1
|
Nejadhamzeeigilani H, Buende T, Saleem N, Goddard T, Patankar T. Single centre experience of stent-assisted coiling of wide-necked basilar tip aneurysms. Br J Radiol 2023; 96:20220504. [PMID: 37660365 PMCID: PMC10607421 DOI: 10.1259/bjr.20220504] [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: 05/13/2022] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE To report clinical and radiological follow-up outcomes of stent-assisted coiling of wide-necked basilar tip aneurysms and to evaluate the safety and efficacy of this treatment choice. METHODS A retrospective review was carried out of 19 patients with wide-necked basilar tip aneurysms in our institution between 2010 and 2020. The rates of perioperative complication, morbidity, mortality, imaging follow-up and re-treatment were analysed. RESULTS Our technical complication rate was 11% but did not result in treatment failure. The combined procedure related morbidity and mortality rate of the 19 patients who underwent stent assisted coiling was also 11%. 16 of 19 patients had undergone angiographic follow-up with a mean period of 32 months. 81% of patients with angiographic follow-up had a satisfactory occlusion (RROI or II) with 11% requiring re-treatment. Those requiring re-treatment were both treated with laser-cut stents; this is in contrast with no re-treatments required in the patients treated with braided stents. CONCLUSION Our report provides acceptable outcomes in wide-necked basilar termination aneurysms which are very challenging to treat. Aneurysms treated with braided stents had better efficacy outcomes than those with laser-cut stents. ADVANCES IN KNOWLEDGE Given the emergent and increasing utility of alternative endovascular techniques such as intrasaccular devices and flow diverters, real-world data are lacking on more conventional approaches such stent-assisted coiling, especially so in the posterior circulation. The associated relatively higher aneurysmal haemorrhagic risk in this location warrants further additional safety and efficacy data for this treatment approach, which this paper provides.
Collapse
Affiliation(s)
- Hamed Nejadhamzeeigilani
- Department of Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Thierry Buende
- Department of Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Nayyar Saleem
- Department of Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Tony Goddard
- Department of Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Tufail Patankar
- Department of Interventional Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| |
Collapse
|
2
|
Maurer CJ, Berlis A, Maus V, Behrens L, Weber W, Fischer S. Treatment of broad-based intracranial aneurysms with the LVIS EVO stent: a retrospective observational study at two centers with short- and medium-term follow-up. Sci Rep 2023; 13:7232. [PMID: 37142694 PMCID: PMC10157134 DOI: 10.1038/s41598-023-34270-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
The use of stents is well established in the treatment of broad-based intracranial aneurysms. The aim of this study is to report on safety, feasibility and midterm follow-up of the new LVIS EVO braided stent for the treatment of cerebral aneurysms. All consecutive patients with intracranial aneurysms who were treated with the LVIS EVO stent in two high volume neurovascular centers were retrospectively enrolled in this observational study. Clinical and technical complications, angiographic outcome and clinical short-term and midterm results were evaluated. The study included 112 patients with 118 aneurysms. 94 patients presented with incidental aneurysms, 13 patients with acute SAH and 2 patients with acute cranial nerve palsy. For 100 aneurysms a jailing technique was used, re-crossing of the stent was performed in 3 cases. For the residual 15 cases the stent was placed as a bail-out or as a second step. Immediate complete occlusion was observed in 85 aneurysms (72%). Midterm follow-up was available for 84 patients with 86 aneurysms (72.9%). One stent showed asymptomatic complete occlusion on follow-up imaging, in all other cases no in-stent stenosis was observed. The rate of complete occlusion was 79.1% at 6 months and 82.2% at 12-18 months. Midterm follow-up data of this retrospective observational cohort of two neurovascular centers corroborates the safety profile of the LVIS EVO device for treatment of ruptured and unruptured intracranial aneurysms.
Collapse
Affiliation(s)
- Christoph J Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Volker Maus
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Lars Behrens
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Stenglinstraße 2, 86156, Augsburg, Germany
| | - Werner Weber
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Sebastian Fischer
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| |
Collapse
|
3
|
Lauzier DC, Root BK, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. Need for Y-stenting in stent-assisted coiling of wide-neck bifurcation aneurysms. Clin Neurol Neurosurg 2023; 229:107748. [PMID: 37146368 DOI: 10.1016/j.clineuro.2023.107748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/06/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown. MATERIALS AND METHODS Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting. RESULTS Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43). CONCLUSION Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.
Collapse
Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA.
| | - Brandon K Root
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA; Department of Neurological Surgery, Washington University School of Medicine, USA; Department of Neurology, Washington University School of Medicine, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA; Department of Neurological Surgery, Washington University School of Medicine, USA; Department of Neurology, Washington University School of Medicine, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA; Department of Neurological Surgery, Washington University School of Medicine, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, USA; Department of Neurological Surgery, Washington University School of Medicine, USA; Department of Neurology, Washington University School of Medicine, USA
| |
Collapse
|
4
|
Zhu D, Li Z, Zou C, Cao W, Zhang P, Yu Y, Li Q, Zhao R, Huang Q, Yang P, Xu Y, Hong B, Liu J, Fang Y. Treatment of intracranial bifurcation aneurysms with "X" stent-assisted coiling: A case series and literature review. J Stroke Cerebrovasc Dis 2023; 32:106946. [PMID: 36527944 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106946] [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: 11/13/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To clarify the safety and efficacy of "X" stent-assisted coiling (X-stenting) for the treatment of intracranial bifurcation aneurysms and to review the literature. METHODS We retrospectively reported five consecutive patients with six intracranial bifurcation aneurysms who underwent X-stenting between June 2014 and June 2020. The clinical and angiographic results were analyzed. We also performed an extensive PubMed review of medical literature up to June 2021. RESULTS Endovascular procedures were successfully applied to all six aneurysms. No procedure-related complications were noted. Follow-up angiograms were available for all patients and revealed occlusion in five aneurysms and improvement in one aneurysm. Clinical follow-up was performed for all patients, and the mRS score at follow-up was 0 in all patients. Thus, good outcomes were achieved in all patients, and no ischemic or hemorrhagic events were observed. CONCLUSIONS X-stenting appears to be safe for treating intracranial bifurcation aneurysms and effective in immediate and short-term outcome. Further research is required with well-designed, prospective studies with large sample sizes.
Collapse
Affiliation(s)
- Deyuan Zhu
- Department of Neurovascular Disease, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Address: 1279 Sanmen Road, Shanghai 200080, China
| | - Zhe Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Chao Zou
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei Cao
- Department of Neurovascular Disease, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Address: 1279 Sanmen Road, Shanghai 200080, China
| | - Ping Zhang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Ying Yu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Rui Zhao
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yi Xu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yibin Fang
- Department of Neurovascular Disease, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Address: 1279 Sanmen Road, Shanghai 200080, China.
| |
Collapse
|
5
|
λ stenting: a novel technique for posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome. Neuroradiology 2021; 64:151-159. [PMID: 34351498 PMCID: PMC8724119 DOI: 10.1007/s00234-021-02775-y] [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: 05/16/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
Purpose Endovascular treatment of posterior communicating artery aneurysms with fetal-type posterior communicating artery originating from the aneurysm dome is often challenging because, with conventional techniques, dense packing of aneurysms for posterior communicating artery preservation is difficult; moreover, flow-diversion devices are reportedly less effective. Herein, we describe a novel method called the λ stenting technique that involves deploying stents into the internal carotid artery and posterior communicating artery. Methods Between January 2018 and September 2020, the λ stenting technique was performed to treat eight consecutive cases of aneurysms. All target aneurysms had a wide neck (dome/neck ratio < 2), a fetal-type posterior communicating artery with hypoplastic P1, and a posterior communicating artery originating from the aneurysm dome. The origin of the posterior communicating artery from the aneurysm, relative to the internal carotid artery, was steep (< 90°: V shape). Results The maximum aneurysm size was 8.0 ± 1.9 mm (6–12 mm). The average packing density (excluding one regrowth case) was 32.7 ± 4.2% (26.8–39.1%). Initial occlusion was complete occlusion in 6 (75.0%) patients and neck remnants in 2 (25.0%) patients. Follow-up angiography was performed at 18.4 ± 11.6 months (3–38 months). There were no perioperative complications or reinterventions required during the study period. Conclusion The λ stenting technique enabled dense coil packing and preservation of the posterior communicating artery. This technique enabled safe and stable coil embolization. Thus, it could become an alternative treatment option for this sub-type of intracranial aneurysms. Supplementary Information The online version contains supplementary material available at 10.1007/s00234-021-02775-y.
Collapse
|
6
|
The Geometry of Y-Stent Configurations Used for Wide-Necked Aneurysm Treatment: Analyzing Double-Barrel Stents In Vitro Using Flat-Panel Computed Tomography. World Neurosurg 2021; 151:e363-e371. [PMID: 33887500 DOI: 10.1016/j.wneu.2021.04.042] [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: 01/15/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Stent-assisted coil embolization of wide-necked bifurcation aneurysms often employs a Y configuration stent. A similar stent configuration, termed kissing/double-barrel (KDB), is used often at the aortoiliac bifurcation. Studies of KDB stents in aortoiliac disease show that rates of thromboembolic complications vary with the cross-sectional geometry of the stent pair, a function of the radial crush resistive force of each stent. We assessed cross-sectional geometry of intracranial stent pairs in an in vitro model of the basilar artery using flat-panel computed tomography. METHODS In a silicone model of a wide-necked basilar tip aneurysm, 6 simulated KDB stent deployment trials were performed using combinations of 5 stents (Enterprise 1, Enterprise 2, Neuroform Atlas, LVIS, LVIS Jr.). Flat-panel computed tomography reconstructions were used to assess cross-sectional stent geometry. Relative conformability, defined by ovalization and D-ratio, radial crush resistive force (predicted vs. actual), and radial mismatch fraction were compared by stent type (braided vs. laser-cut). RESULTS Several distinct forms of cross-sectional stent geometry were observed. Braided stents had lower ovalization and D-ratio (P = 0.015) than laser-cut stents. The Neuroform Atlas/LVIS combination yielded the lowest radial mismatch fraction (19.7% vs. mean 44.3% ± 0.7%). Braided stents tended to have a deployed stent radius closer to the expected (nominal) diameter (i.e., higher relative crush resistive force) than laser-cut stents (measured vs. nominal diameter discrepancy +38.6% ± 21.1% vs. -10.7% ±16.1%, P = 0.14). CONCLUSIONS In constant anatomy, cross-sectional geometry of the KDB stent configuration will vary depending on the design and structure of the stents employed.
Collapse
|
7
|
Combination of temporary bridging device (Comaneci) and permanent stenting in the treatment of unruptured wide neck bifurcation aneurysms. Neuroradiology 2021; 63:975-980. [PMID: 33677621 DOI: 10.1007/s00234-021-02677-z] [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: 12/01/2020] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
The double stent-assisted techniques for the treatment of wide neck bifurcation aneurysms (WNBAs) may be more complicating than single stent-assisted or balloon-assisted coiling. The Comaneci device (Rapid Medical, Yokneam, Israel) is a new temporary bridging device developed for covering the aneurysm neck during coiling. This new design enabled us to treat unruptured WNBAs with the use of single stent-assisted coiling instead of double stent in eight patients. At the 1-year angiographic follow-up, there was no filling in any aneurysm. There was no mortality or morbidity cases related to the procedure. In this study, we are reporting our experience of using single stent-assisted coiling combined with a Comaneci device in the treatment of unruptured WNBAs.
Collapse
|
8
|
Sato K, Matsumoto Y, Kanoke A, Ito A, Fujimura M, Tominaga T. Y-Configuration Stenting for Coil Embolization of Complex Intracranial Aneurysms: Distinguishing Between Use of Crossing-Y and Kissing-Y. World Neurosurg 2020; 146:e1054-e1062. [PMID: 33246177 DOI: 10.1016/j.wneu.2020.11.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/15/2020] [Accepted: 11/16/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Coil embolization with Y stenting is recognized as a suitable treatment for complex wide-necked aneurysms. Y stenting comprises crossing-Y stenting, in which a stent is passed through the interstices of another stent, and kissing-Y stenting, in which 2 stents are arranged in parallel. The purpose of this study was to elucidate how to distinguish between use of the 2 Y-stenting techniques. METHODS Clinical and angiographic data of patients who underwent coil embolization with Y stenting at our department from 2015 to 2019 were retrospectively analyzed. Basic characteristics, endovascular procedure, complications, and outcomes were compared between kissing-Y and crossing-Y stenting groups. RESULTS Thirty-eight intracranial aneurysms in 38 consecutive patients were included in this study. Nineteen patients (50%) were treated with coil embolization with kissing-Y stenting and 19 (50%) with crossing-Y. Endovascular procedures were successfully performed in all but 1 patient, in the kissing-Y group, who had stent migration. One hemorrhage (2.6%) recurred 12 months after coiling with kissing-Y stenting. Angiographic follow-up (mean, 15.8 months) was available in 35 patients. Adequate occlusion was shown in 14 patients (77.8%) and 13 patients (76.5%) in the kissing-Y and crossing-Y groups, respectively. Larger, wider-necked, and more proximal aneurysms were treated with kissing-Y stenting than with crossing-Y stenting, although there were no significant differences between the groups in complication rates or clinical outcomes. CONCLUSIONS Kissing-Y and crossing-Y stenting of intracranial aneurysms were both feasible and yielded reasonable angiographic and clinical results. The choice between the kissing-Y or crossing-Y-stenting technique should be decided according to the angioarchitecture of targeted aneurysms.
Collapse
Affiliation(s)
- Kenichi Sato
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan; Department of Neurosurgery, Tohoku Medical and Pharmaceutical University, Sendai, Japan.
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | - Atsushi Kanoke
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Akira Ito
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan; Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
9
|
Goertz L, Smyk MA, Siebert E, Turowski B, Borggrefe J, Mpotsaris A, Bohner G, Schlamann M, Dorn F, Liebig T, Kabbasch C. Low-Profile Laser-Cut Stents for Endovascular Treatment of Intracranial Aneurysms : Incidence, Clinical Presentation and Risk Factors of Thromboembolic Events. Clin Neuroradiol 2020; 31:107-115. [PMID: 31970465 DOI: 10.1007/s00062-019-00874-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/27/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Low-profile intracranial stents are characterized by a miniaturized design that enables deployment via a 0.0165″ or 0.017″ internal diameter microcatheter, which is typically intended for coil delivery. This study analyzed the incidence, clinical relevance and risk factors of thromboembolic events (TEE) occurring during low-profile stent-assisted coiling of intracranial aneurysms. METHODS This was a retrospective, multicenter analysis of consecutive patients who underwent stent-assisted aneurysm coiling (SAC) with the laser-cut Acandis Acclino and Neuroform Atlas stents. The study evaluated the incidence of symptomatic and asymptomatic TEEs and the impact on functional outcome. Risk factors for TEEs were determined by univariate and bivariate logistic regression analyses. RESULTS Among 131 procedures (mean patient age 56.5 ± 12.8 years, mean aneurysm size: 6.7 ± 3.9 mm) TEEs occurred in 14 cases (10.7%) of which 2 patients (1.5%) developed ischemic stroke, while the remaining TEEs remained asymptomatic. Multivariate analysis revealed Y‑stenting as potential risk factor for TEEs (odds ratio: 3.9, 95% confidence interval: 1.0-16.5; p = 0.08). CONCLUSION The use of SAC with low-profile intracranial stents is associated with a favorable safety profile; however, Y‑stenting may carry an increased risk of TEEs, which needs to be considered during treatment planning.
Collapse
Affiliation(s)
- Lukas Goertz
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Str. 67, 50937, Cologne, Germany. .,Center for Neurosurgery, Faculty of Medicine and University Hospital, University of Cologne, Kerpener Str. 67, 50937, Cologne, Germany.
| | - Michael Artur Smyk
- Department of Neuroradiology, University Hospital of Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Bernd Turowski
- Department of Neuroradiology, University Hospital of Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Jan Borggrefe
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Str. 67, 50937, Cologne, Germany
| | - Anastasios Mpotsaris
- Department of Neuroradiology, University Hospital of Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marc Schlamann
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Str. 67, 50937, Cologne, Germany
| | - Franziska Dorn
- Department of Neuroradiology, LMU University Hospital of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, LMU University Hospital of Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christoph Kabbasch
- Department of Neuroradiology, University Hospital of Cologne, Kerpener Str. 67, 50937, Cologne, Germany
| |
Collapse
|
10
|
Granja MF, Cortez GM, Aguilar-Salinas P, Agnoletto GJ, Imbarrato G, Jaume A, Aghaebrahim A, Sauvageau E, Hanel RA. Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis. J Neurointerv Surg 2019; 11:683-689. [PMID: 30610070 DOI: 10.1136/neurintsurg-2018-014517] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/08/2018] [Accepted: 11/26/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I2 statistics. RESULTS The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001). CONCLUSIONS Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.
Collapse
Affiliation(s)
- Manuel F Granja
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | | | - Gregory Imbarrato
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | | | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| |
Collapse
|
11
|
Cagnazzo F, Limbucci N, Nappini S, Renieri L, Rosi A, Laiso A, Tiziano di Carlo D, Perrini P, Mangiafico S. Y-Stent-Assisted Coiling of Wide-Neck Bifurcation Intracranial Aneurysms: A Meta-Analysis. AJNR Am J Neuroradiol 2018; 40:122-128. [PMID: 30523146 DOI: 10.3174/ajnr.a5900] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/15/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation. PURPOSE Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms. DATA SOURCES We performed a systematic search of 3 data bases for studies published from 2000 to 2018. STUDY SELECTION According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms. DATA ANALYSIS Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%-93%; I2 = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%-97%; I2 = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%-4.5%; I2 = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%-12.1%; I2 = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%-3.7%; I2 = 0%) and 1.1% (5/668; 95% CI, 0.3%-1.9%; I2 = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%-11%; I2 = 46% versus 4/30 = 12.7%; 95% CI, 3%-24%; I2 = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%-11%; I2 = 0%) compared with the others (20/131 = 14%; 95% CI, 5%-26%; I2 = 69% and 9/64 = 11%; 95% CI, 3%-20%; I2 = 18%). LIMITATIONS This was a small, retrospective series. CONCLUSIONS Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.
Collapse
Affiliation(s)
- F Cagnazzo
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - N Limbucci
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - S Nappini
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - L Renieri
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - A Rosi
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - A Laiso
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| | - D Tiziano di Carlo
- Department of Neurosurgery (D.T.d.C., P.P.), Cisanello Hospital, University of Pisa, Pisa, Italy
| | - P Perrini
- Department of Neurosurgery (D.T.d.C., P.P.), Cisanello Hospital, University of Pisa, Pisa, Italy
| | - S Mangiafico
- From the Interventional Neuroradiology Unit (F.C., N.L., S.N., L.R., A.R., A.L., S.M.), Careggi University Hospital, Florence, Italy
| |
Collapse
|
12
|
Park KY, Kim BM, Kim DJ, Chung J, Lee JW. Y-configuration stenting for coiling of wide-neck bifurcation aneurysms using Low-profile Visualized Intraluminal Support Junior. J Neurointerv Surg 2018; 11:400-404. [DOI: 10.1136/neurintsurg-2018-014128] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/10/2018] [Accepted: 08/13/2018] [Indexed: 11/03/2022]
Abstract
BackgroundLittle has been reported about the feasibility and durability of a Low-profile Visualized Intraluminal Support Junior (LVIS Jr) Y-stenting device for wide-neck bifurcation aneurysms.PurposeTo evaluate the feasibility and durability of LVIS Jr Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms.MethodsWe identified patients in whom LVIS Jr Y-stenting was attempted for unruptured wide-neck bifurcation aneurysms from a prospectively maintained registry of a referral hospital. Procedural success rate, treatment-related morbidity, and clinical and angiographic outcomes were retrospectively assessed.ResultsLVIS Jr Y-stenting was attempted for a total of 21 aneurysms in 21 patients (mean age 60±8.9 years; M:F=6:15): nine basilar artery, six anterior communicating artery, four middle cerebral artery, one internal carotid artery, and one vertebrobasilar fenestration aneurysms. The mean dome and neck size were 7.9±2.7 mm and 5.7±1.8 mm, respectively. All attempts were successful. Treatment-related morbidity occurred in one individual with a modified Rankin Scale (mRS) score of 2. Immediate postprocedural angiograms showed complete occlusion in 15 (71.4%) and neck remnant in 6 (28.6%) patients. All 21 patients had good outcomes (mRS score 0–2) for a mean of 12 months' follow-up (range 6–27 months); mRS score 0 in 20 patients and mRS score 2 in one patient, respectively. Follow-up imaging over a mean of 11 months (range 6–18 months) was available in 18 patients (85.7%). All aneurysms showed complete occlusion at follow-up.ConclusionsLVIS Jr Y-stenting and coiling for wide-neck bifurcation aneurysms seems to be feasible with acceptable safety and to provide durable aneurysm occlusion for wide-neck bifurcation aneurysms.
Collapse
|
13
|
Samaniego EA, Mendez AA, Nguyen TN, Kalousek V, Guerrero WR, Dandapat S, Dabus G, Linfante I, Hassan AE, Drofa A, Kouznetsov E, Leedahl D, Hasan D, Maud A, Ortega-Gutierrez S. LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience. INTERVENTIONAL NEUROLOGY 2018; 7:271-283. [PMID: 29765397 DOI: 10.1159/000487545] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
Abstract
Background and Purpose Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms. Methods Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. Results Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. Conclusions In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.
Collapse
Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Aldo A Mendez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice,", Zagreb, Croatia
| | - Waldo R Guerrero
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Sudeepta Dandapat
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Guilherme Dabus
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Italo Linfante
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | | | - Alexander Drofa
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - Evgueni Kouznetsov
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - David Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa, Iowa, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | | |
Collapse
|
14
|
Spiotta AM, Chaudry MI, Turner RD, Turk AS, Derdeyn CP, Mocco J, Tateshima S. An Update on the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction Trial: 1-Year Safety and Angiographic Results. AJNR Am J Neuroradiol 2018; 39:848-851. [PMID: 29599174 DOI: 10.3174/ajnr.a5599] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/10/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of the PulseRider for the treatment of wide-neck, bifurcation aneurysms at the basilar and carotid terminus locations were studied in a prospective trial, the Adjunctive Neurovascular Support of Wide-Neck Aneurysm Embolization and Reconstruction (ANSWER) trial, reporting on initial 6-month angiographic and clinical results. This report provides insight into the longer term durability and safety with 12-month data. MATERIALS AND METHODS Aneurysms treated with the PulseRider among enrolled sites were prospectively studied. Updated 12-month data on clinical and imaging end points are included. RESULTS Thirty-four patients were enrolled (29 women, 5 men) with a mean age of 60.9 years. The mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range, 2.3-11.6 mm). At 1 year, there were no device migrations or symptomatic in-stent stenoses. Raymond-Roy I occlusion was achieved in 53% of cases at the time of treatment and progressed to 61% and 67% at 6 and 12 months, respectively. Adequate occlusion (Raymond-Roy I/II) progressed from 88% at 6 months to 90% at 12 months. No recanalizations were observed. There was 1 delayed ischemic event. Good outcome (mRS 0-2) was achieved in 90% of patients. CONCLUSIONS The updated 1-year results from the ANSWER trial demonstrate aneurysm stability and an acceptable safety profile for aneurysms treated at the basilar apex and carotid terminus. Prospective data from a larger set of aneurysms treated at other locations are required to assess how treatment with PulseRider compares with alternatives for treating wide-neck bifurcation aneurysms.
Collapse
Affiliation(s)
- A M Spiotta
- From the Department of Neurosurgery (A.M.S., M.I.C., R.D.T., A.S.T.), Medical University of South Carolina, Charleston, South Carolina
| | - M I Chaudry
- From the Department of Neurosurgery (A.M.S., M.I.C., R.D.T., A.S.T.), Medical University of South Carolina, Charleston, South Carolina
| | - R D Turner
- From the Department of Neurosurgery (A.M.S., M.I.C., R.D.T., A.S.T.), Medical University of South Carolina, Charleston, South Carolina
| | - A S Turk
- From the Department of Neurosurgery (A.M.S., M.I.C., R.D.T., A.S.T.), Medical University of South Carolina, Charleston, South Carolina
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa, Iowa City, Iowa
| | - J Mocco
- Department of Neurosurgery (J.M.), Mount Sinai Hospital, New York, New York
| | - S Tateshima
- Department of Radiology (S.T.), University of California, Los Angeles, Los Angeles, California
| |
Collapse
|
15
|
Aydin K, Sencer S, Barburoglu M, Berdikhojayev M, Aras Y, Sencer A, İzgi N. Midterm results of T-stent–assisted coiling of wide-necked and complex intracranial bifurcation aneurysms using low-profile stents. J Neurosurg 2017; 127:1288-1296. [DOI: 10.3171/2016.9.jns161909] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVECoiling of wide-necked and complex bifurcation aneurysms frequently requires implantation of double stents in various configurations. T-stent–assisted coiling involves the nonoverlapping implantation of 2 stents to protect the daughter vessels of bifurcation and is followed by coiling of the aneurysm. The authors studied the feasibility, efficacy, and safety of the T-stent–assisted coiling procedure as well as the midterm angiographic/clinical outcomes of patients with wide-necked bifurcation intracranial aneurysms treated using this technique.METHODSThe authors retrospectively identified patients with wide-necked bifurcation intracranial aneurysms treated using double-stent–assisted coiling with a T-stent configuration.RESULTSTwenty-four patients with 24 aneurysms and a mean of age of 51.91 years were identified. The most common locations were the middle cerebral bifurcation (45.8%) and anterior communicating artery (35.7%). T stentings were performed using low-profile stents. The procedures were performed with a technical success rate of 95.8%, and an immediate total occlusion rate of 79.2% was achieved. We observed periprocedural complications in 16.7% of cases and a delayed thromboembolic event in 4.2%. The complications caused permanent morbidity in 1 patient (4.2%). No deaths occurred. The mean angiographic follow-up duration was 9.3 months. The total occlusion rate at the last follow-up was 81.2%. The recanalization rate was 4.5%. Modified Rankin Scale scores of all patients at the last follow-ups were between zero and 2.CONCLUSIONST-stent–assisted coiling using low-profile stents is a feasible, effective, and relatively safe endovascular technique used to treat wide-necked and complex intracranial aneurysms. The midterm angiographic and clinical outcomes are outstanding.
Collapse
Affiliation(s)
- Kubilay Aydin
- 1Department of Radiology, Neuroradiology Division, and
- 2Department of Radiology, Koc University Hospital, Topkapi, Istanbul, Turkey; and
| | - Serra Sencer
- 1Department of Radiology, Neuroradiology Division, and
| | | | | | - Yavuz Aras
- 4Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Capa
| | - Altay Sencer
- 4Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Capa
| | - Nail İzgi
- 4Department of Neurosurgery, Istanbul University, Istanbul Faculty of Medicine, Capa
| |
Collapse
|
16
|
Cheung NK, Chiu AHY, Cheung A, Wenderoth JD. Long term follow-up of bifurcation aneurysms treated with braided stent assisted coiling and complex T- and Y- stent constructs. J Neurointerv Surg 2017; 10:560-565. [DOI: 10.1136/neurintsurg-2017-013399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/05/2017] [Accepted: 09/08/2017] [Indexed: 11/03/2022]
Abstract
BackgroundStent assisted coil embolization (SACE) of bifurcation aneurysms is challenging. Heterogeneous results have been achieved to date, but largely for laser cut stents. While braided stents offer multiple technical advantages, their long term efficacy has yet to be validated.ObjectiveTo report the first long term 18 month results for the durability of bifurcation aneurysms treated with braided stents.Materials and methodsOver a 4 year period, 59 consecutive patients with 60 bifurcation aneurysms underwent elective braided SACE across three Australian neurovascular centers. 17 of these aneurysms underwent T- or Y-shaped stent constructs. All patients had immediate, 6 month and 18 month clinical and radiological follow-up. Radiological assessment was made on modified Raymond–Roy occlusion scores while clinical assessment was based on the modified Rankin Scale. Subgroup analysis of 17 aneurysms treated with multi-stent constructs was conducted.Results6 month follow-up data were available for 59 aneurysms and 18 month follow-up data for 58 aneurysms. Satisfactory aneurysm occlusion was achieved in 97% at inception and at 6 months, and 98% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Similar satisfactory results were achieved with the multi-stent construct cohort. Intraprocedural thromboembolic events were recorded in 5% and delayed events in 2%. Technical complications were found in 5%. All complication rate was 13%.ConclusionBraided SACE was safe, efficacious, and durable at the long term 18 month follow-up, including for multi-stent constructs. Preliminary results indicate favorable clinical and radiological outcomes compared with laser cut stents.
Collapse
|
17
|
Spiotta AM, Derdeyn CP, Tateshima S, Mocco J, Crowley RW, Liu KC, Jensen L, Ebersole K, Reeves A, Lopes DK, Hanel RA, Sauvageau E, Duckwiler G, Siddiqui A, Levy E, Puri A, Pride L, Novakovic R, Chaudry MI, Turner RD, Turk AS. Results of the ANSWER Trial Using the PulseRider for the Treatment of Broad-Necked, Bifurcation Aneurysms. Neurosurgery 2017; 81:56-65. [DOI: 10.1093/neuros/nyx085] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 04/05/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: The safety and probable benefit of the PulseRider (Pulsar Vascular, Los Gatos, California) for the treatment of broad-necked, bifurcation aneurysms was studied in the context of the prospective, nonrandomized, single arm clinical trial—the Adjunctive Neurovascular Support of Wide-neck aneurysm Embolization and Reconstruction (ANSWER) Trial.
OBJECTIVE: To present the results of the United States cases employing the PulseRider device as part of the ANSWER clinical trial.
METHODS: Aneurysms treated with the PulseRider device among sites enrolling in the ANSWER trial were prospectively studied and the results are summarized. Aneurysms arising at either the carotid terminus or basilar apex that were relatively broad necked were considered candidates for inclusion into the ANSWER study.
RESULTS: Thirty-four patients were enrolled (29 female and 5 male) with a mean age of 60.9 years (27 basilar apex and 7 carotid terminus). Mean aneurysm height ranged from 2.4 to 15.9 mm with a mean neck size of 5.2 mm (range 2.3-11.6 mm). In all patients, the device was delivered and deployed. Immediate Raymond I or II occlusion was achieved in 82.4% and progressed to 87.9% at 6-month follow-up. A modified Rankin Score of 2 or less was seen in 94% of patients at 6 months.
CONCLUSION: The results from the ANSWER trial demonstrate that the PulseRider device is safe and offers probable benefit as for the treatment of bifurcation aneurysms arising at the basilar apex or carotid terminus. As such, it represents a useful addition to the armamentarium of the neuroendovascular specialist.
Collapse
Affiliation(s)
- Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Colin P. Derdeyn
- Department of Radiolo-gy, Neurology and Neurosurgery, Univer-sity of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Satoshi Tateshima
- Department of Radiology, UCLA Medical Center, Santa Monica, Cali-fornia
| | - Jay Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, Miami Beach, Florida
| | - R. Webster Crowley
- Department of Neuro-surgery, Rush University Medical Center, Chicago, Illinois
| | - Kenneth C. Liu
- Department of Neuro-surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lee Jensen
- De-partment of Radiology, University of Vir-ginia School of Medicine, Charlottesville, Virginia
| | - Koji Ebersole
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Alan Reeves
- Department of Ra-diology, University of Kansas Medical Center, Kansas City, Kansas
| | - Demetrius K. Lopes
- Department of Neuro-surgery, Rush University Medical Center, Chicago, Illinois
| | - Ricardo A. Hanel
- Depart-ment of Neurosurgery, Baptist Health, Jacksonville, Florida
| | - Eric Sauvageau
- Depart-ment of Neurosurgery, Baptist Health, Jacksonville, Florida
| | - Gary Duckwiler
- Department of Radiology, UCLA Medical Center, Santa Monica, Cali-fornia
| | - Adnan Siddiqui
- Department of Neurosurgery, University at Buffalo, Buf-falo, New York
| | - Elad Levy
- Department of Neurosurgery, University at Buffalo, Buf-falo, New York
| | - Ajit Puri
- Department of Ra-diology, UMass Memorial Medical Cen-ter, Worcester, Massachusetts
| | - Lee Pride
- Depart-ment of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - Roberta Novakovic
- Depart-ment of Radiology, UT Southwestern Medical Center, Dallas, Texas
| | - M. Imran Chaudry
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Raymond D. Turner
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Aquilla S. Turk
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
18
|
Mukherjee S, Chandran A, Gopinathan A, Putharan M, Goddard T, Eldridge PR, Patankar T, Nahser HC. PulseRider-assisted treatment of wide-necked intracranial bifurcation aneurysms: safety and feasibility study. J Neurosurg 2016; 127:61-68. [PMID: 27689454 DOI: 10.3171/2016.2.jns152334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The goal of this study was to assess the safety and feasibility of PulseRider, a novel endovascular stent, in the treatment of intracranial bifurcation aneurysms with wide necks. The authors present the initial results of the first 10 cases in which the PulseRider device was used. METHODS Patients whose aneurysms were intended to be treated with the PulseRider device at 2 institutions in the United Kingdom were identified prospectively. Patient demographics, procedural details, immediate neurological and clinical status, and immediate angiographic outcomes and 6-month clinical and imaging follow-up were recorded prospectively. RESULTS At the end of the procedure, all 10 patients showed complete aneurysm occlusion (Raymond Class 1). There were no significant intraprocedural complications except for an occurrence of thromboembolism without clinical sequelae. There was no occurrence of aneurysm rupture or vessel dissection. At 6-month follow-up, 7 and 3 patients had modified Rankin Scale scores of 0 and 1, respectively. All 10 patients had stable aneurysm occlusion (Raymond Class 1) and daughter vessel intraluminal patency on 6-month follow-up catheter angiography. CONCLUSIONS The authors' early experience with the PulseRider device demonstrates that it is a safe and effective adjunct in the treatment of bifurcation aneurysms with wide necks arising at the middle cerebral artery bifurcation, anterior cerebral artery, basilar apex, and carotid terminus. It works by providing a scaffold at the neck of the bifurcation aneurysm, enabling neck remodeling and coil support while maintaining parent vessel intraluminal patency. Early clinical and radiological follow-up showed good functional outcome and stable occlusion rates, respectively. Further data are needed to assess medium- and long-term outcomes with PulseRider.
Collapse
Affiliation(s)
| | | | - Anil Gopinathan
- Interventional Neuroradiology, Leeds General Infirmary, Leeds;,Departments of 2 Neuroradiology and
| | | | - Tony Goddard
- Interventional Neuroradiology, Leeds General Infirmary, Leeds
| | - Paul R Eldridge
- Neurosurgery, The Walton Centre, Lower Lane, Fazakerley, Liverpool, United Kingdom
| | - Tufail Patankar
- Interventional Neuroradiology, Leeds General Infirmary, Leeds
| | | |
Collapse
|
19
|
Zhao WY, Zhao KJ, Huang QH, Xu Y, Hong B, Liu JM. Single-stage endovascular treatment of subarachnoid hemorrhage related to bilateral vertebral artery dissecting aneurysms. Interv Neuroradiol 2015; 22:138-42. [PMID: 26686384 DOI: 10.1177/1591019915617325] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/09/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Treatment of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage remains challenging as bilateral deconstructive procedures may not be feasible. In this case series, we describe our approach to their management and review the pertinent literature. METHOD A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute subarachnoid hemorrhage in the setting of bilateral intradural vertebral artery dissections (VAD) encompassing a period from January 2000 and March 2012. RESULT Four patients (M/F = 2/2; mean age, 51.5 years) were identified. In two cases the site of rupture could be identified by angiographic and cross-sectional features; in these patients deconstructive treatment (proximal obliteration or trapping) of the ruptured site and reconstructive treatment of the unruptured site (using stents and coils) were performed. In the patients in whom the site of hemorrhage could not be determined, bilateral reconstructive treatment was performed. No treatment-related complications were encountered. Modified Rankin scale scores were 0-1 at discharge, and on follow-up (mean 63 months), no recurrence, in-stent thrombosis or new neurological deficits were encountered. CONCLUSION We believe that single-stage treatment in patients with bilateral VAD is indicated: If the site of hemorrhage can be determined, we prefer deconstructive treatment on the affected site and reconstructive treatment on the non-affected site to prevent increased hemodynamic stress on the unruptured but diseased wall. If the site of dissection cannot be determined, we prefer bilateral reconstructive treatment to avoid increasing hemodynamic stress on the potentially untreated acute hemorrhagic dissection.
Collapse
Affiliation(s)
- Wen-Yuan Zhao
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Kai-Jun Zhao
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Qing-Hai Huang
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Yi Xu
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Bo Hong
- Changhai Hospital, Second Military Medical University Shanghai, China
| | - Jian-Min Liu
- Changhai Hospital, Second Military Medical University Shanghai, China
| |
Collapse
|
20
|
Caroff J, Neki H, Mihalea C, D'Argento F, Abdel Khalek H, Ikka L, Moret J, Spelle L. Flow-Diverter Stents for the Treatment of Saccular Middle Cerebral Artery Bifurcation Aneurysms. AJNR Am J Neuroradiol 2015; 37:279-84. [PMID: 26405085 DOI: 10.3174/ajnr.a4540] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 06/12/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The flow-diverter stent has been proved a feasible, safe, and efficient technique, particularly for the treatment of large and broad-neck carotid siphon aneurysms. Wide-neck bifurcation aneurysms remain, in some cases, a challenge for neurointerventionalists. We report the outcomes of the treatment of saccular middle cerebral artery bifurcation aneurysms with flow diversion in our institution. MATERIALS AND METHODS From the institution data base, all saccular, nondissecting MCA bifurcation aneurysms, treated with flow-diverter stents, were retrospectively reviewed. Technical issues, immediate posttreatment and follow-up angiographic findings, and clinical outcomes were assessed. RESULTS Fourteen patients with 15 aneurysms were included in the study. Ischemic complications, as confirmed by MR imaging, occurred in 6 patients (43%). Procedure-related morbidity and mortality at last follow-up were 21% and 0%, respectively. Angiographic follow-up was available for 13 aneurysms, with a mean follow-up of 16 months. Complete occlusion was obtained for 8 aneurysms (62%). CONCLUSIONS Compared with other available therapeutic options, the flow-diverter stent does not appear to be a suitable solution for the treatment of saccular MCA bifurcation aneurysms.
Collapse
Affiliation(s)
- J Caroff
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - H Neki
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neurosurgery (H.N.), Saitama University, Saitama, Japan
| | - C Mihalea
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neurosurgery (C.M.), University of Medicine and Pharmacy "Victor Babes," Timisoara, Romania
| | - F D'Argento
- Department of Bioimaging and Radiological Sciences (F.D.), Policlinico "A. Gemelli," Rome, Italy
| | - H Abdel Khalek
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France Department of Neuropsychiatry (H.A.K.), Tanta University Hospital, Tanta, Egypt
| | - L Ikka
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - J Moret
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| | - L Spelle
- From the Department of Interventional Neuroradiology (J.C., H.N., C.M., H.A.K., L.I., J.M., L.S.), Neuro Brain Vascular Center, Hôpital Bicêtre, APHP, Paris Sud Université, France
| |
Collapse
|
21
|
Sağlam M, Kızılkılıç O, Anagnostakou V, Yıldız B, Koçer N, Işlak C. Geometrical characteristics after Y-stenting of the basilar bifurcation. Diagn Interv Radiol 2015; 21:483-7. [PMID: 26359879 DOI: 10.5152/dir.2015.14523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to investigate the angular changes after Y-stenting of the basilar bifurcation aneurysms. METHODS A total of 19 patients (age range, 27-80 years; mean age, 52.5 years) underwent Y-stent coiling for basilar bifurcation aneurysm. Three vascular angles (α, β1, β2) were measured in the anteroposterior plane. β1 and β2 represented the angles between the basilar artery and the proximal P1 segments of the right and left posterior cerebral arteries, respectively. α represented the complementary angle between the β1 and β2 angles. Angles were measured before and after stent deployment. Diameters of the basilar artery and P2 segment of the posterior cerebral artery were measured at both sides. Correlation between vascular diameter and angular change of the basilar bifurcation was investigated. RESULTS Statistically significant α, β1, and β2 angle changes were found after stent deployment (P < 0.001). There was no statistically significant relationship between the diameter of the basilar artery and the α, β1, β2 angle changes (P > 0.05). There was no statistically significant relationship between the diameter of the posterior cerebral artery and the β angle change (P > 0.05). We found a statistically significant inverse correlation between pre-stent β angle and post-stent angle change (right side, P = 0.008; left side, P < 0.001). CONCLUSION Y-stenting narrows the effective neck and straightens the vascular bifurcation angle. Most of the angular remodeling occurs on the side that had a more acute angle before stent deployment.
Collapse
Affiliation(s)
- Muzaffer Sağlam
- Department of Radiology, GATA Haydarpaşa Training and Research Hospital, İstanbul, Turkey.
| | | | | | | | | | | |
Collapse
|
22
|
Wang CC, Lv N, Feng ZZ, Li ZF, Zhao R, Li Q, Liu JM, Huang QH. Intra-aneurysmal microcatheter looping technique for stent-assisted embolization of complex intracranial aneurysms. Interv Neuroradiol 2015; 21:580-4. [PMID: 26179063 DOI: 10.1177/1591019915594330] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The endovascular treatment of wide-necked, large and giant aneurysms remains challenging. This retrospective study investigated the feasibility and safety of an intra-aneurysmal microcatheter looping technique for stent-assisted embolization of complicated intracranial aneurysms.This technique was used for 31 patients with complicated cerebral aneurysms from January 2007 to November 2013. The clinical and angiographic results were retrospectively evaluated.The target aneurysms were successfully treated in all cases (100%). A flow diverter was used in seven procedures. There were no aneurysmal perforations or ischemic complications, except for a microguidewire perforation of the distal vessel in one case. Among the 24 cases with conventional stent-assisted embolization, complete embolization or neck residual was obtained in 21 cases. Partial occlusion occurred in three cases.In conclusion, the intra-aneurysmal microcatheter looping technique is a safe and feasible alternative treatment of complicated intracranial aneurysms. This approach is a reasonable choice for patients and leads to successful outcomes.
Collapse
Affiliation(s)
- C-C Wang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - N Lv
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Z-Z Feng
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Z-F Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - R Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Q Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - J-M Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Q-H Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| |
Collapse
|
23
|
Chen Z, Niu Y, Tang J, Li L, Feng Z, Feng H, Zhu G. Endovascular treatment of posterior communicating artery aneurysms in the presence of the fetal variant of posterior cerebral artery. Interv Neuroradiol 2015; 21:456-61. [PMID: 26111986 DOI: 10.1177/1591019915590532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Posterior communicating artery (PcomA) aneurysms in the presence of the fetal variant of posterior cerebral artery (PCA) often pose technical challenges for endovascular treatment because of a greater potential for ischemic injury with the fetal PCA compromise. The purpose of this study was to assess the feasibility and results of endovascular treatment for these lesions. We retrospectively reviewed our experience and results of endovascular treatments for a series of nine consecutive patients with PcomA aneurysms occurring at the origin of fetal PCAs at the Department of Neurosurgery of Southwest Hospital, Chongqing, China, between June 2011 and June 2014. Depending on the angiographic findings, location and shape of the aneurysms, various therapeutic strategies were used including coiling by single or double microcatheter, balloon remodeling technique, and single or Y-stenting technique. Overall, fetal PCA was preserved patent in all cases, and complete or near complete occlusion was achieved in 8/9 cases. There was no procedure-related morbidity or mortality. With the exception of one patient who died of pneumonia 6 weeks after treatment, no clinical evidence of neurologic deterioration and hemorrhagic complication was seen during the follow-up period in the remaining 8 patients. Our experience suggests that endovascular treatment is relatively safe and technically feasible in most patients with PcomA aneurysms in the presence of fetal PCA using multiple strategies.
Collapse
Affiliation(s)
- Zhi Chen
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Yin Niu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Jun Tang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Lin Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Zhou Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Gang Zhu
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing, China
| |
Collapse
|
24
|
Ding D. Expanding the boundaries of endovascular aneurysm treatment: emerging technologies for wide-necked bifurcation aneurysms. Acta Neurochir (Wien) 2015; 157:1049-50. [PMID: 25236934 DOI: 10.1007/s00701-014-2238-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Dale Ding
- University of Virginia Department of Neurosurgery Surgery, P.O. Box 800212, Charlottesville, VA, 22908, USA,
| |
Collapse
|
25
|
Brassel F, Melber K, Schlunz-Hendann M, Meila D. Kissing-Y stenting for endovascular treatment of complex wide necked bifurcation aneurysms using Acandis Acclino stents: results and literature review. J Neurointerv Surg 2015; 8:386-95. [DOI: 10.1136/neurintsurg-2015-011691] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/23/2015] [Indexed: 11/04/2022]
Abstract
IntroductionY-configured stent assisted coiling is a promising therapeutic option to ensure safe coil embolization and preserve the affected arteries in complex wide necked aneurysms. We present our experience with self-expanding Acandis Acclino stents for the treatment of complex aneurysms using the kissing-Y technique.MethodsWe retrospectively reviewed seven patients with seven complex aneurysms (three anterior communicating artery (AcomA), two middle cerebral artery, one basilar artery/superior cerebellar artery, and one vertebral artery/posterior inferior cerebellar artery) who were treated with the kissing-Y technique by stent assisted coiling from June 2013 to July 2014, with follow-up until January 2015. DSA follow-up was up to 17 months, with a mean follow-up period of 10 months. Six patients were treated electively and one in the acute phase of a subarachnoid hemorrhage. In all cases, closed cell Acandis Acclino stents were used. We evaluated procedural complications, clinical outcomes, and mid term angiographic follow-up. Additionally, a literature review is provided.ResultsIn all patients, stents were successfully placed and implanted. One patient developed a periprocedural thromboembolic complication not directly related to the stents. No other periprocedural or postprocedural complications were encountered. Follow-up examinations showed stable and total occlusion of all coiled aneurysms.ConclusionsThe results of our study show that the kissing-Y technique using closed cell Acandis Acclino stents followed by coil embolization is a feasible treatment option for selected complex bifurcation aneurysms.
Collapse
|
26
|
Crossing Y-stent technique with dual open-cell stents for coiling of wide-necked bifurcation aneurysms. Clin Neurol Neurosurg 2015; 132:54-60. [PMID: 25777137 DOI: 10.1016/j.clineuro.2015.02.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 01/24/2015] [Accepted: 02/03/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Double stenting in a Y-configuration is a promising therapeutic option for wide-necked cerebral aneurysms not amenable to reconstruction with a single stent. We retrospectively evaluated the efficacy and safety of the crossing Y-stent technique for coiling of wide-necked bifurcation aneurysms. METHODS By collecting clinical and radiological data we evaluated from January 2007 through December 2013, 20 wide-necked bifurcation aneurysms. RESULTS Twelve unruptured and eight ruptured aneurysms in 20 patients were treated with crossing Y-stent-assisted coiling. Aneurysm size and neck size ranged from 3.2 to 28.2mm (mean 7.5mm) and from 1.9 to 9.1mm (mean 4.5mm). A Y-configuration was established successfully in all 20 patients. All aneurysms were treated with a pair of Neuroform stents. The immediate angiographic results were total occlusion in 17 aneurysms, residual neck in two, and residual sac in one. Peri-operative morbidity was only 5%. Fifteen of 18 surviving patients underwent follow-up conventional angiography (mean, 10.9 months). The result showed stable occlusion in all 15 aneurysms and asymptomatic in-stent occlusion in one branch artery. At the end of the observation period (mean, 33.5 months), all 12 patients without subarachnoid hemorrhage had excellent clinical outcomes (mRS 0), except one (mRS 2). Of eight patients with subarachnoid hemorrhage, four remained symptom free (mRS 0), while the other four had were dependent or dead (mRS score, 3-6). CONCLUSION In this report on 20 patients, crossing Y-stent technique for coiling of wide-necked bifurcation aneurysms showed a good technical safety and favorable clinical and angiographic outcome.
Collapse
|
27
|
Spiotta AM, Chaudry MI, Turk AS, Turner RD. Initial experience with the PulseRider for the treatment of bifurcation aneurysms: report of first three cases in the USA. J Neurointerv Surg 2015; 8:186-9. [DOI: 10.1136/neurintsurg-2014-011531] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 12/12/2014] [Indexed: 12/21/2022]
Abstract
IntroductionThe PulseRider is a novel device intended for use in the treatment of aneurysms arising at bifurcations. We present the initial results of the first three cases in the USA employing the PulseRider device.MethodsAneurysms intended to be treated with the PulseRider device at a single institution were identified prospectively. Aneurysms arising at either the carotid terminus or basilar apex that were relatively broad-necked were considered candidates for treatment with the novel device.ResultsPatients were pretreated with dual antiplatelet therapy. All cases were performed under general endotracheal anesthesia. An appropriately sized PulseRider device was deployed across the neck of the aneurysm. A microcatheter was then navigated over a 0.014 inch microwire through the device into the aneurysm. Complete occlusion of the aneurysm was achieved in all cases without intraprocedural complications.ConclusionsWe have found in our early experience with the Pulse Rider device that its use is safe and effective as an adjunct in the treatment of bifurcation aneurysms arising at the basilar apex or carotid terminus. As such, it represents a useful addition to the armamentarium of the neuroendovascular specialist.
Collapse
|
28
|
Limbucci N, Renieri L, Nappini S, Consoli A, Rosi A, Mangiafico S. Y-stent assisted coiling of bifurcation aneurysms with Enterprise stent: long-term follow-up. J Neurointerv Surg 2014; 8:158-62. [PMID: 25501447 DOI: 10.1136/neurintsurg-2014-011483] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/24/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Y-stent assisted coiling has been proposed for the treatment of wide-neck bifurcation aneurysms, but there are many technical variations. We report our single-center experience of Y-stent assisted coiling of bifurcation aneurysms with the closed cell Enterprise stent in order to evaluate the safety and long-term results of this technique. The literature on Y-stenting and its hemodynamic effects are reviewed. METHODS Fifty-two consecutive patients with wide-neck bifurcation aneurysms underwent Y-stent assisted coiling with two Enterprise stents. The procedure was completed in 48 cases (92.3%) and technical failure occurred in 4 cases (7.3%). Cases performed with other stents were excluded. All procedures were performed under double antiplatelet therapy. Periodic clinical and neuroradiological follow-up was performed. RESULTS Mean neuroradiological follow-up time was 26 months. Complete immediate occlusion was obtained in 87.5% of patients. Two remnants had regrown at follow-up and were recoiled, achieving complete occlusion. The late neuroradiological occlusion rate was: complete occlusion 93.6%, neck remnant 4.3%, sac remnant 2.1%. No in-stent stenosis was detected at follow-up. Among the 48 procedures, two complications occurred (4.2%). Mortality was 2.1%. No delayed ischemic stroke occurred. CONCLUSIONS Y-stent assisted coiling has a high immediate occlusion rate and very good long-term stability. The procedure is relatively safe, although the complication and mortality rates are not negligible. Two Enterprise stents can be safely used for Y-stenting and, indeed, offer the advantage of easier catheterization, delivery and deployment into distal and tortuous vessels than open cell stents.
Collapse
Affiliation(s)
- Nicola Limbucci
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Sergio Nappini
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Arturo Consoli
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Andrea Rosi
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Unit, Careggi University Hospital, Florence, Italy
| |
Collapse
|
29
|
Islak C, Kizilkilic O, Kocak B, Saglam M, Yildiz B, Kocer N. Use of buddy wire to facilitate Y-configured stent placement in middle cerebral artery bifurcation aneurysms with daughter branches arising from the sac: a technical note. Neurosurgery 2014; 10 Suppl 1:E167-71; discussion E171. [PMID: 23921705 DOI: 10.1227/neu.0000000000000130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Endovascular treatment of geometrically complex bifurcation aneurysms using a standard Y-configured stenting technique might be extremely difficult, particularly in aneurysms with daughter branches that acutely arise from the aneurysm sac itself. In those cases, deployment of the second stent through interstices of the first stent could be troublesome because of untoward angular changes in the vascular bifurcation prompted by angular changes resulting from placement of the first stent. Here, we describe a novel application of the buddy wire technique to facilitate Y-configured stenting in middle cerebral artery (MCA) bifurcation aneurysms with unfavorable anatomic configuration. CLINICAL PRESENTATION A 60-year-old man with a left-sided MCA bifurcation aneurysm was treated using the buddy wire technique. In addition to the standard Y-configured stenting procedure, we also inserted a 0.014-inch exchange microguidewire into the superior daughter branch, which more acutely emanated from the sac, to attain a favorable bifurcation configuration before deployment of the stents in the Y configuration. The new technique was successful, and the postprocedural course of the treatment was uneventful. CONCLUSION Use of a buddy wire in MCA bifurcation aneurysms with unfavorable anatomic configurations may be a promising method to facilitate Y-configured stent placement.
Collapse
Affiliation(s)
- Civan Islak
- Division of Neuroradiology, Department of Radiology, Cerrahpasa Medical Faculty, Istanbul University, Kocamustafapasa-Istanbul, Turkey
| | | | | | | | | | | |
Collapse
|
30
|
Y-configuration double-stent-assisted coiling using two closed-cell stents for wide-neck basilar tip aneurysms. Acta Neurochir (Wien) 2014; 156:1677-86. [PMID: 24969176 DOI: 10.1007/s00701-014-2163-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study aimed to evaluate clinical and angiographic outcomes of Y-configuration double-stent-assisted (Y-stent) coiling using two closed-cell stents for wide-necked basilar tip aneurysm (BTA). MATERIALS A total of 25 patients underwent Y-stent coiling using two closed-cell stents as a first-time treatment in 18 (3 ruptured) BTAs, retreatment in 2 BTAs and as a third treatment in 5 wide-necked BTAs. Clinical and angiographic outcomes were evaluated retrospectively. RESULTS Treatment-related complications were three (12.0 %) thromboembolic infarctions due to two acute in-stent thromboses and one embolism. Twenty-two (88 %) patients had favorable outcomes (modified Rankin scale score [mRS], 0-2) during the follow-up period (mean, 30 months; range, 6-54 months). Two patients died: one from initial subarachnoid hemorrhage and the other from intracerebral hemorrhage due to underlying Moyamoya disease. Post-treatment angiograms showed complete occlusion in nine aneurysms, residual neck in 11 aneurysms and residual sac in five aneurysms. Follow-up angiograms were available at least once between 5 to 34 months (mean, 16 months) in 21 patients. Nineteen patients showed improved or stable states (complete occlusion, n = 17; residual neck, n = 2). Major recurrences occurred in two BTAs (9.5 %). Those two major recurrent aneurysms had been large-sized aneurysms at the initial coiling procedure. Both showed not only coil compaction but also progressive growth to giant-sized aneurysms and intra-aneurysmal thrombus formation at the Y-stent coiling as a third-time treatment. CONCLUSIONS Y-stent coiling using two closed-cell stents is a safe and durable treatment option for wide-necked BTA, but may have limited efficacy for large/giant sized and thrombosed aneurysms.
Collapse
|
31
|
Bartolini B, Blanc R, Pistocchi S, Redjem H, Piotin M. "Y" and "X" stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms. AJNR Am J Neuroradiol 2014; 35:2153-8. [PMID: 25059700 DOI: 10.3174/ajnr.a4060] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling with two stents has been described in some series for the treatment of complex and wide-neck bifurcation aneurysms. Our aim was to report our experience of a stent-assisted coiling technique with double stents in "Y" and "X" configurations, with emphasis on safety, feasibility, and efficacy. MATERIALS AND METHODS Clinical and angiographic outcomes of patients for whom the strategic therapeutic option was the stent-assisted coiling technique in a Y or X configuration for neck scaffolding from June 2006 to June 2013 were retrospectively analyzed. RESULTS One hundred five aneurysms in 97 patients were treated during 100 consecutive procedures. There were 54.2% (57/105) MCA, 28.6% (30/105) anterior communicating artery, 16.2% (17/105) basilar tip, and 1.0% (1/105) ICA termination aneurysms. A Y stent placement was used to treat 87 aneurysms in 85 procedures; an X stent placement was used to treat 7 aneurysms in 6 procedures, while 9 procedures failed for 11 aneurysms. There were 10.0% (10/100) procedure-related permanent neurologic deficits and 1.0% (1/100) death. The immediate angiographic controls showed a complete occlusion in 47.6% (50/105) of the aneurysms and a partial (neck or sac remnant) occlusion in 52.4% (55/105). To date, 81.0% (85/105) of the aneurysms have been followed up (mean, 17 months) with angiography, disclosing a recanalization in 5.9% (5/85) and an improvement in 42.4% (36/85). At discharge and follow-up, the mRS score was 0 in 83.5% (81/97) of patients, 1 in 4.1% (4/97), 2 in 3.1% (3/97), 3 in 4.1% (4/97), 4 in 3.1% (3/97), and 6 in 2.1% (2/97). CONCLUSIONS Y and X stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms is an effective technique.
Collapse
Affiliation(s)
- B Bartolini
- From the Department of Interventional and Functional Neuroradiology, Foundation Rothschild Hospital, Paris, France.
| | - R Blanc
- From the Department of Interventional and Functional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - S Pistocchi
- From the Department of Interventional and Functional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - H Redjem
- From the Department of Interventional and Functional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| | - M Piotin
- From the Department of Interventional and Functional Neuroradiology, Foundation Rothschild Hospital, Paris, France
| |
Collapse
|
32
|
Y-Stenting for Bifurcation Aneurysm Coil Embolization: What is the Risk? Stroke Res Treat 2014; 2014:762389. [PMID: 25120940 PMCID: PMC4121189 DOI: 10.1155/2014/762389] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 04/29/2014] [Indexed: 11/17/2022] Open
Abstract
The use of two stents in a “Y” configuration (Y-stenting) to assist with coil embolization of complex bifurcation aneurysms has been accepted as an alternative to clip reconstruction of a select subset of challenging aneurysms. We review the risks associated with Y-stenting, including its procedural complication rates, angiographic occlusion rates, rerupture, and retreatment rates.
Collapse
|
33
|
Zhang JZ, Yang PF, Huang QH, Xu Y, Hong B, Zhao WY, Liu JM. Stent-assisted coiling strategies for the treatment of wide-necked basilar artery bifurcation aneurysms. J Clin Neurosci 2014; 21:962-7. [DOI: 10.1016/j.jocn.2013.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 08/21/2013] [Accepted: 08/31/2013] [Indexed: 11/30/2022]
|
34
|
Aguilar-Pérez M, Kurre W, Fischer S, Bäzner H, Henkes H. Coil occlusion of wide-neck bifurcation aneurysms assisted by a novel intra- to extra-aneurysmatic neck-bridging device (pCONus): initial experience. AJNR Am J Neuroradiol 2014; 35:965-71. [PMID: 24356676 DOI: 10.3174/ajnr.a3807] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The pCONus is a new stentlike self-expanding nitinol implant with 4 distal petals, which is fully retrievable and electrolytically detachable. The distal end is implanted inside the aneurysm at the neck. The shaft is anchored in the parent vessel. In selected wide-neck bifurcation aneurysms, the pCONus was used to assist coiling. The device was evaluated for its safety and efficacy. MATERIAL AND METHODS Twenty-eight patients with 28 wide-neck aneurysms (9 recently ruptured) were treated with pCONus-assisted coiling at the discretion of the operator. Other treatment options were considered but were discarded due to anticipated difficulties. Technical issues, immediate posttreatment angiographic findings, clinical outcome, and follow-up imaging were assessed. RESULTS There were 11 MCA, 7 anterior communicating artery, 1 posterior cerebral artery, 1 A2, and 8 basilar artery aneurysms. Insertion and deployment of the pCONus and subsequent coiling were possible in all cases. There were no clinically evident complications associated with the use of the device. Initial anatomic outcome showed 8 complete occlusions, 9 neck remnants, and 11 incomplete occlusions. Neurologic status remained unchanged at follow-up. Angiographic controls were obtained in 22 patients (mean, 7.5 months). Of these, 13 had complete occlusion, 9 showed improvement, and 7 were unchanged. Four died from SAH sequelae or other diseases, and 2 have not yet undergone follow-up. No intimal hyperplasia was observed. CONCLUSIONS The pCONus facilitates coil occlusion of unruptured and ruptured wide-neck bifurcation aneurysms. The device can be deployed safely. Coil retention is sufficient to protect the efferent vessels. So far, no intimal hyperplasia in the shaft has been observed.
Collapse
Affiliation(s)
- M Aguilar-Pérez
- From the Departments of Neuroradiology (M.A.-P., W.K., S.F., H.H.)
| | - W Kurre
- From the Departments of Neuroradiology (M.A.-P., W.K., S.F., H.H.)
| | - S Fischer
- From the Departments of Neuroradiology (M.A.-P., W.K., S.F., H.H.)
| | - H Bäzner
- Neurology (H.B.), Klinikum Stuttgart, Stuttgart, Germany
| | - H Henkes
- From the Departments of Neuroradiology (M.A.-P., W.K., S.F., H.H.)
| |
Collapse
|
35
|
Zhou Y, Yang PF, Li Q, Zhao R, Fang YB, Xu Y, Hong B, Zhao WY, Huang QH, Liu JM. Stent placement for complex middle cerebral artery aneurysms. J Stroke Cerebrovasc Dis 2014; 23:1447-56. [PMID: 24774440 DOI: 10.1016/j.jstrokecerebrovasdis.2013.12.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 11/14/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND To evaluate the safety and effectiveness of stent placement for ruptured or unruptured middle cerebral artery (MCA) aneurysms in a larger number. METHODS Between October 2003 and December 2012, data for 70 patients with 72 complex MCA aneurysms treated with stents at our institution were retrospectively collected and analyzed. RESULTS Eighty-five stents were successfully deployed in this series. However, failure of followed coiling was encountered in 2 (2.8%) tiny aneurysms of them. Of the 63 aneurysms treated with stent-assisted coiling, complete occlusion was achieved in 22 (34.9%), neck remnant in 15 (23.8%), and residual sac in 26 (36.5%). Of the 9 aneurysms treated with stent alone, the results were contrast stasis in 3 aneurysms and no change in 6. Procedure-related complications occurred in 9 (12.5%) procedures, including 7 of 27 (25.9%) with ruptured aneurysms and 2 of 45 (4.4%) with unruptured aneurysms, which resulted in 1 death and 5 disabilities. Univariate and multivariate analyses show that ruptured aneurysm is an independent factor for the outcome of these patients (odds ratio, 7.35; 95% confidence interval, 1.35-40.0). Angiographic follow-up results (mean, 10.5±8.8 months) showed that 72.1% (44 of 61) were completely occluded, 4.9% (3 of 61) recurred, and others were stable or had improved. Intrastent stenosis was observed in 1 (1.6%) patient, which was managed conservatively. During a clinical follow-up period ranging from 7 to 113 months (mean, 33.0±22.4 months), 1 disabled patient died from severe pneumonia, whereas the clinical status of the others had improved or was stable. Procedure-related morbidity/mortality during the follow-up for the ruptured and unruptured groups were 3.7%/3.7% and 0/0, respectively. CONCLUSIONS Our study shows that stent placement for the treatment of certain wide-neck MCA aneurysms is feasible, safe, and effective. However, stent placement for acutely ruptured MCA aneurysms harbors a much higher complication rate.
Collapse
Affiliation(s)
- Yu Zhou
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Peng-Fei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qiang Li
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wen-Yuan Zhao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China.
| |
Collapse
|
36
|
Piotin M, Blanc R. Balloons and stents in the endovascular treatment of cerebral aneurysms: vascular anatomy remodeled. Front Neurol 2014; 5:41. [PMID: 24782817 PMCID: PMC3986530 DOI: 10.3389/fneur.2014.00041] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 03/19/2014] [Indexed: 11/13/2022] Open
Abstract
Wide-neck intracranial aneurysms were originally thought to be either untreatable or very challenging to treat by endovascular means because of the risk of coil protrusion into the parent vessel. The introduction of the balloon remodeling technique (BRT) and later stents specifically designed for intracranial use has progressively allowed these lesions to be endovascularly treated. BRT and stent-assisted coiling technique (SACT) were first designed to treat sidewall aneurysms but, with gained experience and further technical refinement, bifurcation complex-shaped wide-neck aneurysms have been treated by coiling enhanced by BRT and SACT. In this article, we will review and describe the inherent benefits and drawbacks of BRT as well as SACT.
Collapse
Affiliation(s)
- Michel Piotin
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital , Paris , France
| | - Raphaël Blanc
- Department of Interventional Neuroradiology, Foundation Rothschild Hospital , Paris , France
| |
Collapse
|
37
|
Kono K, Terada T. Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography. Acta Neurochir (Wien) 2014; 156:39-43. [PMID: 24190455 DOI: 10.1007/s00701-013-1925-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 10/15/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents. METHODS Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010" coils or a PX Slim microcatheter for 0.020" Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography. RESULTS It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41 ± 0.18 mm vs 0.69 ± 0.20 mm; P = 0.008). The SL-10 microcatheter was smaller than approximately 80% of the stent pores of the first stent and 30% of those of the second stent. The PX Slim microcatheter was smaller than 20% of the stent pores of the first stent and 0% of those of the second stent. CONCLUSIONS It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020" Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.
Collapse
Affiliation(s)
- Kenichi Kono
- Department of Neurosurgery, Wakayama Rosai Hospital, 93-1 Kinomoto, Wakayama, 640-8505, Japan,
| | | |
Collapse
|
38
|
Makoyeva A, Darsaut TE, Salazkin I, Raymond J. Y-crossing of braided stents with stents and flow diverters does not cause significant stenosis in bench-top studies. Interv Neuroradiol 2013; 19:455-60. [PMID: 24355149 DOI: 10.1177/159101991301900408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 08/03/2013] [Indexed: 11/16/2022] Open
Abstract
Y-stent placement to treat bifurcation aneurysms requires the second device to cross the confines of the first stent, with concerns regarding the formation of stenosis of the second device at the site of crossing. Various braided stents and flow diverters (FDs) were deployed to cross through a high porosity braided stent, in a Y configuration, with the ends of the devices inserted in plastic tubes of various diameters, leaving the mid-portion free to expand. The ensuing constructs were photographed, paying attention to the degree of stenosis, if any, created where the second device crosses the first stent. Experiments were repeated selecting different zones of the first stent as the site of crossing for the second device, different tube diameters, and changing the angle of the bifurcation. Crossing the first stent did not cause the second stent to become significantly stenosed in any case. Crossing through the transition or expansion zone of the first device had no influence on results. Different bifurcation angles had no influence on the occurrence of stenosis. Y-stent placement to treat arterial bifurcations using braided self-expanding stents and FDs does not lead to significant stenosis in bench-top studies.
Collapse
Affiliation(s)
- Alina Makoyeva
- Department of Radiology, University of Montreal, CHUM Notre-Dame Hospital; Montreal, Quebec, Canada -
| | | | | | | |
Collapse
|
39
|
Raymond J, Darsaut TE, Makoyeva A, Bing F, Salazkin I. Endovascular treatment with flow diverters may fail to occlude experimental bifurcation aneurysms. Neuroradiology 2013; 55:1355-63. [PMID: 23989462 DOI: 10.1007/s00234-013-1272-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/13/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Animal models may explain how stents and flow diverters (FDs) may succeed or fail to treat bifurcation aneurysms. METHODS In vitro studies were designed to anticipate device deformations in bifurcations. Large, wide-necked bifurcation aneurysms were constructed in 21 animals and treated 4-8 weeks later using stents and FDs in various combinations, forming four main groups: parent artery to right branch flow diversion (RBFD, n = 6), parent artery to left branch flow diversion (LBFD, n = 6), Y flow diversion (YFD, n = 4), and compared with high-porosity Y-stenting (YHPS, n = 4). The results include immediate and follow-up angiography at 3 months, followed by grading of the extent of neointimal coverage of devices at pathology. RESULTS In vitro, all braided devices showed varying porosities according to characteristic zones. FDs can be compacted to decrease porosities, but a limiting factor is the constant presence of a more porous transition zone. In vivo, 3/6 RBFD, 4/6 LBFD, and 2/4 YFD treated aneurysms had decreased in size by 3 months, while those treated with YHPS increased in size (P = 0.15). There was a significant correlation between device porosities and extent of neointimal coverage (r = 0.639, P = 0.002), and between porosities and angiographic evolution (r = -0.655, P = 0.002), but not between neointima formation and angiographic evolution (r = -0.278, P = 0.235). Failures could be explained in all cases by the presence of leaks or holes in the neointima at the level of the transition zones. CONCLUSION FDs did not successfully treat most bifurcation aneurysms, at least in this animal model.
Collapse
Affiliation(s)
- Jean Raymond
- Department of Radiology, Notre-Dame Hospital, Centre Hospitalier de l'Université de Montréal, 1560 Sherbrooke East, Montreal, QC, H2L 4M1, Canada,
| | | | | | | | | |
Collapse
|
40
|
Triple antiplatelet therapy with addition of cilostazol to aspirin and clopidogrel for Y-stent-assisted coil embolization of cerebral aneurysms. Acta Neurochir (Wien) 2013; 155:1549-57. [PMID: 23715948 DOI: 10.1007/s00701-013-1771-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dual antiplatelet therapy for stent-assisted coiling of cerebral aneurysms is essential to prevent thromboembolic complications. There is concern that Y-stent-assisted coiling may increase thromboembolic complications compared with coiling with a single stent. Several reports have demonstrated that cilostazol may improve clopidogrel responsiveness. We investigated whether triple antiplatelet therapy with addition of cilostazol to aspirin plus clopidogrel for Y-stents can prevent thromboembolic events. METHODS Between July 2010 and October 2012, we treated 40 consecutive aneurysms with coil embolization using Enterprise stents. At the peri-procedural period, dual antiplatelet agents (100 mg aspirin and 75 mg clopidogrel) were used for the single stent group (n = 36), and triple antiplatelet agents (addition of 200 mg cilostazol) were used for the Y-stent group (n = 4). We evaluated post-operative diffusion-weighted imaging (DWI) and any complications. We assessed the following for statistical analysis: age, sex, aneurysm location, shape, and size, neck size, size of parent vessels, and stent length. RESULTS We found two neurological peri-procedural complications: one transient ischemic attack and one infarction. Both complications belonged to the Y-stent group, which was a significant factor of thromboembolic events (P = 0.008). There were no other significant factors related to neurological complications or positive DWI. For subgroup analysis of the single stent group, stent length was significantly longer in positive DWI than negative DWI (P = 0.04). In the follow-up period of 20 ± 8.6 months, there were no symptomatic late complications in any patients. CONCLUSIONS Although the number of patients in the Y-stent group is small, this group had a significantly higher risk of thromboembolic complications. While our protocol of a routine dose of dual antiplatelet therapy may be sufficient for single stent therapy, our protocol of a routine dose of triple antiplatelet therapy for Y-stents may not prevent thromboembolic events. This suggests that evaluation of platelet function may be essential, especially for Y-stents.
Collapse
|
41
|
Conrad MD, Brasiliense LBC, Richie AN, Hanel RA. Y stenting assisted coiling using a new low profile visible intraluminal support device for wide necked basilar tip aneurysms: a technical report. J Neurointerv Surg 2013; 6:296-300. [PMID: 23794675 DOI: 10.1136/neurintsurg-2013-010818] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Many endovascular techniques have been described in recent years for the management of wide necked aneurysms. The Y stent assisted technique has been generally used for coil embolization of wide necked bifurcation aneurysms. This technique was first described for the treatment of basilar tip aneurysms in combination with several different devices, demonstrating encouraging results. We report the results of the first two cases of wide necked basilar tip aneurysms treated with Y stent assisted coil embolization using a new low profile visible intraluminal stent (LVIS Jr; MicroVention, Tustin, California, USA) delivered through a 0.017 inch microcatheter. We also reviewed the literature comparing other endovascular techniques (coiling alone, stent assisted coiling, and Y stent assisted coiling) for wide necked aneurysms. The LVIS Jr device offers a new option for the treatment of these challenging lesions, with clear advantages over currently available intracranial stents. Larger series and long term results are needed to confirm the applicability and durability of this technique/technology.
Collapse
Affiliation(s)
- Marcelo D Conrad
- Neuroendovascular Section, CardioLages Clinic and Nossa Senhora dos Prazeres Hospital (HNSP), Centro, Lages, Brazil
| | | | | | | |
Collapse
|
42
|
Fargen KM, Mocco J, Neal D, Dewan MC, Reavey-Cantwell J, Woo HH, Fiorella DJ, Mokin M, Siddiqui AH, Turk AS, Turner RD, Chaudry I, Kalani MYS, Albuquerque F, Hoh BL. A Multicenter Study of Stent-Assisted Coiling of Cerebral Aneurysms With a Y Configuration. Neurosurgery 2013; 73:466-72. [PMID: 23756744 DOI: 10.1227/neu.0000000000000015] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Abstract
BACKGROUND:
Stent-assisted coiling with 2 stents in a Y configuration is a technique for coiling complex wide-neck bifurcation aneurysms.
OBJECTIVE:
We sought to provide long-term clinical and angiographic outcomes with Y-stent coiling, which are not currently established.
METHODS:
Seven centers provided deidentified, retrospective data on all consecutive patients who underwent stent-assisted coiling for an intracranial aneurysm with a Y-stent configuration.
RESULTS:
Forty-five patients underwent treatment by Y-stent coiling. Their mean age was 57.9 years. Most aneurysms were basilar apex (87%), and 89% of aneurysms were unruptured. Mean size was 9.9 mm. Most aneurysms were treated with 1 open-cell and 1 closed-cell stent (51%), with 29% treated with open-open stents and 16% treated with 2 closed-cell stents. Initial aneurysm occlusion was excellent (84% in Raymond grade I or II). Procedural complications occurred in 11% of patients. Mean clinical follow-up was 7.8 months, and 93% of patients had a modified Rankin Scale score of 0 to 2 at last follow-up. Mean angiographic follow-up was 9.8 months, and 92% of patients had Raymond grade I or II occlusion on follow-up imaging. Of those patients with initial Raymond grade III occlusion and follow-up imaging, all but 1 patient progressed to a better occlusion grade (83%; P < .05). Three aneurysms required retreatment because of recanalization (10%). There was no difference in initial or follow-up angiographic occlusion, clinical outcomes, incidence of aneurysm retreatment, or in-stent stenosis among open-open, open-closed, or closed-closed stent groups.
CONCLUSION:
In a large multicenter series of Y-stent coiling for bifurcation aneurysms, there were low complication rates and excellent clinical and angiographic outcomes.
Collapse
Affiliation(s)
- Kyle M. Fargen
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - J Mocco
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Dan Neal
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Michael C. Dewan
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - John Reavey-Cantwell
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia
| | - Henry H. Woo
- Departments of Neurosurgery and Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - David J. Fiorella
- Departments of Neurosurgery and Radiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Maxim Mokin
- Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Adnan H. Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Aquilla S. Turk
- Departments of Neurosurgery and Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Raymond D. Turner
- Departments of Neurosurgery and Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Imran Chaudry
- Departments of Neurosurgery and Radiology, Medical University of South Carolina, Charleston, South Carolina
| | | | - Felipe Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Brian L. Hoh
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| |
Collapse
|
43
|
Kono K, Terada T. Hemodynamics of 8 different configurations of stenting for bifurcation aneurysms. AJNR Am J Neuroradiol 2013; 34:1980-6. [PMID: 23578668 DOI: 10.3174/ajnr.a3479] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE SACE is performed for complex aneurysms. There are several configurations of stent placement for bifurcation aneurysms. We investigated hemodynamics among 8 different configurations of stent placement, which may relate to the recanalization rate. MATERIALS AND METHODS We created a silicone block model of a patient-specific asymmetric bifurcation aneurysm. Enterprise closed-cell stents were deployed in the model as various configurations. 3D images of these stents were obtained by micro-CT. We performed CFD simulations for a no-stent model and 8 stent models: a single stent from a proximal vessel to a right or left distal vessel, a horizontal stent, a kissing-Y stent with a uniformly narrowed structure, a nonoverlapping-Y stent, a virtual-Y stent with no narrowed structure (fusion of 2 single stents), and 2 different crossing-Y stents with a focally narrowed structure. Hemodynamic parameters were evaluated. RESULTS Cycle-averaged velocity and WSS in the aneurysm were reduced because of stent placement in the following order: single stent (19% reduction in cycle-averaged velocity) < nonoverlapping-Y stent (29%) < virtual-Y stent (32%) < horizontal stent (39%) < kissing-Y stent (48%) < crossing-Y stent (54%). Kissing- and crossing-Y stents redirected impingement flow into the distal vessels because of lowered porosity of stents due to narrowed structures. CONCLUSIONS Among 8 different configurations of stent placement, kissing- and crossing-Y stents showed the strongest reduction in flow velocity in the aneurysm because of lowered porosity of stents and redirection of impingement flow. This may be a desirable reconstruction of flow hemodynamics and may decrease recanalization rates in SACE.
Collapse
Affiliation(s)
- K Kono
- Department of Neurosurgery, Wakayama Rosai Hospital, Wakayama, Japan
| | | |
Collapse
|