects of coil application are their easy retrievability and better control. In the case of large/multiple fistulas, adjunctive techniques, including balloon- and stent-assisted techniques, are often needed to occlude the CCF while preserving the ICA. To avoid cranial nerve palsy related to over-packing of the CS with detachable coils or a detachable balloon, selective embolization of the fistula portion is required. Use of liquid embolic materials and covered stents was recently reported as another adjunctive technique. In cases in which it is impossible to occlude the CCF while preserving the ICA, parent artery occlusion (PAO) is considered. The selection of additional/alternative techniques and devices depends on the anatomy and hemodynamics of each CCF, and the skill and experience of individual operators.
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Affiliation(s)
- Satomi Ide
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Hiro Kiyosue
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Kohei Tokuyama
- Department of Radiology, Oita University Faculty of Medicine, Yufu, Oita, Japan
| | - Yuzo Hori
- Department of Radiology, Nagatomi Neurosurgical Hospital, Oita, Oita, Japan
| | - Yoshiko Sagara
- Department of Radiology, Tsurumi Hospital, Beppu, Oita, Japan
| | - Takeshi Kubo
- Department of Neurosurgery, Oita University Faculty of Medicine, Yufu, Oita, Japan
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