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Meyer L, Stracke CP, Bester M, Kallmes KM, Zeleňák K, Rouchaud A, Martínez-Galdámez M, Jabbour P, Nguyen TN, Siddiqui AH, Fiehler J, Gellissen S. Predictors of aneurysm occlusion after treatment with flow diverters: a systematic literature review. J Neurointerv Surg 2024; 16:482-490. [PMID: 37316195 DOI: 10.1136/jnis-2022-019993] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/24/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Flow diverters (FDs) have become an integral part of treatment for brain aneurysms. AIM To summarize available evidence of factors associated with aneurysm occlusion (AO) after treatment with a FD. METHODS References were identified using the Nested Knowledge AutoLit semi-automated review platform between January 1, 2008 and August 26, 2022. The review focuses on preprocedural and postprocedural factors associated with AO identified in logistic regression analysis. Studies were included if they met the inclusion criteria of study details (ie, study design, sample size, location, (pre)treatment aneurysm details). Evidence levels were classified by variability and significancy across studies (eg, low variability ≥5 studies and significance in ≥60% throughout reports). RESULTS Overall, 2.03% (95% CI 1.22 to 2.82; 24/1184) of screened studies met the inclusion criteria for predictors of AO based on logistic regression analysis. Predictors of AO with low variability in multivariable logistic regression analysis included aneurysm characteristics (aneurysm diameter), particularly complexity (absence of branch involvement) and younger patient age. Predictors of moderate evidence for AO included aneurysm characteristics (neck width), patient characteristics (absence of hypertension), procedural (adjunctive coiling) and post-deployment variables (longer follow-up; direct postprocedural satisfactory occlusion). Variables with a high variability in predicting AO following FD treatment were gender, FD as re-treatment strategy, and aneurysm morphology (eg, fusiform or blister). CONCLUSION Evidence of predictors for AO after FD treatment is sparse. Current literature suggests that absence of branch involvement, younger age, and aneurysm diameter have the highest impact on AO following FD treatment. Large studies investigating high-quality data with well-defined inclusion criteria are needed for greater insight into FD effectiveness.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thanh N Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Yoshida S, Kazekawa K, Kamatani K, Maruyama K, Takigawa K, Tashiro N, Hashiguchi Y, Yasaka M, Aikawa H, Go Y. Prediction of obliteration of unruptured cerebral aneurysm by residual aneurysm volume after flow diverter stent treatment. World Neurosurg X 2024; 22:100354. [PMID: 38469386 PMCID: PMC10926355 DOI: 10.1016/j.wnsx.2024.100354] [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: 11/10/2023] [Accepted: 02/21/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction There is no methodology to predict aneurysm occlusion using residual volume after flow diverter stent treatment. We retrospectively examined whether residual aneurysm volume at 6 months postoperatively can predict the degree of aneurysm obliteration at 1 year after flow diverter stent treatment. Materials and Methods This single institution study included 101 consecutive patients who underwent flow diverter stent treatment for unruptured cerebral aneurysm. Based on pre-treatment aneurysm volume, the percentage residual volume was calculated 6 months postoperatively. The volume of the aneurysm was determined using the volume calculation function of the cerebral angiography equipment. 1 year postoperatively, patients were classified into two groups: the good obliteration group (GG; O'KellyMarotta [OKM] grading scale: C and D) and the poor obliteration group (PG; OKM: A and B). Statistical analysis was performed to determine if there was a difference in residual aneurysm volume percentage at 6 months postoperatively between the two groups. Results A total of 20 patients were studied: 6 in the GG and 14 in the PG. Mean residual aneurysm volume at 6 months postoperatively in the GG was 33.1% (±34.7), while that in the PG was 80.6% (±24.8) (P=0.018). A residual aneurysm volume of ≥35.2% at 6 months postoperatively was significantly associated with poor aneurysm obliteration at 1 year postoperatively (AUC=0.88, P=0.008). Conclusions Residual aneurysm volume percentage at 6 months after flow diverter stent treatment might be able to predict the likelihood of aneurysm occlusion at 1 year postoperatively.
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Affiliation(s)
- Shinichiro Yoshida
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Kiyoshi Kazekawa
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Kaisei Kamatani
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Kousei Maruyama
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Kousuke Takigawa
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Noriaki Tashiro
- Depatment of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Yoshiya Hashiguchi
- Depatment of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Masahiro Yasaka
- Depatment of Cerebrovascular Medicine, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Hiroshi Aikawa
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
| | - Yoshinori Go
- Department of Neurosurgery, Fukuoka Neurosurgical Hospital, 5-3-1 Osa, Minamiku, Fukuoka, 811-1313, Japan
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Fujimi Y, Ozaki T, Izutsu N, Nakajima S, Kanemura Y, Kidani T, Kawamoto S, Nishizawa N, Kobayashi K, Fujinaka T. Fungal symptomatic intracranial aneurysm treated with a flow diverting stent: A case report. Surg Neurol Int 2024; 15:58. [PMID: 38468648 PMCID: PMC10927200 DOI: 10.25259/sni_942_2023] [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: 11/24/2023] [Accepted: 01/27/2024] [Indexed: 03/13/2024] Open
Abstract
Background Intracranial infectious aneurysms (IIAs) are very rare, and fungal aneurysms are infrequently reported. We report a case of an unruptured IIA caused by fungal rhinosinusitis and treated with a flow-diverting stent. Case Description An 81-year-old woman visited the ophthalmology department with impaired eye movement and ptosis and was placed under follow-up. A week later, she also developed a headache; magnetic resonance angiography revealed an aneurysm measuring 2 mm in the C4 portion of the right internal carotid artery. A 3-week follow-up with contrast-enhanced magnetic resonance imaging showed an increase in its size to 10 mm, and a contrast lesion was observed surrounding the right cavernous sinus. The patient started treatment with voriconazole and steroids on the same day. Ten weeks later, despite improvements in inflammation, the size of the aneurysm was unchanged; we, therefore, treated the aneurysm with a flow-diverting stent. Oculomotor nerve palsy improved, and the patient was discharged to a rehabilitation hospital 28 days after the placement, with a modified Rankin Scale of 4. A 1-year follow-up angiogram showed a partial decrease in the size of the aneurysm, with an O'Kelly-Marotta grading scale of B3. Conclusion IIAs grow rapidly, and the risk of rupture is high due to the weakening of the aneurysmal wall. To reduce the risks of rupture and recurrence after treatment, the infection should be treated before inserting a flow-diverting stent. Flow-diverting stent placement may be an effective treatment for IIA once the original infection has been cured.
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Affiliation(s)
- Yosuke Fujimi
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Tomohiko Ozaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Nobuyuki Izutsu
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Shin Nakajima
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Yonehiro Kanemura
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
- Department of Biomedical Research and Innovation, Institute for Clinical Research, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Tomoki Kidani
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Saki Kawamoto
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Naoki Nishizawa
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Koji Kobayashi
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
| | - Toshiyuki Fujinaka
- Department of Neurosurgery, National Hospital Organization (NHO) Osaka National Hospital, Osaka, Japan
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Young M, Enriquez-Marulanda A, Salih M, Shutran M, Budohoski K, Grandhi R, Taussky P, Ogilvy CS. Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device. Neurosurgery 2024; 94:271-277. [PMID: 37655903 DOI: 10.1227/neu.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.
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Affiliation(s)
- Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Karol Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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Kashkoush A, El-Abtah ME, Davison MA, Toth G, Moore N, Bain M. Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01027. [PMID: 38251895 DOI: 10.1227/ons.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. METHODS We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. RESULTS Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. CONCLUSION Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark A Davison
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Fujitani S, Tsuruta W, Tomioka A, Ishigami D, Sekine T, Hosoo H, Kamiya Y, Matsumaru Y. Aneurysm Isolation is Associated with Complete Occlusion of Aneurysms After Flow Diverter Treatment. Clin Neuroradiol 2023; 33:1087-1093. [PMID: 37428198 DOI: 10.1007/s00062-023-01312-z] [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: 01/18/2023] [Accepted: 05/22/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Some aneurysms remain patent after treatment with flow diverters (FD) due to residual blood flow in the aneurysm. Several studies have proposed that branches and residual flow are associated with delayed aneurysm occlusion. We propose that aneurysm isolation (i.e., the complete disconnection of the aneurysm from surrounding vessels) might be a possible factor facilitating aneurysm occlusion. This study aimed to determine if aneurysm isolation was a factor associated with aneurysm occlusion after FD treatment. METHODS We reviewed 80 internal carotid artery (ICA) aneurysms treated with FDs between October 2014 and April 2021. Aneurysm isolation was assessed in high-resolution cone-beam computed tomograms at the end of each treatment. Aneurysms with incorporated branches and those with connections to other branches due to stent malapposition were deemed to be nonisolated. Other factors, such as patient age, sex, anticoagulant use, aneurysm size, adjunct coil use, and the presence of incorporated branches, were considered. The degree of aneurysm occlusion (complete or incomplete) was assessed by follow-up angiograms 12 months after treatment. RESULTS Complete occlusion was achieved in 57 of 80 aneurysms (71%). Completely occluded aneurysms had a significantly higher ratio of isolation compared to incompletely occluded aneurysms (91.2% vs. 69.6%, P = 0.032). Multivariate logistic regression analysis showed that aneurysm isolation was the sole significant predictor of complete aneurysm occlusion (odds ratio, OR 19.38; 95% confidence interval, CI 2.280-164.657; P = 0.007). CONCLUSION Aneurysm isolation is a significant factor contributing to complete occlusion after FD treatment.
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Affiliation(s)
- Shigeta Fujitani
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan.
| | - Arisa Tomioka
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daiichiro Ishigami
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomokazu Sekine
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Hisayuki Hosoo
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuki Kamiya
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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7
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Salih M, Young M, Filo J, Shutran M, Taussky P, Ogilvy CS. Effect of Statin on Radiographic and Clinical Outcomes of Intracranial Aneurysms Treated With Pipeline Embolization: A Propensity Score-Matched Analysis. Neurosurgery 2023; 93:1000-1006. [PMID: 37236144 DOI: 10.1227/neu.0000000000002522] [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: 02/11/2023] [Accepted: 03/21/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Studies have shown that use of statin can improve radiographic and clinical outcomes in patients receiving treatment for coronary artery or peripheral vascular stenosis. Statins are thought to be effective by reducing arterial wall inflammation. The same mechanism may have an influence on the efficacy of pipeline embolization device (PED) for intracranial aneurysm treatment. Although this question has been of interest, there is a lack of well-controlled data in the literature. The objective of this study is to analyze the effect of statins on outcomes of aneurysms treated with pipeline embolization through propensity score matching. METHODS Patients who underwent PED for unruptured intracranial aneurysms at our institution between 2013 and 2020 were identified. Patients on statin treatment vs those who were not were matched through propensity score by controlling for confounding factors including age, sex, current smoking status, diabetes, aneurysm morphology, volume, neck size, location of aneurysm, history of treatment for the same aneurysm, type of antiplatelet therapy, and elapsed time at last follow-up. Occlusion status at first follow up and last follow-up, and incidence of in-stent stenosis and ischemic complications during the follow-up period were extracted for comparison. RESULTS In total, 492 patients with PED were identified, of whom 146 were on statin therapy and 346 were not. After one-to-one nearest neighbor matching, 49 cases in each group were compared. At last follow-up, 79.6%, 10.2%, and 10.2% of cases in the statin therapy group and 67.4%, 16.3%, and 16.3% in the nonstatin group were noted to have Raymond-Roy 1, 2, and 3 occlusions, respectively ( P = .45). No significant difference was observed in immediate procedural thrombosis ( P > .99), long-term in-stent stenosis ( P > .99), ischemic stroke ( P = .62), or retreatment ( P = .49). CONCLUSION Statin use does not affect occlusion rate or clinical outcomes in patients treated with PED treatment for unruptured intracranial aneurysms.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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8
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Salem MM, Khorasanizadeh M, Nwajei F, Gomez-Paz S, Akamatsu Y, Jordan N, Maroufi SF, Thomas AJ, Ogilvy CS, Moore JM. Predictors of aneurysmal occlusion following intracranial aneurysms treatment with pipeline embolization device. Acta Neurochir (Wien) 2023; 165:2801-2809. [PMID: 37615726 DOI: 10.1007/s00701-023-05740-1] [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: 05/04/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE Pipeline embolization device (PED) is thought to induce aneurysmal occlusion through diversion of flow away from the aneurysmal sac with subsequent thrombosis and endothelialization. The impact of different factors especially hypertension (HTN)-a known predisposing factor to hypercoagulability and altered endothelial function-on aneurysmal occlusion after flow diversion has not been studied. We sought to determine predictors of aneurysmal occlusion following PED treatment focusing on impact of blood pressure. METHODS Database of patients with cerebral aneurysms treated with PED from 2013 to 2019 at our institution was retrospectively reviewed. Patients were defined as hypertensive if (1) they had a documented history of HTN requiring anti-HTN medications or (2) average systolic blood pressure on three measurements was > 130 mmHg. The primary outcome was aneurysm occlusion status at the last imaging follow-up. Multivariable logistic regression model was constructed to assess the effect of HTN on occlusion, controlling for age, smoking, aneurysmal size, fusiform morphology, posterior circulation location, and incorporated branches. RESULTS A total of 331 aneurysms in 294 patients were identified for this analysis. The mean age was 59 years (79.9% female). Fifty-five percent of the cohort were classified as hypertensive. When controlling for other potential confounders, hypertensive patients trended toward higher odds of achieving complete occlusion compared to non-hypertensive patients (OR = 2.05; 95% CI = 0.99-4.25; p = 0.052). Meanwhile, age (OR = 0.91; 95% CI = 0.88-0.95; p < 0.001) and an incorporated branch into an aneurysm (OR = 0.22; 95% CI = 0.08-0.58; p < 0.002) were associated with decreased odds for complete aneurysmal occlusion. CONCLUSION Hypertensive patients show a trend toward higher odds of achieving complete occlusion when controlling for potential confounders. The HTN-induced hypercoagulable state, enhanced endothelial activation, and altered extracellular matrix regulation might be the contributing factors. Further research is warranted to explore clinical implications of these findings.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - MirHojjat Khorasanizadeh
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noah Jordan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Hospital, Camden, NJ, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Hiramatsu R, Yagi R, Kameda M, Nonoguchi N, Furuse M, Kawabata S, Ohnishi H, Miyachi S, Wanibuchi M. Treatment Outcomes of 94 Cases of Pipeline Embolization Device in a Single Center: Predictive Factors of Incomplete Aneurysm Occlusion. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:217-223. [PMID: 37869485 PMCID: PMC10586884 DOI: 10.5797/jnet.oa.2023-0027] [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: 04/21/2023] [Accepted: 07/24/2023] [Indexed: 10/24/2023]
Abstract
Objective This study aimed to report the outcome of an endovascular treatment with a pipeline embolization device (PED) at a single center. We also examined the predictive factors for an incomplete occlusion after the PED placement. Methods The subjects were 94 patients with 109 aneurysms who underwent the PED placement at our single center from June 2015 to September 2022. As treatment outcomes, we investigated the PED placement success rate, perioperative morbidity and mortality, postoperative cranial nerve improvement rate, and the classification of angiographic result at 6 months after the PED placement. Furthermore, the predictors of an incomplete occlusion were investigated in detail. Results One hundred nine aneurysms locations were: C1 (9), C2 (30), C3 (15), C4 (53), and C5 (2) in the internal carotid artery segments. Perioperative morbidity, including the asymptomatic ones, occurred in 10 cases (10.6%). Among these 10 cases, the modified Rankin Scale (mRS) improved to preoperative mRS after 90 days in 9 cases except 1 case. On the other hand, no perioperative mortality was observed. The postoperative cranial nerve improvement rate was 84.4%, and 61.7% of patients had a complete occlusion in the follow-up angiography, 6 months after the PED placement. Predictive factors for an incomplete occlusion after the PED placement were the elderly aged 70 years or older (P-value = 0.0214), the elderly aged 75 years or older (P-value = 0.0009), and the use of anticoagulants (P-value = 0.0388) in an univariate analysis. Further, the multivariate analysis revealed that the elderly aged 75 years or older was a predictive factor of an incomplete occlusion in this study. Conclusion We summarized the outcomes of the PED treatment at our single center. In this study, the elderly aged 75 years or older was a predictive factor of an incomplete occlusion after the PED placement.
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Affiliation(s)
- Ryo Hiramatsu
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Ryokichi Yagi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kameda
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Naosuke Nonoguchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Motomasa Furuse
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Shinji Kawabata
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Hiroyuki Ohnishi
- Department of Neurosurgery, Ohnishi Neurological Center, Akashi, Hyogo, Japan
| | - Shigeru Miyachi
- Department of Neurosurgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery and Neuroendovascular Surgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
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10
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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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11
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Zhang H, Zhang H, Liu J, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Luo B, Shao Q, Chang K, Zhang Q, He Y, Zhang P, Yang X, Li L, Li TX. Pipeline Embolization Device for Small and Medium Vertebral Artery Aneurysms: A Multicenter Study. Neurosurgery 2023; 92:971-978. [PMID: 36700744 PMCID: PMC10158919 DOI: 10.1227/neu.0000000000002319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Pipeline embolization devices (PEDs) have been increasingly used for the treatment of posterior circulation aneurysms. OBJECTIVE To investigate the safety and efficacy of PED in the treatment of small to medium unruptured vertebral artery intracranial aneurysms (VAIAs). METHODS Data from 76 patients with 78 unruptured small and medium (≤12 mm) VAIAs were analyzed. Data for this study come from the PLUS study, which was conducted at 14 centers in China from 2014 to 2019. Univariate analyses were performed to evaluate predictors of the occlusion and complication. RESULTS Seventy-eight aneurysms in 76 patients were treated with PED. The mean aneurysm size was 8.28 ± 2.13 mm, and all PEDs were successfully placed. The median follow-up was 7 months and available for 67 (85.9%) aneurysms. Complete occlusion was seen in 60 (89.6%) aneurysms, which 86.6% met the primary efficacy outcome. All patients received clinical follow-up, the combined major morbidity and mortality was 2.6%, and 98.7% of patients had a good prognosis. Ischemic stroke occurred in 10.5% of patients, and adjuvant coil and successful after adjustment were predictors of ischemic stroke in the early postoperative and follow-up, respectively. There was no significant difference in the occlusion rate of aneurysm involving posterior inferior cerebellar artery ( P = .78). In cases where posterior inferior cerebellar artery was covered by PED, there was no significant difference in ischemic stroke. CONCLUSION In the treatment of unruptured ≤12 mm VAIAs, PED has a high surgical success rate, a high degree of occlusion, and low morbidity and mortality. PED may be a promising endovascular technique.
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Affiliation(s)
- Hongyun Zhang
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, International Neuroscience Institute (China-INI), Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, 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
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiuji Shao
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Kaitao Chang
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Qianqian Zhang
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, International Neuroscience Institute (China-INI), Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Li Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
| | - Tian xiao Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, Henan province, China
- Neurosurgery Department of Stroke Center, Henan Provincial People's, Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou, Henan, China
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12
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Turhon M, Kang H, Li M, Liu J, Zhang Y, Zhang Y, Huang J, Luo B, Liu J, Zhang H, Li T, Song D, Zhao Y, Guan S, Aximujiang A, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Zhang X, Gu Y, Yang X. Treatment of fusiform aneurysms with a pipeline embolization device: a multicenter cohort study. J Neurointerv Surg 2023; 15:315-320. [PMID: 35354575 DOI: 10.1136/neurintsurg-2021-018539] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/10/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intracranial fusiform aneurysms are less common than saccular aneurysms, but are associated with higher mortality and morbidity. We conducted this study to determine the safety and efficacy of the pipeline embolization device (PED) to treat intracranial fusiform aneurysms. METHODS This was a multicenter, retrospective, and observational study. Data for this study came from the PLUS study conducted from 2014 to 2019 across 14 centers in China. Univariate and multivariable logistic regression analyses were performed to evaluate predictors of the occlusion rate and complication. RESULTS A total of 1171 consecutive patients with 1322 intracranial aneurysms participated in this study. Among the participants, 104 patients with 109 fusiform aneurysms were eligible for this analysis (mean age 49 years, 36.5% women, aneurysm mean size 14.7 mm, 55% in the posterior circulation, and 6% in the basilar artery). Mean follow-up time was 9.0 months (range 3-36 months). The last DSA angiographic follow-up was available for 85 patients, and 58 aneurysms (68.2%) were completely occluded. The overall complication rate and mortality were 17.3% and 2.8%, respectively. Multivariate analysis demonstrated that age (OR=1.007, p=0.037) and cerebral atherosclerosis (OR=1.441, p=0.002) were associated with incomplete occlusion of fusiform aneurysms after PED treatment. CONCLUSION PEDs may be an effective treatment for intracranial fusiform aneurysms, with a favorable occlusion rate. However, because these treatments have a relatively high rate of complications, PED treatment for fusiform aneurysms should be carefully and strictly controlled. Our analysis showed that PEDs with adjunctive coiling did not significantly improve the occlusion rate of fusiform aneurysms.
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Affiliation(s)
- Mirzat Turhon
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huibin Kang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Mengxing Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jiliang Huang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Bin Luo
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China.,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China.,Department of Neurosurgery, Peking University International Hospital, Beijing, People's Republic of China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Shanghai, Shanghai, People's Republic of China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tianxiao Li
- Department of Neurosurgery, Zhengzhou University People's Hospital, Zhengzhou, Henan, People's Republic of China
| | - Donglei Song
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, People's Republic of China
| | - Yuanli Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, People's Republic of China
| | - Sheng Guan
- Department of Intervention Neuroradiology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, People's Republic of China
| | - Axir Aximujiang
- Department of Neurosurgery, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, People's Republic of China
| | - Aisha Maimaitili
- Department of Neurosurgery, Xinjiang Medical University Affiliated First Hospital, Urumqi, Xinjiang, People's Republic of China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital, Shandong University, Jinan, Shandong, People's Republic of China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yang Wang
- Department of Neurosurgery, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Department of Neurosurgery, Beijing ChaoYang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jieqing Wan
- Department of Neurosurgery, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, Shanghai, People's Republic of China
| | - Guohua Mao
- Department of Neurosurgery, Nanchang University Second Affiliated Hospital, Nanchang, Jiangxi, People's Republic of China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, People's Republic of China
| | - Xiaolong Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, Shanghai, People's Republic of China
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, Shanghai, People's Republic of China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, People's Republic of China .,Department of Interventional Neuroradiology, Beijing TianTan Hospital, Capital Medical University, Beijing, People's Republic of China
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13
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Kitamura T, Fujii T, Yatomi K, Teranishi K, Mitome-Mishima Y, Oishi H. Safety and efficacy of pipeline embolization device treatments for intradural internal carotid artery aneurysms in a single center in a Japanese population. Surg Neurol Int 2023; 14:92. [PMID: 37025526 PMCID: PMC10070317 DOI: 10.25259/sni_1165_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/25/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
The pipeline embolization device (PED) is the most common flow diverter device in the world. To date, there have been no reports of treatment outcomes specific to intradural internal carotid artery (ICA) aneurysms. The safety and efficacy of the PED treatments for intradural ICA aneurysms are reported.
Methods:
131 patients with 133 aneurysms underwent PED treatments for intradural ICA aneurysms. The mean aneurysm dome size and neck length were 12.7 ± 4.3 mm and 6.1 ± 2.2 mm, respectively. We used adjunctive endosaccular coil embolization for 88 aneurysms (66.2%). A total of 113 aneurysms (85%) were angiographically followed up 6 months following the procedure, and 93 aneurysms (69.9%) were followed up for 1 year.
Results:
The angiographic outcome at 6 months showed that 94 (83.2%) aneurysms had O’Kelly-Marotta (OKM) grade D, 6 (5.3%) had C, 10 (8.8%) had B, and 3 (2.7%) had A. At 1 year, 82 (88.2%) aneurysms had OKM grade D, 6 (6.5%) had C, 3 (3.2%) had B, and 2 (2.2%) had A. Multivariate analysis showed that aneurysm neck size and adjunctive coiling were statistically significant in aneurysm occlusion status. Major morbidity modified Rankin Scale >2 and mortality rates related to procedures were 3.0% and 0%, respectively. Delayed aneurysm ruptures were not observed.
Conclusion:
These results reveal that PED treatment of intradural ICA aneurysms is safe and efficacious. The combined use of adjunctive coil embolization not only prevents delayed aneurysm ruptures but also contributes to an increase in the rate of complete occlusion.
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Affiliation(s)
- Takayuki Kitamura
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Yumiko Mitome-Mishima
- Department of Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy and Neurosurgery, Juntendo University Faculty of Medicine, Bunkyo-ku, Tokyo, Japan
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14
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Enriquez-Marulanda A, Penumaka A, Ogilvy CS, Thomas AJ, Moore JM. In Reply: 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; 91:e136. [PMID: 36053078 DOI: 10.1227/neu.0000000000002126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/19/2022] Open
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15
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Xu C, Wu P, Zou L, Xu S, Luo B, Yang X, Shi H. Anterior Circulation Fusiform Aneurysms Have a Lower Occlusion Rate After Pipeline Embolization Device Treatment Than Posterior Circulation Fusiform Aneurysms: A Multicenter Cohort Study. Front Neurol 2022; 13:925115. [PMID: 35720088 PMCID: PMC9202754 DOI: 10.3389/fneur.2022.925115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objective:Intracranial fusiform aneurysms are uncommon and can occur in vessels of the anterior circulation (AC) or posterior circulation (PC). While flow diversion is one treatment option, research into Pipeline Embolization Device (PED) treatment is lacking. This study explored the efficacy and safety of PED treatment for intracranial fusiform aneurysms, and compared therapeutic effects between AC and PC aneurysms.MethodsIn the post-market multi-center cohort study of embolization of intracranial aneurysms with PED in China (PLUS) registry study, we retrospectively analyzed 71 fusiform aneurysms in 67 patients among 1,171 patients treated with a PED from November 2014 to October 2019. The general characteristics, perioperative status, aneurysm occlusion rate at the last follow-up angiography, and changes in modified Rankin Scale scores were analyzed. Aneurysms were divided into AC and PC groups, and univariate and multivariate analyses were conducted.ResultsThe study included 26 AC (25 patients) and 45 PC (42 patients) aneurysms. A total of 75 PEDs were used, an average of 1.1 PEDs were used, and the median follow-up was 6.7 months. Fifty aneurysms (71.4%) were occluded and twenty (28.5%) were incompletely occluded. There were significantly more occluded aneurysms in the PC group than in the AC group (12 vs. 38; P = 0.001). Risk factors for incomplete occlusion were AC aneurysms (P = 0.001) and a perforating artery originating from the aneurysm (P = 0.006). The mean modified Rankin Scale score was significantly lower at the last follow up than preoperatively (0.58 vs. 0.21; P = 0.0001).ConclusionNon-overlapping PED is a safe and effective treatment for both AC and PC fusiform aneurysms. The occlusion rate of AC fusiform aneurysms is lower than that of PC.
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Affiliation(s)
- Chao Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pei Wu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Liang Zou
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shancai Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Huaizhang Shi
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16
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Salem MM, Kvint S, Hendrix P, Al Saiegh F, Gajjar AA, Choudhri O, Jankowitz BT, Goren O, Gross BA, Jabbour P, Lang M, Schirmer CM, Tjoumakaris SI, Griessenauer CJ, Burkhardt JK. The Pennsylvania Postmarket Multicenter Experience With Flow Redirection Endoluminal Device. Neurosurgery 2022; 91:280-285. [PMID: 35394453 DOI: 10.1227/neu.0000000000001970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The flow redirection endoluminal device (FRED) is a novel self-expanding double-layer nitinol braided flow diverter that recently received FDA approval. However, early postmarket studies from the United States are lacking. OBJECTIVE To report our short-term multicenter experience. METHODS Series of consecutive patients undergoing FRED treatment for intracranial aneurysms were queried from prospectively maintained registries at 4 North-American Centers in Pennsylvania (February 2020-June 2021). The pertinent baseline demographics, aneurysmal characteristics, and procedural outcomes were collected and analyzed, with primary outcome of aneurysmal occlusion and secondary outcome of safety and complications. RESULTS Sixty-one patients (median age 58 years, 82% female) underwent 65 FRED treatment procedures for 72 aneurysms. Most (86.1%) of the aneurysms were unruptured; 80.5% were saccular in morphology, and 87.5% were located along the internal carotid artery, with a median size of 7.1 mm (IQR 5.2-11.9 mm). Radiographic follow-up was available in 86.1% of the aneurysms, showing complete occlusion in 74.2% (80% in catheter angiography-only group), and near-complete occlusion in 11.3% of the cases (median 6.3 months), with 2.8% re-treated. Permanent ischemic complications were encountered in 2.8% of the cases, with no procedural mortality. A modified Rankin Scale of 0 to 2 was documented in 98.1% of the patients at the last clinical follow-up (median 6.1 months). CONCLUSION The results of the early postmarket experience with the FRED device show reasonable safety and adequate aneurysmal occlusion rates comparable with other flow diverters. However, more extensive multicenter studies with more extended follow-up data are needed to assess the long-term safety and durability of the device.
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Affiliation(s)
- Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Svetlana Kvint
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Avi A Gajjar
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Omar Choudhri
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Medical Center, Danville, Pennsylvania, USA.,Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
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17
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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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18
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Hanel RA, Monteiro A, Nelson PK, Lopes DK, Kallmes DF. Predictors of incomplete aneurysm occlusion after treatment with the Pipeline Embolization Device: PREMIER trial 1 year analysis. J Neurointerv Surg 2021; 14:1014-1017. [PMID: 34716215 DOI: 10.1136/neurintsurg-2021-018054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters have revolutionized the treatment of intracranial aneurysms. Nevertheless, some aneurysms fail to occlude with flow diversion. The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device (PREMIER) was a prospective, multicenter and single-arm trial of small and medium wide-necked unruptured aneurysms. In the current study, we evaluate the predictors of treatment failure in the PREMIER cohort. METHODS We analyzed PREMIER patients who had incomplete occlusion (Raymond-Roy >1) at 1 year angiographic follow-up and compared them with those who achieved Raymond-Roy 1, aiming to identify predictors of treatment failure. RESULTS 25 aneurysms demonstrated incomplete occlusion at 1 year. There was a median reduction of 0.9 mm (IQR 0.41-2.43) in maximum diameter between pre-procedure and 1 year measurements, with no aneurysmal hemorrhage. Patients with incomplete occlusion were significantly older than those with complete occlusion (p=0.011). Smoking (p=0.045) and C6 segment location (p=0.005) were significantly associated with complete occlusion, while location at V4 (p=0.01) and C7 (p=0.007) and involvement of a side branch (p<0.001) were significantly associated with incomplete occlusion. In multivariable logistic regression, significant predictors of incomplete occlusion were non-smoker status (adjusted OR 4.49, 95% CI 1.11 to 18.09; p=0.03) and side branch involvement (adjusted OR 11.68, 95% CI 3.84 to 35.50; p<0.0001), while C6 location had reduced odds of incomplete occlusion (adjusted OR 0.29, 95% CI 0.10 to 0.84; p=0.02). CONCLUSIONS The results of our study are consistent with previous retrospective series and warrant consideration for technique adaptations to achieve higher occlusion rates. Further follow-up is needed to assess progression of aneurysm occlusion and clinical behavior in these cases.
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Affiliation(s)
- Ricardo A Hanel
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Andre Monteiro
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Peter K Nelson
- Radiology, NYU Langone Medical Center Neuroradiology Section, New York, New York, USA
| | - Demetrius K Lopes
- Brain and Spine Institute, Advocate Aurora Health, Park Ridge, Illinois, USA
| | - David F Kallmes
- Interventional Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
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19
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Fujii T, Teranishi K, Yatomi K, Suzuki K, Mitome-Mishima Y, Kondo A, Oishi H. Long-term Follow-up Results after Flow Diverter Therapy Using the Pipeline Embolization Device for Large or Giant Unruptured Internal Carotid Artery Aneurysms: Single-center Retrospective Analysis in the Japanese Population. Neurol Med Chir (Tokyo) 2021; 62:19-27. [PMID: 34707069 PMCID: PMC8754679 DOI: 10.2176/nmc.oa.2021-0203] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Flow diverter (FD) therapy using Pipeline embolization device (PED) has become an important alternative to treat internal carotid artery (ICA) aneurysms. Herein, we report the long-term outcome for 3 years after FD therapy using PED for ICA aneurysms in Japan. The patients who underwent angiographical and/or clinical follow-up for 3 years after the FD therapy using PED of large or giant unruptured ICA aneurysms from December 2012 at our university hospital are the subjects of this study. We retrospectively reviewed the in- and outpatients’ medical charts, and written operative and radiological records. There were 84 patients with 90 aneurysms who could be clinically and/or angiographically followed up for 3 years. Of these, 7 aneurysms were only available for clinical follow-up. Of the remaining 83 aneurysms, 6 aneurysms had vessel occlusion due to stent thrombosis or parent artery occlusion, and 60 of the remaining 77 (77.9%) had complete occlusion. In multivariate analysis, older age (>70 years), wide neck, and non-adjunctive coiling contributed statistically significantly to incomplete occlusion. Of the 84 patients, 2 patients (2.4%) had delayed complications between 6 months and 3 years after the initial FD placement. Three patients (3.6%) had poor outcome due to postoperative major stroke complications, 2 of which were acute complications. The long-term results after FD therapy are good both angiographically and clinically. Endothelialization of the aneurysmal neck and intra-aneurysmal thrombosis contribute to complete occlusion. The primary reason for the somewhat low complete occlusion in Japan may be the patients are generally older.
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Affiliation(s)
- Takashi Fujii
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kenji Yatomi
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Kazumoto Suzuki
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | | | - Akihide Kondo
- Department of Neurosurgery, Juntendo University, Graduate School of Medicine
| | - Hidenori Oishi
- Department of Neuroendovascular Therapy, Juntendo University, Graduate School of Medicine.,Department of Neurosurgery, Juntendo University, Graduate School of Medicine
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20
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Salem MM, Sweid A, Kuhn AL, Dmytriw AA, Gomez-Paz S, Maragkos GA, Waqas M, Parra-Farinas C, Salehani A, Adeeb N, Brouwer P, Pickett G, Ku J, X D Yang V, Weill A, Radovanovic I, Cognard C, Spears J, Cuellar-Saenz HH, Renieri L, Kan P, Limbucci N, Mendes Pereira V, Harrigan MR, Puri AS, Levy EI, Moore JM, Ogilvy CS, Marotta TR, Jabbour P, Thomas AJ. Repeat Flow Diversion for Cerebral Aneurysms Failing Prior Flow Diversion: Safety and Feasibility From Multicenter Experience. Stroke 2021; 53:1178-1189. [PMID: 34634924 DOI: 10.1161/strokeaha.120.033555] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD-a frequently utilized strategy in such cases. METHODS A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011-2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%-99% and <90% occlusion) versus complete occlusion (100%) after retreatment. RESULTS Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%-99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%; P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97-20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04-0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1-0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98-6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98-6.8]). CONCLUSIONS Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%-99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Ahmad Sweid
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Adam A Dmytriw
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Carmen Parra-Farinas
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Arsalaan Salehani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Nimer Adeeb
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Patrick Brouwer
- Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden (P.B.)
| | - Gwynedd Pickett
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada (G.P.)
| | - Jerry Ku
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Victor X D Yang
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, QC, Canada (A.W.)
| | - Ivan Radovanovic
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | - Julian Spears
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Hugo H Cuellar-Saenz
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K.)
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Vitor Mendes Pereira
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Thomas R Marotta
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
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21
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Prediction of atherosclerotic changes in cavernous carotid aneurysms based on computational fluid dynamics analysis: a proof-of-concept study. Neuroradiology 2021; 64:575-585. [PMID: 34505180 DOI: 10.1007/s00234-021-02803-x] [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: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Recent computational fluid dynamics (CFD) studies have demonstrated the concurrence of atherosclerotic changes in regions exposed to prolonged blood residence. In this proof-of-concept study, we investigated a small but homogeneous cohort of large, cavernous carotid aneurysms (CCAs) to establish the clinical feasibility of CFD analysis in treatment planning, based on the association between pathophysiology and hemodynamics. METHODS This study included 15 patients with individual large CCAs. We identified calcifications, which indicated atherosclerotic changes, using the masking data of digital subtraction angiography. We conducted a CFD simulation under patient-specific inlet flow rates measured using magnetic resonance (MR) velocimetry. In the post-CFD analysis, we calculated the blood residence time ([Formula: see text]) and segmented the surface exposed to blood residence time over 1 s ([Formula: see text]). We measured the decrease in volume after flow diversion using the original time-of-flight MR angiography data. RESULTS Calcifications were observed in the region with [Formula: see text]. In addition, the ratio of [Formula: see text] to the surface of the aneurysmal domain exhibited a negative relationship with the rate of volume reduction at the 6- and 12-month follow-ups. Post-CFD visualization demonstrated that intra-aneurysmal swirling flow prolonged blood residence time under the condition of a small inlet flow rate, when compared to the aneurysmal volume. CONCLUSION The results of this study suggest the usefulness of CFD analysis for the diagnosis of atherosclerotic changes in large CCAs that may affect the therapeutic response after flow diversion.
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22
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Liang F, Ma C, Zhu H, Liu L, Liang S, Jiang P, Zhang Y, Jiang C. Using angiographic parametric imaging-derived radiomics features to predict complications and embolization outcomes of intracranial aneurysms treated by pipeline embolization devices. J Neurointerv Surg 2021; 14:826-831. [PMID: 34413243 DOI: 10.1136/neurintsurg-2021-017832] [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: 05/27/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pipeline embolization devices (PEDs) have gained widespread popularity in the treatment of intracranial aneurysms (IAs). However, precise predictors of treatment outcomes are still lacking. This study aimed to use angiographic parametric imaging (API)-derived radiomics features to explore whether biomarkers extracted from immediate postprocedural digital subtraction angiography (DSA) were associated with complications and embolization outcomes of IAs treated with PED without adjunctive coils. METHODS Radiomic features were extracted from postprocedural DSA by API, and radiomics feature selection and radiomics score calculation were performed by the least absolute shrinkage and selection operator (LASSO) logistic regression. Angiographic findings and clinical characteristics were screened using stepwise multivariable logistic regression analysis to identify significant variables for predicting the complication endpoint. Radiomics feature selection and radiomics risk score (RadRS) calculations were performed by LASSO Cox regression. Univariate and multivariate Cox regression analyses were used to identify significant predictors for the occlusion endpoint. RESULTS We screened 281 observations for complications and 235 observations for embolization outcomes from IAs treated in our center using PED between June 2015 and July 2020. Multivariate regression analysis showed association of the radiomics score (p<0.01) and hypertension (p=0.04) with complications. RadRS (p<0.01), symptoms (p<0.01), and age (p=0.03) were predictors of embolization outcomes. Kaplan-Meier analysis revealed that symptomatic patients (p<0.01) and those with off-label IAs (p=0.03) had shorter intervals to complete occlusion. CONCLUSIONS Biomarkers extracted from immediate postprocedural DSA by API could be potential indicators for assessing treatment outcomes of IAs treated by PED without adjunctive coils.
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Affiliation(s)
- Fei Liang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Ma
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, 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
| | - Peng Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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23
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In-silico trial of intracranial flow diverters replicates and expands insights from conventional clinical trials. Nat Commun 2021; 12:3861. [PMID: 34162852 PMCID: PMC8222326 DOI: 10.1038/s41467-021-23998-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 05/25/2021] [Indexed: 01/18/2023] Open
Abstract
The cost of clinical trials is ever-increasing. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower these costs. We present the flow diverter performance assessment (FD-PASS) in-silico trial, which models the treatment of intracranial aneurysms in 164 virtual patients with 82 distinct anatomies with a flow-diverting stent, using computational fluid dynamics to quantify post-treatment flow reduction. The predicted FD-PASS flow-diversion success rates replicate the values previously reported in three clinical trials. The in-silico approach allows broader investigation of factors associated with insufficient flow reduction than feasible in a conventional trial. Our findings demonstrate that in-silico trials of endovascular medical devices can: (i) replicate findings of conventional clinical trials, and (ii) perform virtual experiments and sub-group analyses that are difficult or impossible in conventional trials to discover new insights on treatment failure, e.g. in the presence of side-branches or hypertension. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower costs. Here, the authors present the flow diverter performance assessment in-silico trial, which models the treatment of intracranial aneurysms with a flow-diverting stent.
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24
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White TG, Ryu B, Shah KA, Turpin J, Black K, Link T, Dehdashti AR, Katz JM, Woo HH. Quantitative magnetic resonance angiography to assess post embolization hemodynamics following pipeline embolization. Interv Neuroradiol 2021; 28:177-182. [PMID: 34151618 DOI: 10.1177/15910199211023650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Delayed intraparenchymal hemorrhage is a known complication of the Pipeline Embolization device (PED); however, its etiology is unclear and some have suggested it is a flow related phenomenon. Quantitative magnetic resonance angiography (QMRA) serves as a powerful tool to collect and analyze hemodynamic data. We report a detailed characterization of short-term hemodynamics after PED placement. METHODS Patients who underwent PED placement for a distal internal carotid artery (ICA) aneurysm between 2017 to 2019 with post embolization QMRA were reviewed. Aneurysm characteristics, flow volume rate (ml/min), mean, systolic, and diastolic flow velocities (cm/s), vessel diameter (mm), pulsatility index, Lindegaard ratio, and wall shear stress (WSS) were collected. RESULTS A total of 67 patients were included. Post-procedure patients were found to have a significantly lower ICA flow on the side with flow diversion when compared to the side without flow diversion (218 vs. 236.3; P < 0.05). Average ICA flow after flow diversion for aneurysms >2 cm was significantly lower when compared to the untreated side (187.7 vs. 240.4; P < 0.05). There was no difference in MCA or ACA flow or velocity. WSS was significantly lower in the treated ICA (8.2 vs. 9.0; P < 0.05). Lindegaard ratio was not different in the treated vs. contralateral untreated sides. CONCLUSION PED placement for distal ICA aneurysms results in lower flow, mean velocity, and WSS when compared to the contralateral untreated ICA. This is not demonstrated distal to the Pipeline device in the ACA or MCA territories. Ultimately these findings suggest hemodynamic changes are not a cause of PED complications.
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Affiliation(s)
- Timothy G White
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Brendan Ryu
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Kevin A Shah
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Justin Turpin
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Karen Black
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Thomas Link
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Amir R Dehdashti
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Jeffrey M Katz
- Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
| | - Henry H Woo
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, US
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25
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Barbour MC, Chassagne F, Chivukula VK, Machicoane N, Kim LJ, Levitt MR, Aliseda A. The effect of Dean, Reynolds and Womersley numbers on the flow in a spherical cavity on a curved round pipe. Part 2. The haemodynamics of intracranial aneurysms treated with flow-diverting stents. JOURNAL OF FLUID MECHANICS 2021; 915:A124. [PMID: 34658417 PMCID: PMC8519511 DOI: 10.1017/jfm.2020.1115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The flow in a spherical cavity on a curved round pipe is a canonical flow that describes well the flow inside a sidewall aneurysm on an intracranial artery. Intracranial aneurysms are often treated with a flow-diverting stent (FDS), a low-porosity metal mesh that covers the entrance to the cavity, to reduce blood flow into the aneurysm sac and exclude it from mechanical stresses imposed by the blood flow. Successful treatment is highly dependent on the degree of reduction of flow inside the cavity, and the resulting altered fluid mechanics inside the aneurysm following treatment. Using stereoscopic particle image velocimetry, we characterize the fluid mechanics in a canonical configuration representative of an intracranial aneurysm treated with a FDS: a spherical cavity on the side of a curved round pipe covered with a metal mesh formed by an actual medical FDS. This porous mesh coverage is the focus of Part 2 of the paper, characterizing the effects of parent vessel Re, De and pulsatility, Wo, on the fluid dynamics, compared with the canonical configuration with no impediments to flow into the cavity that is described in Part 1 (Chassagne et al., J. Fluid Mech., vol. 915, 2021, A123). Coverage with a FDS markedly reduces the flow Re in the aneurysmal cavity, creating a viscous-dominated flow environment despite the parent vessel Re > 100. Under steady flow conditions, the topology that forms inside the cavity is shown to be a function of the parent vessel De. At low values of De, flow enters the cavity at the leading edge and remains attached to the wall before exiting at the trailing edge, a novel behaviour that was not found under any conditions of the high-Re, unimpeded cavity flow described in Part 1. Under these conditions, flow in the cavity co-rotates with the direction of the free-stream flow, similar to Stokes flow in a cavity. As De increases, the flow along the leading edge begins to separate, and the recirculation zone grows with increasing De, until, above De ≈ 180, the flow inside the cavity is fully recirculating, counter-rotating with respect to the free-stream flow. Under pulsatile flow conditions, the vortex inside the cavity progresses through the same cycle - switching from attached and co-rotating with the free-stream flow at the beginning of the cycle (low velocity and positive acceleration) to separated and counter-rotating as De reaches a critical value. The location of separation within the harmonic cycle is shown to be a function of both De and Wo. The values of aneurysmal cavity Re based on both the average velocity and the circulation inside the cavity are shown to increase with increasing values of De, while Wo is shown to have little influence on the time-averaged metrics. As De increases, the strength of the secondary flow in the parent vessel grows, due to the inertial instability in the curved pipe, and the flow rate entering the cavity increases. Thus, the effectiveness of FDS treatment to exclude the aneurysmal cavity from the haemodynamic stresses is compromised for aneurysms located on high-curvature arteries, i.e. vessels with high De, and this can be a fluid mechanics criterion to guide treatment selection.
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Affiliation(s)
- Michael C. Barbour
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
| | - Fanette Chassagne
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
| | - Venkat K. Chivukula
- Biomedical and Chemical Engineering and Sciences, Florida Institute of Technology, Melbourne, FL 32901, USA
| | | | - Louis J. Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Michael R. Levitt
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
- Department of Radiology, University of Washington, Seattle, WA 98107, USA
| | - Alberto Aliseda
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98107, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA 98107, USA
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26
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Kamide T, Misaki K, Uno T, Yoshikawa A, Uchiyama N, Nakada M. Extracranial-intracranial high-flow bypass as a rescue therapy for incomplete cerebral aneurysm occlusion after flow diversion: A case report. Surg Neurol Int 2021; 12:57. [PMID: 33654560 PMCID: PMC7911044 DOI: 10.25259/sni_836_2020] [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: 11/21/2020] [Accepted: 01/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Excellent treatment outcomes using a pipeline embolization device (PED) have been reported. However, several limitations exist. For example, patients must receive antiplatelet therapy for at least several months, and few alternative treatments exist except for inserting additional flow diverter stents in cases where aneurysm obliteration is not obtained. Case Description: A 67-year-old female suffered from an asymptomatic large aneurysm of the left paraclinoid internal carotid artery (ICA). She underwent endovascular coil embolization, but coil compaction was confirmed at 2-year follow-up. A PED was inserted as an additional treatment. Unfortunately, the patient was required to discontinue antiplatelet therapy to undergo orthopedic surgery for her severe osteoarthritis of the knee. However, surveillance imaging performed 2 years after insertion of the PED revealed persistent filling into the aneurysm, and we could not stop the antiplatelet therapy to proceed with orthopedic surgery. Therefore, we performed ICA trapping with extracranial-intracranial high-flow bypass to cease antiplatelet therapy promptly. Antiplatelet therapy was completed 3 months after the rescue surgery, and the patient underwent orthopedic surgery. Conclusion: The authors describe a case of failure of complete obliteration after treatment using a PED, which required cessation of antiplatelet therapy to receive orthopedic surgery. Although safety and efficacy of PED treatment have been reported, we must consider the possibility of other diseases requiring discontinuation of antiplatelet therapy after PED embolization.
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Affiliation(s)
- Tomoya Kamide
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Kouichi Misaki
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Takehiro Uno
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Akifumi Yoshikawa
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Naoyuki Uchiyama
- Department of Neurosurgery, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Mitsutoshi Nakada
- Department of Neurosurgery, Kanazawa University, Kanazawa, Ishikawa, Japan
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27
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Maragkos GA, Dmytriw AA, Salem MM, Tutino VM, Meng H, Cognard C, Machi P, Krings T, Mendes Pereira V. Overview of Different Flow Diverters and Flow Dynamics. Neurosurgery 2020; 86:S21-S34. [PMID: 31838536 DOI: 10.1093/neuros/nyz323] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.
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Affiliation(s)
- Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Hui Meng
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hopitalier de Toulouse, Toulouse, France
| | - Paolo Machi
- Department of Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Vitor Mendes Pereira
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
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28
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Luo B, Kang H, Zhang H, Li T, Liu J, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X. Pipeline Embolization device for intracranial aneurysms in a large Chinese cohort: factors related to aneurysm occlusion. Ther Adv Neurol Disord 2020; 13:1756286420967828. [PMID: 33224273 PMCID: PMC7649855 DOI: 10.1177/1756286420967828] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The Pipeline Embolization Device (PED, Covidien/Medtronic) is widely used to treat intracranial aneurysms. This PED in China post-market multi-center registry study (PLUS) investigated safety and effectiveness of the PED for intracranial aneurysms in the Chinese population. Methods: This was a panoramic, consecutive, real-world cohort registry study. Patients treated with PED with or without coils between November 2014 and October 2019 at 14 centers in China were included, and those treated by parent vessel occlusion or other stents were excluded. Study outcomes included angiographic evaluation of aneurysm occlusion, complications, in-stent stenosis, and predictors of aneurysm occlusion. A central committee reviewed all imaging and endpoint events. Results: In total, 1171 patients with 1322 intracranial aneurysms were included. The total occlusion rate was 81.4% (787/967) at mean follow-up of 8.96 ± 7.50 months, with 77.1% (380/493) occlusion in the PED alone and 85.9% (407/474) in the PED plus coiling group. On multi-variate analysis, female sex, hyperlipidemia, vertebral aneurysms, PED plus coiling, and blood flow detained to venous phase were significant predictors of aneurysm occlusion. In posterior circulation cohort, there was no variable associated with aneurysm occlusion. In-stent stenosis predictors included current smoking and cerebral sclerosis/stenosis. Conclusion: In the largest series on PED of multi-center date of China, data suggest that treatment with the flow-diverting PED in intracranial aneurysms was efficacious. The treatment of PED combined coiling and blood flow detained to venous phase after PED implant were associated with aneurysmal occlusion. The occlusion rate of vertebral aneurysms was higher than other location aneurysms. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT03831672.
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Affiliation(s)
- Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huibin Kang
- Beijing Neurosurgical Institute, 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
| | - Jianmin Liu
- Changhai Hospital Affiliated to Naval Medical University, Shanghai, China
| | - Donglei Song
- Shanghai Donglei Brain Hospital, Shanghai, China
| | - Yuanli Zhao
- Peking University International Hospital, Beijing, China
| | - Sheng Guan
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aisha Maimaitili
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, 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
| | - Jieqing Wan
- Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huaizhang Shi
- First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing, 100050, China
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29
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Flow diversion of fusiform intracranial aneurysms. Neurosurg Rev 2020; 44:1471-1478. [PMID: 32562019 DOI: 10.1007/s10143-020-01332-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/03/2020] [Accepted: 06/04/2020] [Indexed: 02/07/2023]
Abstract
Fusiform aneurysms are less common than saccular aneurysms, but have higher associated mortality and rebleeding rates. Recently, flow diversion has emerged as a possible treatment option. The purpose of this study was to determine the safety and efficacy of the Pipeline Embolization Device (PED) for the treatment of ruptured and unruptured fusiform aneurysms. This was a retrospective analysis of patients with fusiform intracranial aneurysms treated with a PED at a quaternary care center between January 2012 and September 2019. Occlusion rates, neurologic morbidity/mortality, and other clinical variables were analyzed. Twenty-nine patients with 30 fusiform aneurysms were treated with a PED. Sixteen aneurysms (53%) were located in the anterior circulation and 14 aneurysms (47%) were in the posterior circulation. The mean maximal diameter of the aneurysms was 10.1 ± 5.6 mm (range 2.3-25 mm). Angiographic and clinical follow-up were available for 28 aneurysms (93%). The median follow-up was 17.4 months (IQR 4.8 to 28 months) and occlusion rates were graded according to the O'Kelly-Marotta (OKM) scale. Of patients with DSA follow-up, 15 aneurysms (60%) were completely occluded (OKM D) and 19 aneurysms (76%) had a favorable occlusion result (OKM C1-3 and D). The overall complication rate was 26.7% with a neurological morbidity rate of 6.7% and neurological mortality rate of 3.4%. Flow diversion can be an effective treatment for both ruptured and unruptured fusiform aneurysms. Nevertheless, complete occlusion rates are lower than for saccular aneurysms. Therefore, flow diversion should be considered only if other more direct treatment options, such as clipping or stent/coiling are not applicable. Flow diversion should be used cautiously in patients presenting with rupture.
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30
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Lv X, Jiang C, Wu Z, Jiang W, Wang G. Complex cerebral aneurysms: intra-luminal reconstruction using Pipeline flow-diverting stent and the obliteration mechanism. Neuroradiol J 2020; 33:91-97. [PMID: 31822193 PMCID: PMC7140306 DOI: 10.1177/1971400919894879] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Patients with complex cerebral aneurysms can now be treated intravascularly with the help of flow-diverting stents. The primary purpose of this article is to document the clinical and angiographic outcomes in 80 patients who were treated with the Pipeline flow-diverting stent (PFS; Medtronic, Dublin, Ireland) and the obliteration mechanism was discussed. PATIENTS AND METHODS Between October 2015 and October 2019, 80 patients with 90 complex (undefined neck, large/giant, blood blister-like, and recurrent side-wall) cerebral aneurysms treated with the PFS were retrospectively reviewed. Forty-five patients were women and 35 were men, with a mean age of 52 years. Large or giant aneurysms were defined as 10 mm or larger and small aneurysms were defined as less than 10 mm at the largest diameter measured on angiogram. RESULTS Forty-one aneurysms (45.6%) were large or giant, 41 (45.6%) were small, four (4.4%) were recurrent side-wall aneurysms and four (4.4%) were blood blister-like aneurysms. In total, 87 PFSs were placed in 80 patients with 90 aneurysms. In six patients, coexisting proximal stenosis of parent artery was also covered with PFS without balloon angioplasty. Adjunct coils were placed in 31 aneurysms (34%). One patient died of intracerebral hematoma after thrombolysis. There was one intrastent occlusion at six-month follow-up without any symptoms. The morbidity and the mortality rate is 0% and 1.3% (95% confidence interval (CI), 0%-3.7%). Control angiography was available in 74 (92.5%) patients with 83 aneurysms, and the aneurysm occlusion rate was 98.8% (95% CI, 96.5%-100%) in 6 to 12 months. CONCLUSION For wide-necked saccular, large/giant, blood blister-like aneurysms and recurrent side-wall aneurysms, PFS is a valid and safe treatment option.
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Affiliation(s)
- Xianli Lv
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University,
China
| | - Chuhan Jiang
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University,
China
| | - Zhongxue Wu
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University,
China
| | - Weijian Jiang
- New Era Stroke Care and Research
Institute, The PLA Rocket Force General Hospital, Beijing
| | - Guihuai Wang
- Neurosurgery Department, Beijing
Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University,
China
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31
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Hussein AE, Shownkeen M, Thomas A, Stapleton C, Brunozzi D, Nelson J, Naumgart J, Linninger A, Atwal G, Alaraj A. 2D parametric contrast time-density analysis for the prediction of complete aneurysm occlusion at six months' post-flow diversion stent. Interv Neuroradiol 2020; 26:468-475. [PMID: 32102574 DOI: 10.1177/1591019920908205] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Indications for the treatment of cerebral aneurysms with flow diversion stents are expanding. The current aneurysm occlusion rate at six months ranges between 60 and 80%. Predictability of complete vs. partial aneurysm occlusion is poorly defined. Here, we evaluate the angiographic contrast time-density as a predictor of aneurysm occlusion rate at six months' post-flow diversion stents. METHODS Patients with unruptured cerebral aneurysms proximal to the internal carotid artery terminus treated with single flow diversion stents were included. 2D parametric parenchymal blood flow software (Siemens-Healthineers, Forchheim, Germany) was used to calculate contrast time-density within the aneurysm and in the proximal adjacent internal carotid artery. The area under the curve ratio between the two regions of interests was assessed at baseline and after flow diversion stents deployment. The area under the curve ratio between completely vs. partially occluded aneurysms at six months' follow-up was compared. RESULTS Thirty patients with 31 aneurysms were included. Mean aneurysm diameter was 8 mm (range 2-28 mm). Complete occlusion was obtained in 19 aneurysms. Younger patients (P = 0.006) and smaller aneurysms (P = 0.046) presented higher chance of complete obliteration. Incomplete occlusion of the aneurysm was more likely if the area under the curve contrast time-density ratio showed absolute (P = 0.001) and relative percentage (P = 0.001) decrease after flow diversion stents deployment. Area under ROC curve was 0.85. CONCLUSION Negative change in the area under the curve ratio indicates less contrast stagnation in the aneurysm and lower chance of occlusion. These data provide a real-time analysis after aneurysm treatment. If validated in larger datasets, this can prompt input to the surgeon to place a second flow diversion stents.
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Affiliation(s)
- Ahmed E Hussein
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Meghana Shownkeen
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Andre Thomas
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Denise Brunozzi
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | | | | | - Andreas Linninger
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.,Department of Bioengineering, University of Illinois at Chicago, Chicago, IL, USA
| | - Gursant Atwal
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.,Department of Bioengineering, University of Illinois at Chicago, Chicago, IL, USA
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