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Jeken-Rico P, Chau Y, Goetz A, Lannelongue V, Sédat J, Hachem E. Virtual flow diverter deployment and embedding for hemodynamic simulations. Comput Biol Med 2024; 180:109023. [PMID: 39163828 DOI: 10.1016/j.compbiomed.2024.109023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 08/03/2024] [Accepted: 08/11/2024] [Indexed: 08/22/2024]
Abstract
Flow-diverter stents offer clinicians an effective solution for treating intracranial aneurysms, especially in cases where other devices may be unsuitable. However, strongly deviating success rates among different centres, manufacturers, and aneurysm phenotypes highlight the need for better in-situ studies of these devices. To support research in this area, virtual stenting algorithms have been proposed that, combined with computational fluid dynamics, provide insights into the hemodynamic alterations induced by the device. Yet, many existing algorithms rely on uncertain parameters, such as the forces applied during operation, fail to predict the length of the device after deployment, or lack robust validation steps, raising concerns about their reliability. Therefore, we developed a robust deployment technique that builds upon the geometrical features of the vessel and includes advancements from previous works. The algorithm is detailed and validated against literature examples, in-vitro experiments, and patient data, achieving a mean angular error below 5° in the latter. Furthermore, we describe and demonstrate how the deployed device can be embedded in a computational mesh using open-source tools and anisotropic meshing routines.
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Affiliation(s)
- Pablo Jeken-Rico
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France.
| | - Yves Chau
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, 06000, France
| | - Aurèle Goetz
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
| | - Vincent Lannelongue
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
| | - Jacques Sédat
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, 06000, France
| | - Elie Hachem
- Mines Paris, Université PSL, CEMEF, UMR7635 CNRS, Sophia Antipolis, 06904, France
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Sharashidze V, Raz E, Nossek E, Kvint S, Riina H, Rutledge C, Baranoski J, Khawaja A, Chung C, Nelson PK, Shapiro M. Comprehensive Analysis of Post-Pipeline Endothelialization and Remodeling. AJNR Am J Neuroradiol 2024; 45:893-898. [PMID: 38663989 DOI: 10.3174/ajnr.a8228] [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: 11/27/2023] [Accepted: 02/06/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND AND PURPOSE Successful post-flow-diverter endoluminal reconstruction is widely believed to require endothelial overgrowth of the aneurysmal inflow zone. However, endothelialization/neointimal overgrowth is a complex process, over which we currently have very limited influence. Less emphasized is vascular remodeling of the target arterial segment, the dynamic response of the vessel to flow-diverter implantation. This process is distinct from flow modifications in covered branches. It appears that basic angiographic methods allow simple and useful observations. The purpose of this article was to quantitatively evaluate observable postimplantation changes in target vessels following deployment of Pipeline endoluminal constructs. MATERIALS AND METHODS One hundred consecutive adults with unruptured, previously untreated, nondissecting aneurysms treated with the Pipeline Embolization Device with Shield Technology and the availability of follow-up conventional angiography were studied with 2D DSA imaging. Target vessel size; Pipeline Embolization Device diameter; endothelial thickness; and various demographic, antiplatelet, and device-related parameters were recorded and analyzed. RESULTS The thickness of neointimal overgrowth (mean, 0.3 [SD, 0.1] mm; range, 0.1-0.7 mm) is inversely correlated with age and is independent of vessel size, smoking status, sex, and degree of platelet inhibition. The decrease in lumen diameter caused by neointimal overgrowth, however, appears counteracted by outward remodeling (dilation) of the target arterial segment. This leads to an increase in the diameter with a corresponding decrease in length (foreshortening) of the implanted Pipeline Embolization Device. This physiologic remodeling process affects optimally implanted devices and is not a consequence of stretching, device migration, vasospasm, and so forth. A direct, linear, statistically significant relationship exists between the degree of observed outward remodeling and the diameter of the implanted Pipeline Embolization Device relative to the target vessel. Overall, remodeled arterial diameters were reduced by 15% (SD, 10%) relative to baseline and followed a normal distribution. Clinically relevant stenosis was not observed. CONCLUSIONS Vessel healing involves both outward remodeling and neointimal overgrowth. Judicial oversizing could be useful in specific settings to counter the reduction in lumen diameter due to postimplant neointimal overgrowth; however, this overszing needs to be balanced against the decrease in metal coverage accompanying the use of oversized devices. Similar analysis for other devices is essential.
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Affiliation(s)
- Vera Sharashidze
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Eytan Raz
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Erez Nossek
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Svetlana Kvint
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Howard Riina
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Caleb Rutledge
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Jacob Baranoski
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Ayaz Khawaja
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Charlotte Chung
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Peter Kim Nelson
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
| | - Maksim Shapiro
- From the Department of Radiology (V.S., E.R.., S.K., H.R., A.K., C.C., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurosurgery (V.S., E.R, E.N., H.R., C.R., J.B., P.K.N., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
- Department of Neurology (H.R., M.S.), NYU Grossman School of Medicine and Bellevue H+Hospitals, New York, New York
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Ramirez-Velandia F, Enriquez-Marulanda A, Young M, Orrego-González E, Filo J, Fodor TB, Sconzo D, Shutran M, Ogilvy CS, Taussky P. Thromboembolic Events After the Coverage of Anterior Cerebral Artery with Flow Diversion: A Single Institution Series and Systematic Review. World Neurosurg 2024; 187:e1040-e1053. [PMID: 38754548 DOI: 10.1016/j.wneu.2024.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 05/08/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Advances in the use of flow diversion (FD) now extend to bifurcation aneurysms; herein, we compare thromboembolic events in patients with internal carotid artery (ICA) aneurysms treated with and without exclusion of the anterior cerebral artery (ACA). METHODS Retrospective analysis of aneurysms in the terminal ICA treated with FD from 2013 to 2023 at a single-center study. Procedures were classified according to the coverage at the origin of the ACA and compared through bivariate-analysis. A review was also carried on PubMed, Web of Science, and EMBASE until April 2024, adhering to the PRISMA reporting guidelines. RESULTS Ninety-five patients harboring 113 aneurysms treated in 102 procedures were evaluated. Fifty-eight were treated covering the ACA origin. Dual antiplatelet regimens included aspirin-clopidogrel (50%), aspirin-ticagrelor (44.1%), and aspirin-prasugrel (4.9%). Thromboembolic events occurred in 6 patients (5.9%), all of which presented with large vessel occlusion of the ICA, but without reaching statistical difference in the 2 treated cohorts (P = 0.46). At a median clinical follow-up of 5.95 months, there were no differences in the functional outcomes in the 2 groups (P = 0.22). Contralateral angiographic runs post-treatment after covering the ACA origin demonstrated increase in the A1 (median: 0.45 mm; IQR = 0.4-1.2) and ICA diameter (median: 0.55 mm; IQR = 0.1-1.2). After pooling data from literature and our cohort, complete side branch occlusion after the coverage of ACA was seen in 25% of branches (95%CI = 0.16-0.36), and thromboembolic events were observed after 3% (95%CI = 0.01-0.04) of procedures. CONCLUSIONS Thromboembolic events can occur in distal ICA aneurysms treated with FD, but no significant association was seen with covering the ACA origin.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | | | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Eduardo Orrego-González
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Ramirez-Velandia F, Enriquez-Marulanda A, Filo J, Young M, Fodor TB, Sconzo D, Muram S, Granstein JH, Shutran M, Taussky P, Ogilvy CS. Thromboembolic Events in the Posterior Circulation After Flow Diversion-A Closer Look at Coverage of the Posterior Cerebral Artery. World Neurosurg 2024; 187:e920-e928. [PMID: 38734173 DOI: 10.1016/j.wneu.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Flow diversion for bifurcation aneurysms requires excluding one of the branches from the parent artery, raising concern for ischemic events. We evaluated thromboembolic events and their relationship with covering the origin of the posterior cerebral artery (PCA). METHODS This retrospective analysis included patients with confirmed basilar and proximal PCA aneurysms treated with flow diversion between 2013 and 2023. Procedures were classified according to the coverage of the origin of the PCA. Thromboembolic events associated with the excluded PCA were evaluated. RESULTS Of the total 28 aneurysms included, 7 were at the basilar tip, 16 in the basilar trunk, and 5 in the first segment of the PCA; 15 were treated by excluding one of the PCAs. Dual antiplatelet therapy included aspirin and ticagrelor (57.1%), aspirin and clopidogrel (35.7%), or aspirin and prasugrel (3.57%). Complete and near-complete aneurysm occlusion was achieved in 80.8% of the aneurysms treated at a median follow-up of 12.31 months. Thromboembolic complications occurred in 3 patients (2 with basilar perforator stroke and 1 with basilar in-stent thrombosis). However, the difference in these events was not statistically significant between patients with PCA coverage and those without (P = 0.46). Diminished flow and a lack of flow was seen in 8 and 7 of the covered vessels, respectively. A modified Rankin scale score of ≤2 was reported for 89.3% of patients at a median clinical follow-up of 5.5 months. CONCLUSIONS The incidence of thromboembolic events is high in distal basilar and proximal PCA aneurysms; however, PCA coverage was not associated with their occurrence. There was no difference in postprocedural disability between patients whose aneurysms were treated by excluding one of the PCAs and those who were not.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Jean Filo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Sconzo
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sandeep Muram
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin H Granstein
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Huang C, Feng X, Tong X, Wen Z, Zhu Y, Xu A, Huang M, Ma G, Hu Y, Shi H, Guo Z, Liu A, Duan C. Stent-to-vessel diameter ratio is associated with in-stent stenosis after flow-diversion treatment of intracranial aneurysms. J Stroke Cerebrovasc Dis 2024; 33:107833. [PMID: 38925449 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND AND PURPOSE Flow-diversion treatment for intracranial aneurysms has been associated with the development of in-stent stenosis (ISS) for unclear reasons. We assess whether the size of the stent relative to that of the vessel (the stent-to-vessel diameter ratio, or SVR) may be predictive of the development of ISS after treatment with flow diverters. METHODS We retrospectively reviewed patients with unruptured intracranial aneurysms who underwent flow-diversion treatment using either the Pipeline or Tubridge embolization device from September 2018 to September 2022. The relationship between SVR and ISS was analyzed. Multiple logistic regression models were used to determine the significant predictors. RESULTS A total of 458 patients with 481 aneurysms were included. In a mean angiographic follow-up of 10.73 ± 3.97 months, ISS was detected in 68 cases (14.1 %). After adjusting for candidate variables, a higher distal SVR (DSVR) was associated with an increased risk of ISS (adjusted odds ratio [aOR] = 3.420, 95 % confidence interval [CI] = 1.182 - 9.889, p = 0.023). We conducted a subgroup analysis of the two different flow diverters to assess the effects of their individual characteristics. Our results showed a significant association between the DSVR and the incidence of ISS in both the Pipeline (aOR = 4.033, 95 % CI = 1.156-14.072, p = 0.029) and Tubridge groups (aOR = 11.981, 95 % CI=1.005-142.774, p = 0.049). CONCLUSION A higher DSVR was associated with an increased risk of ISS. This may help neurointerventionalists select an appropriate stent size when conducting flow-diversion treatment for intracranial aneurysms.
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Affiliation(s)
- Chi Huang
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Xin Feng
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Xin Tong
- Beijing Neurosurgical Institute, Neurointervention Center Beijing, Beijing, CN
| | - Zhuohua Wen
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Yajun Zhu
- The First Affiliated Hospital of Chongqing Medical University, Department of Neurosurgery, Chongqing, CN
| | - Anqi Xu
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Mengshi Huang
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Gengwu Ma
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Yuqi Hu
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Hongyu Shi
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
| | - Zongduo Guo
- The First Affiliated Hospital of Chongqing Medical University, Department of Neurosurgery, Chongqing, CN
| | - Aihua Liu
- Beijing Neurosurgical Institute, Neurointervention Center Beijing, Beijing, CN.
| | - Chuanzhi Duan
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, CN
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Goetz A, Jeken-Rico P, Pelissier U, Chau Y, Sédat J, Hachem E. AnXplore: a comprehensive fluid-structure interaction study of 101 intracranial aneurysms. Front Bioeng Biotechnol 2024; 12:1433811. [PMID: 39007055 PMCID: PMC11243300 DOI: 10.3389/fbioe.2024.1433811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 06/03/2024] [Indexed: 07/16/2024] Open
Abstract
Advances in computational fluid dynamics continuously extend the comprehension of aneurysm growth and rupture, intending to assist physicians in devising effective treatment strategies. While most studies have first modelled intracranial aneurysm walls as fully rigid with a focus on understanding blood flow characteristics, some researchers further introduced Fluid-Structure Interaction (FSI) and reported notable haemodynamic alterations for a few aneurysm cases when considering wall compliance. In this work, we explore further this research direction by studying 101 intracranial sidewall aneurysms, emphasizing the differences between rigid and deformable-wall simulations. The proposed dataset along with simulation parameters are shared for the sake of reproducibility. A wide range of haemodynamic patterns has been statistically analyzed with a particular focus on the impact of the wall modelling choice. Notable deviations in flow characteristics and commonly employed risk indicators are reported, particularly with near-dome blood recirculations being significantly impacted by the pulsating dynamics of the walls. This leads to substantial fluctuations in the sac-averaged oscillatory shear index, ranging from -36% to +674% of the standard rigid-wall value. Going a step further, haemodynamics obtained when simulating a flow-diverter stent modelled in conjunction with FSI are showcased for the first time, revealing a 73% increase in systolic sac-average velocity for the compliant-wall setting compared to its rigid counterpart. This last finding demonstrates the decisive impact that FSI modelling can have in predicting treatment outcomes.
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Affiliation(s)
- Aurèle Goetz
- Computing and Fluids Research Group, CEMEF, Mines Paris PSL, Sophia Antipolis, France
| | - Pablo Jeken-Rico
- Computing and Fluids Research Group, CEMEF, Mines Paris PSL, Sophia Antipolis, France
| | - Ugo Pelissier
- Computing and Fluids Research Group, CEMEF, Mines Paris PSL, Sophia Antipolis, France
| | - Yves Chau
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, France
| | - Jacques Sédat
- Department of Neuro-Interventional and Vascular Interventional, University Hospital of Nice, Nice, France
| | - Elie Hachem
- Computing and Fluids Research Group, CEMEF, Mines Paris PSL, Sophia Antipolis, France
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Kim S, Yang H, Oh JH, Kim YB. Quantitative analysis of hemodynamic changes induced by the discrepancy between the sizes of the flow diverter and parent artery. Sci Rep 2024; 14:10653. [PMID: 38724557 PMCID: PMC11081945 DOI: 10.1038/s41598-024-61312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
The efficacy of flow diverters is influenced by the strut configuration changes resulting from size discrepancies between the stent and the parent artery. This study aimed to quantitatively analyze the impact of size discrepancies between flow diverters and parent arteries on the flow diversion effects, using computational fluid dynamics. Four silicone models with varying parent artery sizes were developed. Real flow diverters were deployed in these models to assess stent configurations at the aneurysm neck. Virtual stents were generated based on these configurations for computational fluid dynamics analysis. The changes in the reduction rate of the hemodynamic parameters were quantified to evaluate the flow diversion effect. Implanting 4.0 mm flow diverters in aneurysm models with parent artery diameters of 3.0-4.5 mm, in 0.5 mm increments, revealed that a shift from oversized to undersized flow diverters led to an increase in the reduction rates of hemodynamic parameter, accompanied by enhanced metal coverage rate and pore density. However, the flow diversion effect observed transitioning from oversizing to matching was less pronounced when moving from matching to undersizing. This emphasizes the importance of proper sizing of flow diverters, considering the benefits of undersizing and not to exceed the threshold of advantages.
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Affiliation(s)
- Sunghan Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyeondong Yang
- Department of Mechanical Engineering and BK21 FOUR ERICA-ACE Center, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do, 15588, Republic of Korea
| | - Je Hoon Oh
- Department of Mechanical Engineering and BK21 FOUR ERICA-ACE Center, Hanyang University, 55 Hanyangdaehak-ro, Sangnok-gu, Ansan, Gyeonggi-do, 15588, Republic of Korea.
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Oliver AA, Senol YC, Bilgin C, Schaffer JE, Kadirvel R, Kallmes DF, Wainwright JM. Intraluminal Flow Diverter Design Primer for Neurointerventionalists. AJNR Am J Neuroradiol 2024; 45:365-370. [PMID: 38164542 PMCID: PMC11288553 DOI: 10.3174/ajnr.a8076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
The clinical use of flow diverters for the treatment of intracranial aneurysms has rapidly grown. Consequently, the market and technology for these devices has also grown. Clinical performance characteristics of the flow diverter are well-known to the clinician. However, the engineering design principles behind how these devices achieve ideal clinical performance are less understood. This primer will summarize flow diverter design parameters for neurointerventionalists with the aim of promoting collaboration between clinicians and engineers.
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Affiliation(s)
- Alexander A Oliver
- From the Department of Biomedical Engineering and Physiology (A.A.O., D.F.K.), Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Yigit Can Senol
- Department of Neurologic Surgery (Y.C.S., R.K.), Mayo Clinic, Rochester, Minnesota
| | - Cem Bilgin
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | | | - Ramanathan Kadirvel
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery (Y.C.S., R.K.), Mayo Clinic, Rochester, Minnesota
| | - David F Kallmes
- From the Department of Biomedical Engineering and Physiology (A.A.O., D.F.K.), Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minnesota
- Department of Radiology (A.A.O., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - John M Wainwright
- MIVI Neuroscience (J.M.W.), Eden Prairie, Minnesota
- The Henry Samueli School of Engineering (J.M.W.), University of California, Irvine, California
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Abdollahi R, Shahi A, Roy D, Lessard S, Mongrain R, Soulez G. Virtual and analytical self-expandable braided stent treatment models. Med Eng Phys 2024; 126:104145. [PMID: 38621838 DOI: 10.1016/j.medengphy.2024.104145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/25/2024] [Accepted: 03/09/2024] [Indexed: 04/17/2024]
Abstract
The Flow Diverter is a self-expandable braided stent that has helped improve the effectiveness of cerebral aneurysm treatment during the last decade. The Flow Diverter's efficiency heavily relies on proper decision-making during the pre-operative phase, which is currently based on static measurements that fail to account for vessel or tissue deformation. In the context of providing realistic measurements, a biomechanical computational method is designed to aid physicians in predicting patient-specific treatment outcomes. The method integrates virtual and analytical treatment models, validated against experimental mechanical tests, and two patient treatment outcomes. In the case of both patients, deployed stent length was one of the validated result parameters, which displayed an error inferior to 1.5% for the virtual and analytical models. These results indicated both models' accuracy. However, the analytical model provided more accurate results with a 0.3% error while requiring a lower computational cost for length prediction. This computational method can offer designing and testing platforms for predicting possible intervention-related complications, patient-specific medical device designs, and pre-operative planning to automate interventional procedures.
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Affiliation(s)
- Reza Abdollahi
- Faculté de médecine, Université de Montréal, H3T 1J4, Montréal, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, H2X 0A9, Montréal, Canada
| | - Amirali Shahi
- Faculté de médecine, Université de Montréal, H3T 1J4, Montréal, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, H2X 0A9, Montréal, Canada
| | - Daniel Roy
- Faculté de médecine, Université de Montréal, H3T 1J4, Montréal, Canada; Département de Radiologie, Centre Hospitalier de l'Université de Montréal, H2X 0C1, Montréal, Canada
| | - Simon Lessard
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, H2X 0A9, Montréal, Canada; École de Technologie Supérieure, H3C 1K3, Montréal, Canada
| | - Rosaire Mongrain
- Mechanical Engineering Department, McGill University, H3A 0C3, Montréal, Canada
| | - Gilles Soulez
- Faculté de médecine, Université de Montréal, H3T 1J4, Montréal, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal, H2X 0A9, Montréal, Canada; Département de Radiologie, Centre Hospitalier de l'Université de Montréal, H2X 0C1, Montréal, Canada.
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10
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Zhao Y, Lu J, Zhang H, Li T, Song D, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J, Zhao Y. Pipeline Embolization Device for intracranial aneurysms presenting with mass effect: a large Chinese cohort. Stroke Vasc Neurol 2024; 9:50-58. [PMID: 37295810 PMCID: PMC10956105 DOI: 10.1136/svn-2022-002213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Unruptured intracranial aneurysm treatment aims to reduce the risk of aneurysm rupture and bleeding, relieves symptoms and improve the quality of life for patients. This study aimed to assess the safety and efficacy of Pipeline Embolization Device (PED, Covidien/Medtronic, Irvine, CA) treatment for intracranial aneurysms presenting with mass effect in real-world settings. METHODS We selected patients from the PED in China Post-Market Multi-Center Registry Study with mass effect presentation. The study endpoints included postoperative mass effect deterioration and mass effect relief at follow-up (3-36 months). We conducted multivariate analysis to identify factors associated with mass effect relief. Subgroup analyses by aneurysm location, size and form were also performed. RESULTS This study included 218 patients with a mean age of 54.3±11.8 years and a female predominance of 74.0% (162/218). The postoperative mass effect deterioration rate was 9.6% (21/218). During a median follow-up period of 8.4 months, the mass effect relief rate was 71.6% (156/218). Notably, immediate aneurysm occlusion following treatment was significantly associated with mass effect relief (OR 0.392, 95% CI, 0.170 to 0.907, p=0.029). Subgroup analysis demonstrated that adjunctive coiling contributed to mass effect relief in cavernous aneurysms, while dense embolism impeded symptom relief in aneurysms<10 mm and saccular aneurysms. CONCLUSIONS Our data confirmed the efficacy of PED in relieving mass effect. The findings of this study provide support for endovascular treatment to alleviate mass effect in unruptured intracranial aneurysms. TRIAL REGISTRATION NUMBER NCT03831672.
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Affiliation(s)
- Yang Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tianxiao Li
- Department of Interventional Neuroradiology, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Donglei Song
- Department of Neurosurgery, Shanghai Donglei Brain Hospital, Shanghai, China
| | - Sheng Guan
- Department of Interventional Neuroradiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Aisha Maimaitili
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Yunyan Wang
- Department of Neurosurgery, Qilu Hospital of Shandong University Qingdao, Jinan, Shandong, China
| | - Wenfeng Feng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guohua Mao
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Huaizhang Shi
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xinjian Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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11
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Belanger BL, Morrish R, McClarty D, Barnstable C, Muir W, Ghazizadeh S, Eesa M, Fiorella D, Wong JH, Sadasivan C, Mitha AP. In vitro flow diversion effect of the ReSolv stent with the shelf technique in a bifurcation aneurysm model. J Neurointerv Surg 2024; 16:296-301. [PMID: 37188503 DOI: 10.1136/jnis-2022-020023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Flow-diverting stents are not currently indicated for the treatment of bifurcation aneurysms, and some case series have demonstrated low occlusion rates, possibly due to a lack in neck coverage. The ReSolv stent is a unique hybrid metal/polymer stent that can be deployed with the shelf technique in order to improve neck coverage. METHODS A Pipeline, unshelfed ReSolv, and shelfed ReSolv stent were deployed in the left-sided branch of an idealized bifurcation aneurysm model. After determining stent porosity, high-speed digital subtraction angiography runs were acquired under pulsatile flow conditions. Time-density curves were created using two region of interest (ROI) paradigms (total aneurysm and left/right), and four parameters were extracted to characterize flow diversion performance. RESULTS The shelfed ReSolv stent demonstrated better aneurysm outflow alterations compared to the Pipeline and unshelfed ReSolv stent when using the total aneurysm as the ROI. On the left side of the aneurysm, there was no significant difference between the shelfed ReSolv stent and the Pipeline. On the right side of the aneurysm, however, the shelfed ReSolv stent had a significantly better contrast washout profile than the unshelfed ReSolv stent and the Pipeline stent. CONCLUSIONS The ReSolv stent with the shelf technique demonstrates the potential to improve flow diversion outcomes for bifurcation aneurysms. Further in vivo testing will help to determine whether the additional neck coverage leads to better neointimal scaffolding and long-term aneurysm occlusion.
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Affiliation(s)
- Brooke L Belanger
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Rosalie Morrish
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Davis McClarty
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Colette Barnstable
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Warren Muir
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Soheil Ghazizadeh
- Department of Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
| | - Muneer Eesa
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - John H Wong
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Chandar Sadasivan
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - Alim P Mitha
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Biomedical Engineering, University of Calgary, Calgary, Alberta, Canada
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12
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Sreenivasan S, Roychowdhury S, Kashibathla A, Kumarapuram S, Nourollah-Zadeh E, Sundararajan S, Sun H, Nanda A, Gupta G. Flow Diversion for Treatment of Anterior Inferior Cerebellar Artery Aneurysms: Mechanism and Pitfalls from a Novel Management Strategy. World Neurosurg 2024; 182:e163-e170. [PMID: 37992994 DOI: 10.1016/j.wneu.2023.11.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Anterior inferior cerebellar artery (AICA) aneurysms present a challenge for neurosurgeons and neurointerventionalists alike. METHODS Cases of AICA aneurysms managed with endovascular flow diversion at our institute are reviewed with their angiographic outcomes. RESULTS Both direct and indirect flow diversion provide complete aneurysm occlusion at follow-up. We propose a stratified method of approaching AICA aneurysms based on location, rupture status, and neck size. CONCLUSIONS Careful evaluation of preoperative parameters is paramount in deciding between a surgical or a neuroendovascular approach. Low-profile stents in the future may assist in direct flow diversion of AICA trunk aneurysms. In addition, neurosurgeons need to be well versed in endovascular approaches.
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Affiliation(s)
- Sanjeev Sreenivasan
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Sudipta Roychowdhury
- Department of Interventional Radiology, University Radiology, Robert Wood Johnson Medical School, New Jersey, USA
| | - Ananth Kashibathla
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Siddhant Kumarapuram
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Emad Nourollah-Zadeh
- Department of Neurology, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Srihari Sundararajan
- Department of Interventional Radiology, University Radiology, Robert Wood Johnson Medical School, New Jersey, USA
| | - Hai Sun
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Anil Nanda
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Jersey, USA.
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13
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Jun YJ, Hwang DK, Lee HS, Kim BM, Park KD. Flow Diverter Performance Comparison of Different Wire Materials for Effective Intracranial Aneurysm Treatment. Bioengineering (Basel) 2024; 11:76. [PMID: 38247953 PMCID: PMC10813681 DOI: 10.3390/bioengineering11010076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
A flow diverter (FD) is an effective method for treating wide-necked intracranial aneurysms by inducing hemodynamic changes in aneurysms. However, the procedural technique remains challenging, and it is often not performed properly in many cases of deployment or placements. In this study, three types of FDs that changed the material of the wire were prepared within the same structure. Differences in physical properties, such as before and after delivery loading stent size, radial force, and radiopacity, were evaluated. The performances in terms of deployment and trackability force were also evaluated in a simulated model using these FDs. Furthermore, changes of deployment patterns when these FDs were applied to a 3D-printed aneurysm model were determined. The NiTi FD using only nitinol (NiTi) wire showed 100% size recovery and 42% to 45% metal coverage after loading. The low trackability force (10.9 to 22.9 gf) allows smooth movement within the delivery system. However, NiTi FD cannot be used in actual surgeries due to difficulties in X-ray identification. NiTi-Pt/W FD, a combination of NiTi wire and platinum/tungsten (Pt/W) wire, had the highest radiopacity and compression force (6.03 ± 0.29 gf) among the three FDs. However, it suffered from high trackability force (22.4 to 39.9 gf) and the end part braiding mesh tended to loosen easily, so the procedure became more challenging. The NiTi(Pt) FD using a platinum core nitinol (NiTi(Pt)) wire had similar trackability force (11.3 to 22.1 gf) to NiTi FD and uniform deployment, enhancing procedural convenience. However, concerns about low expansion force (1.79 ± 0.30 gf) and the potential for migration remained. This comparative analysis contributes to a comprehensive understanding of how different wire materials influence the performance of FDs. While this study is still in its early stages and requires further research, its development has the potential to guide clinicians and researchers in optimizing the selection and development of FDs for the effective treatment of intracranial aneurysms.
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Affiliation(s)
- Yeo Jin Jun
- Taewoong Medical, 14, Gojeong-ro, Wolgot-myeon, Gimpo-si 10022, Republic of Korea; (Y.J.J.); (D.K.H.); (H.S.L.)
- Department of Molecular Science and Technology, Ajou University, 206, World Cup-ro, Yeongtong-gu, Suwon-si 16499, Republic of Korea
| | - Doo Kyung Hwang
- Taewoong Medical, 14, Gojeong-ro, Wolgot-myeon, Gimpo-si 10022, Republic of Korea; (Y.J.J.); (D.K.H.); (H.S.L.)
| | - Hee Sun Lee
- Taewoong Medical, 14, Gojeong-ro, Wolgot-myeon, Gimpo-si 10022, Republic of Korea; (Y.J.J.); (D.K.H.); (H.S.L.)
| | - Byung Moon Kim
- Department of Radiology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | - Ki Dong Park
- Department of Molecular Science and Technology, Ajou University, 206, World Cup-ro, Yeongtong-gu, Suwon-si 16499, Republic of Korea
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14
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Lv B, Sun M, Shan Y, Cao X, Du Z, Liu X, Zhang R, Leng X, Fiehler J, Siddiqui AH, Xiang J, Wang J. AneuGuide™ software-assisted vs. manual measurements in sizing for pipeline embolization device: An agreement study. Comput Biol Med 2024; 168:107715. [PMID: 38007975 DOI: 10.1016/j.compbiomed.2023.107715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/14/2023] [Accepted: 11/15/2023] [Indexed: 11/28/2023]
Abstract
Sizing of flow diverters (FDs) is a challenging task in the treatment of intracranial aneurysms due to their foreshortening behavior. The purpose of this study is to evaluate the difference between the sizing results from the AneuGuide™ software and from conventional 2D measurement. Ninety-eight consecutive patients undergoing pipeline embolization device (PED) treatment between October 2018 and April 2023 in the First Medical Center of Chinese PLA General Hospital (Beijing, China) were retrospectively analyzed. For all cases, the optimal PED dimensions were both manually determined through 2D measurements on pre-treatment 3D-DSA and computed by AneuGuide™ software. The inter-rater reliability between the two sets of sizing results for each methodology was analyzed using intraclass correlation coefficient (ICC). The degree of agreement between manual sizing and software sizing were analyzed with the Bland-Altman plot and Pearson's test. Differences between two methodologies were analyzed with Wilcoxon signed rank test. Statistical significance was defined as p < 0.05. There was better inter-rater reliability between AneuGuide™ measurements both for diameter (ICC 0.92, 95%CI 0.88-0.95) and length (ICC 0.93, 95%CI 0.89-0.96). Bland-Altman plots showed a good agreement for diameter selection between two methodologies. However, the median length proposed by software group was significantly shorter (16 mm versus 20 mm, p < 0.001). No difference was found for median diameter (4.25 mm versus 4.25 mm). We demonstrated that the AneuGuide™ software provides highly reliable results of PED sizing compared with manual measurement, with a shorter stent length. AneuGuide™ may aid neurointerventionalists in selecting optimal dimensions for FD treatment.
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Affiliation(s)
- Bin Lv
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Mingguang Sun
- Department of Neurology, Beijing Hospital of Integrated Traditional Chinese and Western Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yejie Shan
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | - Xiangyu Cao
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Zhihua Du
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xinfeng Liu
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Rongju Zhang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | | | - Jun Wang
- Department of Neurology, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
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15
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Duan Y, Shen J, Qin X, Xu B, Mao R, Li J, An Q, Liao Y, Zhang F, Chen G. The Safety and Efficacy of Leo Stents with Coiling or Alone for Anterior Cerebral Artery Aneurysms. Curr Neurovasc Res 2024; 20:560-567. [PMID: 39004959 DOI: 10.2174/0115672026271147231130111233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/14/2023] [Accepted: 10/19/2023] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Treatment of anterior cerebral artery (ACA) aneurysms is still not well established. The Leo stent with blood flow direction is a retrievable stent for intracranial aneurysms, whereas it needs to be studied clearly in patients with ACA aneurysms. METHODS Consecutive patients with ACA aneurysms were retrospectively enrolled in three neurosurgical centers between January 2016 and October 2021. The data on demographics, aneurysm characteristics, symptom resolution, and postoperative course were collected and analyzed. The aneurysm occlusion status was appraised by Raymond-Ray Occlusion Class (RROC). RESULTS A total of 57 patients with ACA aneurysms were included in our study. Immediate postprocedural angiograms showed that 20 aneurysms (35.1%) were in complete occlusion (RROC 1), 26 aneurysms (45.6%) were in near-complete occlusion (RROC 2), 11 aneurysms (19.3%) were in incomplete occlusion (RROC 3). The angiographic follow-up found that the rate of complete occlusion increased to 57.9%, and near-completion and incomplete occlusion dropped to 29.8% and 12.3%, respectively. The angiographic result of the last follow-up improved significantly (Z=- 2.805, P=0.005). Univariate analysis indicated that distal location of aneurysms (Z=4.538, P=0.033) and ruptured aneurysms (χ2=.6120, P=0.032) were potential risk factors for intra-parent artery narrowing. Furthermore, multivariate logistic regression analysis found that A3 aneurysms (95% CI 1.427~32.744, P=0.016) are the key risk factor for intra-parent artery narrowing. CONCLUSIONS The Leo stent is safe and effective for aneurysms located in ACA circulations. The overall occlusion degree improved during follow-up. A distal, small artery was the risk factor for intra-parent artery narrowing.
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Affiliation(s)
- Yu Duan
- Department of Neurosurgery, Huadong Hospital, Fudan University, China
| | - Jun Shen
- Department of Neurology, Huadong Hospital, Fudan University, China
| | - Xuanfeng Qin
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Binbin Xu
- Department of Neurosurgery, Putuo District People's Hospital, Tongji University, Shanghai, China
| | - Renling Mao
- Department of Neurosurgery, Huadong Hospital, Fudan University, China
| | - Jian Li
- Department of Neurosurgery, Huadong Hospital, Fudan University, China
| | - Qinzhu An
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yujun Liao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Fayong Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Gong Chen
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
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16
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Long S, Shi S, Tian Q, Wei Z, Ma J, Wang Y, Yang J, Han X, Li T. Correlation of Flow Diverter Malapposition at the Aneurysm Neck with Incomplete Aneurysm Occlusion in Patients with Small Intracranial Aneurysms: A Single-Center Experience. AJNR Am J Neuroradiol 2023; 45:16-21. [PMID: 38164561 PMCID: PMC10756576 DOI: 10.3174/ajnr.a8079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND PURPOSE Flow diversion treatment repairs aneurysms by altering the hemodynamics of the aneurysmal sac and providing a scaffold for endothelial cell adhesion. The purpose of this study was to investigate the correlation of flow diverter (FD) malapposition at the aneurysm neck with incomplete occlusion of small intracranial aneurysms (IAs) and investigate other factors that are possibly related to incomplete occlusion. MATERIALS AND METHODS From January 2019 to June 2022, the clinical and imaging data for 153 patients (175 aneurysms) with unruptured small IAs treated with flow diversion were retrospectively analyzed. FD apposition at the aneurysm neck was evaluated by high-resolution conebeam CT (HR-CBCT), and the complete occlusion rate for aneurysms was judged according to the latest follow-up conventional angiography findings (≥6 months). Multivariate logistic regression analysis was used to determine factors associated with incomplete aneurysm occlusion. RESULTS In total, 159 FDs were implanted in 153 patients. HR-CBCT performed after the deployment revealed FD malapposition at the aneurysm neck in 18 cases. According to the latest follow-up angiograms (average: 9.47 ± 3.35 months), the complete aneurysm occlusion rate was 66.9%. The complete occlusion rates for incomplete and complete stent apposition at the neck were 38.9% (7/18) and 70.1% (110/157), respectively. The results of regression analysis showed that an aneurysm sac with branch vessels (OR, 2.937; P = .018), incomplete stent apposition at the aneurysm neck (OR, 3.561; P = .023), and a large aneurysm diameter (OR, 1.533; P = .028) were positive predictors of incomplete aneurysm occlusion. CONCLUSIONS An aneurysm sac with branch vessels, a large aneurysm diameter, and malapposition at the aneurysm neck significantly affect aneurysm repair after FD stent-only treatment for small IAs.
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Affiliation(s)
- Shuhai Long
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shuailong Shi
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi Tian
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuangzhuang Wei
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ji Ma
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ye Wang
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jie Yang
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xinwei Han
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tengfei Li
- From the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Al-Smadi AS, Ali R, Kappel AD, Intikhab O, Rajah GB, Luqman A. Patch Technique for Primary Treatment of Type A Carotid Cavernous Fistula: A Case Series and Technical Notes. J Neuroophthalmol 2023; 43:541-546. [PMID: 37166977 DOI: 10.1097/wno.0000000000001867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND The utilization of flow diverters (FDs) in the treatment of high-flow Type A carotid cavernous fistulas (CCFs) has been described before mainly as an adjunct to the traditional endovascular techniques and rarely as a stand-alone treatment. In this study, we retrospectively evaluated our experience with FDs as the solo nonadjunctive treatment of Type A CCF with severe cortical venous reflux (CVR). METHODS A retrospective review was performed of patients with Type A CCFs who were treated using FDs' patch technique (PT). Patients' demographics, clinical data, and preoperative and postoperative ocular examination were recorded. The procedure technique, pipeline embolization device (PED) diameters, and immediate and late procedure outcomes were described. RESULTS Three patients were included in this case series. All patients had history of trauma and presented with decreased visual acuity, cranial nerve II deficit, limited extraocular muscles' movement, and increased intraocular pressure (IOP). Diagnostic angiography was performed, which confirmed high-flow Type A CCF. Endovascular treatment was performed through distal radial access in 2 patients and femoral access in 1 patient by deploying 4 sequentially enlarging PEDs with immediate resolution of the ocular symptoms. Follow-up angiography confirmed complete resolution of CCF in 2 patients. One patient was lost to follow-up; however, angiogram at 4 months demonstrated residual small CCF with significant improvement from postprocedure angiogram. CONCLUSIONS The patch technique using sequentially enlarging FDs is a reasonable alternative solo technique for the treatment of direct CCF symptoms and results in immediate resolution of CVR while preserving the cavernous sinus anatomy.
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Affiliation(s)
- Anas S Al-Smadi
- Department of Neuroradiology (ASA-S, OI), The University of Chicago, Chicago, Illinois; Departments of Radiology (RA) and Neurosurgery (ADK, GBR, AL), School of Medicine, Wayne State University, Detroit, Michigan; and Department of Neurosurgery (GBR), Munson Medical Center, Traverse City, Michigan
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18
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Boite Y, Suaiden Klein T, de Andrade Medronho R, Wajnberg E. Numerical simulation of flow-diverting stent: comparison between branches in bifurcation brain aneurysm. Biomech Model Mechanobiol 2023; 22:1801-1814. [PMID: 37335373 DOI: 10.1007/s10237-023-01733-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
The usage of flow-diverting stents in the treatment of intracranial aneurysms is widespread due to their high success and low complication rates. However, their use is still not officially recommended for bifurcation aneurysms, as there is a risk of generating ischemic complications due to the reduced blood flow to the jailed branch. Many works utilize computational fluid dynamics (CFD) to study how hemodynamic variables respond to flow diverter placement, but few seem to use it to verify flow variation between branches of bifurcation aneurysms and to aid in the choice of the best ramification for device placement. This investigation was performed in the present work, by comparing wall shear stress (WSS) and flowrates for a patient-specific scenario of a middle cerebral artery (MCA) aneurysm, considering device placement on each branch. A secondary objective was to follow a methodology that provides fast results, envisioning application to daily medical practice. The device was simplified as a homogeneous porous medium, and extreme porosity values were simulated for comparison. Results suggest that stent placement on either branch is both safe and effective, significantly reducing WSS and flow into the aneurysm while maintaining flow to the different ramifications within acceptable thresholds.
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Affiliation(s)
- Yasmin Boite
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil.
| | - Tânia Suaiden Klein
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil
| | - Ricardo de Andrade Medronho
- Programa de Pós-Graduação em Engenharia de Processos Químicos e Bioquímicos da Escola de Química, UFRJ, LabCFD, Rua Moniz de Aragão, Bloco K, Rio de Janeiro, RJ, 21941972, Brazil
| | - Eduardo Wajnberg
- Radiologia Intervencionista, Hospital Américas, Avenida Jorge Curi, 550, Rio de Janeiro, RJ, 22793334, Brazil
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19
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Sirakova K, Sirakov A, Ninov K, Minkin K, Sirakov S. Comaneci stent-angioplasty for the optimization of inadequately deployed flow diverter stents. Interv Neuroradiol 2023:15910199231184520. [PMID: 37402394 DOI: 10.1177/15910199231184520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND PURPOSE In endovascular procedures, inadequate deployment of a flow diverter stent is a highly concerning technical complication that can lead to acute parent vessel occlusion and ischaemic events. This study aimed to assess the off-label use of the Comaneci device in managing technical difficulties associated with flow diversion. MATERIALS AND METHODS We conducted an analysis of all flow diverter procedures documented in our prospectively collected database. Our objective was to identify patients with inadequately deployed implants who underwent Comaneci stent-angioplasty. Both Comaneci 17 and Comaneci 21 devices were utilized to address and remediate technical complications related to stent deployment. We reviewed anatomical features, technical details, intraprocedural complications, as well as clinical and angiographic outcomes. RESULTS Thirty-one Comaneci devices were employed to remediate 31 inadequately deployed flow diverter stents. Successful resolution of technical complications associated with flow diverter placement was achieved in all attempted cases. No clinically significant complications were attributed to the technique, and no mortality was observed during the study. CONCLUSION Technical issues arising from flow diverter stent deployment are formidable complications. Familiarity with appropriate corrective manoeuvres is essential to achieve successful outcomes. The Comaneci device can be safely and effectively incorporated into the range of techniques used to rectify inadequately deployed stents.
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Affiliation(s)
| | | | - Kristian Ninov
- Neurosurgery Department, UH St Ivan Rilski, Sofia, Bulgaria
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20
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Altındağ B, Bahadır Olcay A, Furkan Tercanlı M, Bilgin C, Hakyemez B. Determining flow stasis zones in the intracranial aneurysms and the relation between these zones and aneurysms' aspect ratios after flow diversions. Interv Neuroradiol 2023:15910199231162878. [PMID: 36945841 DOI: 10.1177/15910199231162878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Flow diverter stents (FDSs) are widely used to treat aneurysms in the clinic. However, even the same flow diverter (FD) use on different patients' aneurysm sites can cause unexpected hemodynamics at the aneurysm region yielding low success rates for the overall treatment. Therefore, the present study aims to unfold why FDs do not work as they are supposed to for some patients and propose empirical correlation along with a contingency table analysis to estimate the flow stasis zones in the aneurysm sacs. METHODS The present work numerically evaluated the use of FRED4518 FDS on six patients' intracranial aneurysms based on patient-specific aneurysm geometries. Computational fluid dynamics (CFD) simulation results were further processed to identify the time evolution of weightless blood particles for six patients' aneurysms. RESULTS Stagnation zone formation, incoming and outgoing blood flow at the aneurysm neck, and statistical analysis of six patients indicated that FRED4518 showed a large flow stasis zone for an aspect ratio larger than 0.75. However, FRED4518, used for aneurysms with an aspect ratio of less than 0.65, caused small stagnant flow zones based on the number of blood particles that stayed in the aneurysm sac. CONCLUSION A patient-specific empirical equation is derived considering aneurysms' morphological characteristics to determine the amount of stagnated fluid flow zones and magnitude of the mean aneurysm velocity in the aneurysm sac for FRED4518 based on weightless fluid particle results for the first time in the literature. As a result, numerical simulation results and patient data-driven equation can help perceive stagnated fluid zone amount before FRED4518 placement by shedding light on neuro-interventional surgeons and radiologists.
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Affiliation(s)
- Batı Altındağ
- Faculty of Engineering, Department of Mechanical Engineering, 52998Yeditepe University, Istanbul, Turkey
| | - Ali Bahadır Olcay
- Faculty of Engineering, Department of Mechanical Engineering, 52998Yeditepe University, Istanbul, Turkey
| | - Muhammed Furkan Tercanlı
- Faculty of Engineering, Department of Mechanical Engineering, 52998Yeditepe University, Istanbul, Turkey
| | - Cem Bilgin
- Department of Radiology, 4352Mayo Clinic Rochester, Rochester, MN, USA
| | - Bahattin Hakyemez
- Department of Radiology, Uludag University School of Medicine, Gorukle, Bursa, Turkey
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21
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Lee CH, Luo CB, Lai YC, Chang FC, Lin CJ. Single flow diverter to manage multiple intracranial aneurysms in a parent artery. J Chin Med Assoc 2023; 86:289-294. [PMID: 36692425 DOI: 10.1097/jcma.0000000000000868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Endovascular coil embolization has become an important method in the management of intracranial aneurysm. However, simultaneously coiling multiple intracranial aneurysms (MIAs) in unilateral parent artery in one-stage may fail or insufficient in geographic difficult aneurysm. Flow diverter (FD) has the potential to manage MIAs with nonamenable to coiling. Herein, we report periprocedural morphologic change and outcomes using single FD to manage unruptured MIAs in a parent artery. METHODS Over a 3-year period, a total of 63 patients with 126 MIAs successful managed by single FD with complete angiographic follow-up. There were 49 women and 14 men, with ages ranging from 42 to 77 years (mean: 59 years). We retrospectively assessed the clinical data, aneurysm characteristic, angiographic and clinical outcomes of all patients and compared with 171 patients with single aneurysm managed by FD. RESULTS Sixty-one patients with 118 aneurysms (94%) located in internal carotid artery or middle cerebral artery (n = 4, 3%), two patients with four aneurysms (4%) were found in the basilar artery. The mean aneurysm size was 5.6 mm (range from 1.8 to 38 mm). Mean angiographic follow-up was 14 months. Complete obliteration of aneurysm was achieved in 102 aneurysms (83%), subtotal or partial aneurysm obliteration was demonstrated in 18 aneurysms (15%), unchanged aneurysm morphology in three (2%). Aneurysm morphology synchronized alteration in 55 patients (87%), other eight patients (13%) with 16 aneurysms showed different morphologic alteration in angiographic follow-up. Four patients (6.3%) had intraprocedural ischemic complication. During the follow-up period, 61 patients (97%) were neurologic stable; there was no hemorrhagic or ischemic event. CONCLUSION Single FD was feasible to treat MIAs in a parent artery with both effective and safe in one-stage management. Most aneurysms synchronized alteration of morphology in a mid-term follow-up. The procedure was almost the same with FD managing single aneurysm, but longer FD is needed in MIAs.
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Affiliation(s)
- Chien-Hui Lee
- Department of Neurosurgery, Buddhist Tzu-Chi General Hospital and Tzu-Chi University, Hualien, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yen-Chun Lai
- Department of Radiology, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital and School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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22
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Tong X, Han M, Wu Z, Feng X, Liu A. Effects of different stent size selection on pipeline embolization device treatment of intracranial aneurysms. Ther Adv Neurol Disord 2023; 16:17562864231151475. [PMID: 36776531 PMCID: PMC9909058 DOI: 10.1177/17562864231151475] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Background Pipeline embolization device (PED) is becoming increasingly common in therapeutic practice. In idealized model studies, treatment effectiveness may vary with different stent sizes in the same vasculature. The true effect of stent size selection in the clinical setting remains unknown, however. Objective To determine the true effect of stent size selection in the clinical setting. Design It is a retrospective review. Methods A retrospective review was conducted on consecutive patients with aneurysms treated with a PED at our institution. The primary exposures were the difference between the diameter of the stent and the parent artery (DD) and the difference between the length of the stent and the aneurysm neck (DL). The outcomes were the clinical and angiographic results, perioperative complications, balloon application, and in-stent stenosis. The results were generated using univariable and multivariable logistic regression and restricted cubic spline (RCS) curves. Results A larger DD was significantly associated with incomplete occlusion [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.43-3.98; p < 0.001], while a larger DL was significantly associated with balloon application (OR = 1.12; 95% CI = 1.02-1.23; p = 0.021) and in-stent stenosis (>25%) (OR = 1.07; 95% CI = 1.01-1.16; p = 0.042). The RCS curve indicated that the risk of incomplete occlusion increased as the DD became larger, the possibility of balloon application increased as the DL increased when the DL was >5.7 mm, and the risk of in-stent stenosis (>25%) increased as the DL increased. Conclusion In the clinical setting, stent selection was associated with treatment effectiveness and may add to the treatment burden. These occurrences should be considered for aneurysms treated with PED.
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Affiliation(s)
| | | | - Zhongxue Wu
- Neurointerventional Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital University, Beijing, China
| | - Xin Feng
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China,Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou, China
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23
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Tong X, Shan Y, Leng X, Chen J, Fiehler J, Siddiqui AH, Hu X, Liu A, Xiang J. Predicting flow diverter sizing using the AneuGuide TM software: a validation study. J Neurointerv Surg 2023; 15:57-62. [PMID: 35039401 DOI: 10.1136/neurintsurg-2021-018353] [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: 10/22/2021] [Accepted: 12/23/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Stent sizing remains a challenging task for flow diverter implantation because of stent foreshortening. In this study, we aimed to quantify the change in length after implantation and assess the error in length prediction using AneuGuideTM software. METHODS In a retrospective cohort of 101 patients with 102 aneurysms undergoing treatment with a pipeline embolization device (PED; Covidien, Irvine, California, USA), we used AneuGuideTM software to obtain measured lengths (ML) and calculated lengths (CL) after stent implantation. Stent elongation was defined as the ratio of ML-LL to the labeled length (LL). Simulation error was defined as the ratio of the absolute value of CL-ML to ML. The correlation and consistency between ML and LL and between ML and CL were analyzed using Pearson's correlation test and the Bland-Altman plot. Statistical significance was set at p<0.05. RESULTS The mean elongation of ML was 32.6% (range 26.3-109.2%). Moderate consistency was observed between LL and ML (ρ=0.74, p<0.001). With the AneuGuideTM software, the mean simulation error was 6.6% (range 0.32-21.2%). Pearson's correlation test and the Bland-Altman plot showed a high correlation and consistency between ML and CL (ρ=0.96, p<0.001). CONCLUSION Labeled length provides only a low reference value for predicting the actual length of the flow diverter after implantation. The high consistency between ML and CL obtained from AneuGuideTM software shows its great potential for the optimization of the flow diverter sizing process.
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Affiliation(s)
- Xin Tong
- Neurointervention Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Beijing, China
| | - Yejie Shan
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | | | - Jigang Chen
- Neurointervention Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Beijing, China
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Xuebin Hu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Aihua Liu
- Neurointervention Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Beijing, China
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24
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Vladev G, Sirakov A, Sirakova K, Sirakov SS. Mechanical Comaneci 17-stent angioplasty for a sub-optimally deployed flow-diverter stent. Interv Neuroradiol 2022:15910199221149633. [PMID: 36583607 DOI: 10.1177/15910199221149633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Flow diverter stents are increasingly used as the sole endovascular treatment method for complex or wide-necked intracranial aneurysms.1 Technical complications related to stent deployment are infrequently reported in the literature. During treatment, implant misbehaviors may occur, including incomplete tubular expansion with insufficient aneurysmal coverage and wall apposition, proximal or distal narrowing, and twisting along the axis.2- 4 Little is known about this phenomenon, especially if it relates to the operator experience, deployment techniques, different devices, and implant properties. The management of these complications requires technical precision and is often remediated by "massaging" the stent with the delivery system, balloon angioplasty, or placement of additional self-expandable stents. Lastly, if critically damaged, the stent could be taken out of the vessel with a combination of maneuvers called "stentectomy."5 These techniques often necessitate multiple navigations and the utilization of a larger microcatheter. We aim to highlight the feasibility of Comaneci 17 stent-angioplasty as an effective bailout strategy for inadequately deployed flow diverter stents. The suggested approach's technical aspects, including pros and cons, have been discussed.
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Affiliation(s)
- Georgi Vladev
- Radiology Department, 266309UH St Ivan Rilski, Sofia, Bulgaria
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25
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Li L, Shao QJ, Li TX, Wang ZL, Zhang K, Gao BL. Effect and safety of Tubridge flow diverter in the treatment of unruptured intracranial aneurysms. Medicine (Baltimore) 2022; 101:e31672. [PMID: 36550831 PMCID: PMC9771248 DOI: 10.1097/md.0000000000031672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The effect and safety of the Tubridge flow diverting device are unknown in the treatment of intracranial aneurysms after optimization of the device, improvement in the deployment of the device, and accumulation of experience of using the device. This retrospective one-center study was performed to investigate the clinical effect and safety of the Tubridge flow diverting device in the treatment of unruptured intracranial aneurysms. Twenty-three patients with 33 unruptured intracranial aneurysms which were treated with the Tubridge device were retrospectively enrolled. The clinical data, endovascular procedure, complications, and follow-up were analyzed. Twenty-seven Tubridge devices were deployed to treat the 33 aneurysms, and the deployment was failed in 1 case, resulting in the success stenting rate of 96.3%. In 5 (15.2%) aneurysms, coils were loosely packed. Peri-procedural complications occurred in 2 patients (8.7%), including 1 procedure-related complication in which the distal end of a Tubridge device herniated into the aneurysm cavity. In another case, weakness of left upper limb occurred on the second day post procedure, with instent thrombosis being suspected, which was recovered after medication. No other complications occurred. Twenty-three (100%) patients had clinical follow-up 6 months later, with the mRS of 0 in 21 patients, 1 in 1, and 2 in 1. Five (21.7%) patients with 11 aneurysms underwent digital subtraction angiography at 6-month follow-up, with 8 aneurysms being completely occluded (Raymond grade I) and 3 aneurysms still visible (Raymond grade III). The Tubridge flow diverter may be safe and effective in the treatment of unruptured intracranial aneurysms with low perioperative complications and good follow-up outcomes even though multi-center and prospective clinical studies with a large size sample are still needed to validate these results.
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Affiliation(s)
- Li Li
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
| | - Qiu-Ji Shao
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
| | - Tian-Xiao Li
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
- * Correspondence: Tian-Xiao Li, Henan Provincial People’s Hospital, Zhengzhou University, 7 Weiwu Road, Zhengzhou, Henan Province 450000, China (e-mail: )
| | - Zi-Liang Wang
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
| | - Kun Zhang
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
| | - Bu-Lang Gao
- Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, China
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26
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Ma C, Zhu H, Liang S, Liang F, Han J, Jia Z, Zhang Y, Jiang C. Pipeline for the treatment of distal cerebral circulation aneurysms: A multicenter study focusing on periprocedural Complications. Interv Neuroradiol 2022; 28:708-718. [PMID: 34913765 PMCID: PMC9706258 DOI: 10.1177/15910199211063703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/11/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIM Distal cerebral circulation aneurysms (DCCAs) remain treatment challenges for neurointervention. The off-label use of the pipeline embolization device (PED) for these aneurysms remains controversial. This study aimed to evaluate the safety and efficacy of PED for DCCAs in a multicenter cohort of patients. METHODS Between March 2016 and June 2021, we retrospectively analyzed the neurointerventional data on the clinical and radiological records of all patients undergoing PED treatment of DCCAs at three medical centers. RESULTS A total of 53 consecutive patients with 53 DCCAs were treated with PED. The mean aneurysm size was 12.3 ± 5.7 mm. In total, 75.4% (40/53) were fusiform and 24.5% (13/53) were saccular. Of these, 17.0% (9/53) were recurrent aneurysms that were previously treated with endovascular or microsurgical approaches. The technical success rate was 100%, among which 81.1% (43/53) procedures were completed with a single PED, and the rest (10/53, 18.8%) required telescoping with two devices. Angiographic follow-up data were available for 51 patients, with a median follow-up time of 12 months. At the latest follow-up, 46/51 (90.2%) aneurysms showed complete obliteration, and 4/51 (7.8%) showed reduced filling. Periprocedural complications such as hemorrhage were observed in two patients with MCA aneurysms (3.8%, 2/53), and ischemic events occurred in six patients (11.3%, 6/53). The overall mortality and morbidity rates were 7% (4/53). CONCLUSIONS PED is a viable option for treating DCCAs, especially for recurrent aneurysms. Coverage of bifurcation branches and perforator may increase the risk of complications.
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Affiliation(s)
- Chao Ma
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital,
School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Jintao Han
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Zichang Jia
- Department of Vascular Surgery and Interventional Radiology, Peking University Third
Hospital, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical
Institute, Capital Medical University, Beijing, China
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Cai H, Yang F, Xu Y, Geng Y, Li J, Li Y, Fu K, Liu C, Wang M, Li Z. A multicenter retrospective controlled study of the Pipeline™ and Tubridge™ Flow Diverter devices for intracranial wide-necked aneurysms. Front Neurol 2022; 13:1014596. [PMID: 36313488 PMCID: PMC9606650 DOI: 10.3389/fneur.2022.1014596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/26/2022] [Indexed: 08/06/2023] Open
Abstract
PURPOSE To compare the safety and efficacy of PipelineTM and TubridgeTM Flow Diverter devices (FDs) in the treatment of intracranial wide-necked aneurysms. METHODS We retrospectively analyzed the clinical data of 92 patients with intracranial wide-necked aneurysms who were treated with those two flow-diverter devices (FDs) at four participating centers between July 2012 and December 2020. RESULTS This study included 92 patients who underwent endovascular therapy using either Pipeline™ (n = 39) or TubridgeTM (n = 53) for treating intracranial wide-necked aneurysms. The periprocedural complication developed in 2.56% (1/39) patients of Pipeline group and 3.77% (2/53) patients of the TubridgeTM group. During perioperative period, one patient in Pipeline™ group showed subarachnoid hemorrhage (2.56%, 1/39) and two ischemic complications in the Tubridge™ group (3.77%, 2/53). Follow-up assessments were conducted on 31 patients (79.49%) in the Pipeline™ group (the mean follow-up period was 9.7 ± 3.3 months). The rate of complete aneurysm occlusion at the final angiographic follow-up was 77.42%. Patients with a modified Rankin scale (mRS) score of 0.44 ± 0.31. Follow-up assessments were conducted on 42 patients (79.25%) in the TubridgeTM group (the mean follow-up period was 9.1 ± 4.4 months). The rate of complete aneurysm occlusion at the final angiographic follow-up was 85.71%. Patients with mRS score of 0.52 ± 0.28. Three patients showed parent artery stenosis, and one showed parent artery occlusion. CONCLUSION Both the PipelineTM and TubridgeTM are safe and effective for the treatment of intracranial wide-necked aneurysms, with no significant difference in the rate of complete aneurysm occlusion and perioperative complications between the two FDs.
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Affiliation(s)
- Heng Cai
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fangyu Yang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yousong Xu
- Department of Neurosurgery, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yu Geng
- Department of Interventional Radiology, Liaohe Oilfield General Hospital, Panjin, China
| | - Jinwei Li
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
| | - Yugang Li
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
| | - Kailei Fu
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
| | - Chang Liu
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
| | - Meiyan Wang
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
| | - Zhiqing Li
- Department of Stroke Center, First Hospital of China Medical University, Shenyang, China
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, China
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28
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Patankar T, Madigan J, Downer J, Sonwalkar H, Cowley P, Iori F. How precise is PreSize Neurovascular? Accuracy evaluation of flow diverter deployed-length prediction. J Neurosurg 2022; 137:1072-1080. [PMID: 35120310 DOI: 10.3171/2021.12.jns211687] [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: 07/16/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of flow-diverting stents has been increasingly important in intracranial aneurysm treatment. However, accurate sizing and landing zone prediction remain challenging. Inaccurate sizing can lead to suboptimal deployment, device waste, and complications. This study presents stent deployment length predictions offered in medical software (PreSize Neurovascular) that provides physicians with real-time planning support, allowing them to preoperatively "test" different devices in the patient's anatomy in a safe virtual environment. This study reports the software evaluation methodology and accuracy results when applied to real-world data from a wide range of cases and sources as a necessary step in demonstrating its reliability, prior to impact assessment in prospective clinical practice. METHODS Imaging data from 138 consecutive stent cases using the Pipeline embolization device were collected from 5 interventional radiology centers in the United Kingdom and retrospectively analyzed. Prediction accuracy was calculated as the degree of agreement between stent deployed length measured intraoperatively and simulated in the software. RESULTS The software predicted the deployed stent length with a mean accuracy of 95.61% (95% confidence interval [CI] 94.87%-96.35%), the highest reported accuracy in clinical stent simulations to date. By discounting 4 outlier cases, in which events such as interactions with coils and severe push/pull maneuvers impacted deployed length to an extent the software was not able to simulate or predict, the mean accuracy further increases to 96.13% (95% CI 95.58%-96.69%). A wide discrepancy was observed between labeled and measured deployed stent length, in some cases by more than double, with no demonstrable correlation between device dimensions and deployment elongation. These findings illustrate the complexity of stent behavior and need for simulation-assisted sizing for optimal surgical planning. CONCLUSIONS The software predicts the deployed stent length with excellent accuracy and could provide physicians with real-time accurate device selection support.
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Affiliation(s)
- Tufail Patankar
- 1Department of Neuroradiology, Leeds Teaching Hospital, Leeds
| | - Jeremy Madigan
- 2Atkinson Morley Neurosciences Centre, St. George's University Hospital, London
| | - Jonathan Downer
- 3Royal Infirmary of Edinburgh, Department of Clinical Neurosciences, Edinburgh
| | - Hemant Sonwalkar
- 4Department of Neuroradiology, Lancashire Teaching Hospitals, Preston
| | - Peter Cowley
- 5Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London; and
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Russo R, Boghi A, Giorgianni A, Lazzarotti GA, Bozzi A, Chegai F, Saletti A, Gallizioli G, Gavrilovic V, Michelozzi C, Petralia B, Gatti FL, Gorgatti T, Gallesio I, Cristaudo C, Politi MA, Molinaro S, Bergui M. Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study. Neuroradiology 2022; 64:2031-2037. [PMID: 35773522 DOI: 10.1007/s00234-022-03003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). METHODS We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3 months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. RESULTS Twenty-five patients were included; at 3 months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3 months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). CONCLUSIONS Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.
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Affiliation(s)
- Riccardo Russo
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy.
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, S. Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Alessio Bozzi
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Fabrizio Chegai
- Interventional Neuroradiology, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Andrea Saletti
- Azienda Ospedaliero Universitaria Di Ferrara Arcispedale Sant Anna, Neuroradiology, Ferrara, Emilia-Romagna, Italy
| | | | - Vladimir Gavrilovic
- Azienda Sanitaria Universitaria Friuli Centrale, Interventional Radiology, Udine, Italy
| | - Caterina Michelozzi
- Interventional Neuroradiology, Vita-Salute San Raffaele University Hospital, Milan, Italy
| | - Benedetto Petralia
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | | | - Tommaso Gorgatti
- Azienda Sanitaria Alto Adige, Regional Hospital of Bolzano, Radiology Unit, Bolzano, Italy
| | - Ivan Gallesio
- Department of Radiology, Azienda Ospedaliera SS Antonio E Biagio E C. Arrigo, Alessandria, Italy
| | - Concetto Cristaudo
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Marco Angelo Politi
- Department of Diagnostic and Interventional Neuroradiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | | | - Mauro Bergui
- Department of Neuroscience, Azienda Ospedaliero Universitaria Città Della Salute E Della Scienza Di Torino, Neuroradiological Unit, University of Turin, Turin, Italy
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Xu C, Wu P, Zou L, Xu S, Luo B, Yang X, Shi H. Anterior Circulation Fusiform Aneurysms Have a Lower Occlusion Rate After Pipeline Embolization Device Treatment Than Posterior Circulation Fusiform Aneurysms: A Multicenter Cohort Study. Front Neurol 2022; 13:925115. [PMID: 35720088 PMCID: PMC9202754 DOI: 10.3389/fneur.2022.925115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objective:Intracranial fusiform aneurysms are uncommon and can occur in vessels of the anterior circulation (AC) or posterior circulation (PC). While flow diversion is one treatment option, research into Pipeline Embolization Device (PED) treatment is lacking. This study explored the efficacy and safety of PED treatment for intracranial fusiform aneurysms, and compared therapeutic effects between AC and PC aneurysms.MethodsIn the post-market multi-center cohort study of embolization of intracranial aneurysms with PED in China (PLUS) registry study, we retrospectively analyzed 71 fusiform aneurysms in 67 patients among 1,171 patients treated with a PED from November 2014 to October 2019. The general characteristics, perioperative status, aneurysm occlusion rate at the last follow-up angiography, and changes in modified Rankin Scale scores were analyzed. Aneurysms were divided into AC and PC groups, and univariate and multivariate analyses were conducted.ResultsThe study included 26 AC (25 patients) and 45 PC (42 patients) aneurysms. A total of 75 PEDs were used, an average of 1.1 PEDs were used, and the median follow-up was 6.7 months. Fifty aneurysms (71.4%) were occluded and twenty (28.5%) were incompletely occluded. There were significantly more occluded aneurysms in the PC group than in the AC group (12 vs. 38; P = 0.001). Risk factors for incomplete occlusion were AC aneurysms (P = 0.001) and a perforating artery originating from the aneurysm (P = 0.006). The mean modified Rankin Scale score was significantly lower at the last follow up than preoperatively (0.58 vs. 0.21; P = 0.0001).ConclusionNon-overlapping PED is a safe and effective treatment for both AC and PC fusiform aneurysms. The occlusion rate of AC fusiform aneurysms is lower than that of PC.
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Affiliation(s)
- Chao Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Pei Wu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Liang Zou
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shancai Xu
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bin Luo
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Huaizhang Shi
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Ma C, Zhu H, Liang S, Liang F, Sun J, Zhang Y, Jiang C. Comparison of Pipeline Embolization Device and Traditional Endovascular Therapeutic Approaches in Distal Cerebral Circulation Aneurysms Using Propensity Score Matching Analysis. Front Neurol 2022; 13:755122. [PMID: 35665044 PMCID: PMC9157485 DOI: 10.3389/fneur.2022.755122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Coiling and stent-assisted coiling remain the first-line treatments for distal cerebral circulation aneurysms (DCCAs). The off-label use of the pipeline embolization device (PED) for these aneurysms has been explored recently but remains controversial. Objective To compare traditional endovascular therapeutic approaches (coiling and stent-assisted coiling) and PED for DCCAs in a multicenter cohort of patients. Methods A multicenter, retrospective cohort comparison study was conducted that included consecutive patients with unruptured DCCAs treated with either traditional endovascular therapeutic approaches or PED placement at three centers between 2016 and 2020. Propensity score matching analysis was applied to adjust for baseline risk factors between the PED and TET groups. Matching was based on age, sex, aneurysm size, location, morphology, adjunctive coiling, treatment history, and preoperative mRS score. Results In total, 209 patients with DCCAs treated with PED or traditional endovascular therapeutic approaches were identified. Thirty-seven patients underwent PED treatment, and 172 patients underwent traditional endovascular therapeutic approaches. After propensity score matching, 37 aneurysm pairs were matched, and the baseline characteristics of the patients were balanced between the groups. The complete occlusion rate between PED and traditional endovascular therapeutic approach in both matched cohorts (91.7 vs. 92.3%, p > 0.78) was similar. The rate of periprocedural treatment-related complications in both the PED and traditional endovascular therapeutic groups was 13.5%. Univariate analysis identified average parent vessel diameter as the only predictor of complete occlusion (p = 0.038). Conclusions PED is a viable option for treating DCCAs by providing occlusion and complication rates similar to those of traditional endovascular therapeutic approaches. A rigid patient selection procedure and proper planning should be undertaken to reduce treatment-related complications.
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Affiliation(s)
- Chao Ma
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haoyu Zhu
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shikai Liang
- Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Fei Liang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jidian Sun
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yupeng Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Yupeng Zhang
| | - Chuhan Jiang
- Interventional Neuroradiology Center, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- *Correspondence: Chuhan Jiang
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Narata AP, Obradó L, Moyano RK, Macho JM, Blasco J, Rueda AL, Roman LS, Remollo S, Marinelli C, Cepeda R, Fernández H, Larrabide I. Cerebral Aneurysm Occlusion at 12-Month Follow-Up After Flow-Diverter Treatment: Statistical Modeling for V&V With Real-World Data. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:705003. [PMID: 35047944 PMCID: PMC8757794 DOI: 10.3389/fmedt.2021.705003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Flow-Diverter (FD) porosity has been pointed as a critical factor in the occlusion of cerebral aneurysms after treatment. Objective: Verification and Validation of computational models in terms of predictive capacity, relating FD porosity and occlusion after cerebral aneurysms treatment. Methods: Sixty-four aneurysms, with pre-treatment and follow-up images, were considered. Patient demographics and aneurysm morphological information were collected. The computational simulation provided by ANKYRAS provided FD porosity, expansion, and mesh angle. FD occlusion was assessed and recorded from follow-up images. Multiple regression Logit and analysis of covariance (ANCOVA) models were used to model the data with both categorical and continuous models. Results: Occlusion of the aneurysm after 12 months was affected by aneurysm morphology but not by FD mesh morphology. A Time-To-Occlusion (TTO) of 6.92 months on average was observed with an SE of 0.24 months in the aneurysm population surveyed. TTO was estimated with statistical significance from the resulting model for the data examined and was capable of explaining 92% of the data variation. Conclusions: Porosity was found to have the most correction power when assessing TTO, proving its importance in the process of aneurysm occlusion. Still, further Verification and Validation (V&V) of treatment simulation in more extensive, multi-center, and randomized databases is required.
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Affiliation(s)
| | - Laura Obradó
- Neurovascular Unit, Galgo Medical S. L., Barcelona, Spain
| | | | - Juan M Macho
- CDI, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Jordi Blasco
- CDI, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | | | - Sebastian Remollo
- Area de Neurociencias, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | | | - Ignacio Larrabide
- Neurovascular Unit, Galgo Medical S. L., Barcelona, Spain.,Pladema-CONICET/UNICEN, Tandil, Argentina
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Uchiyama Y, Fujimura S, Takao H, Suzuki T, Ishibashi T, Otani K, Karagiozov K, Fukudome K, Yamamoto H, Yamamoto M, Murayama Y. Role of patient-specific blood properties in computational fluid dynamics simulation of flow diverter deployed cerebral aneurysms. Technol Health Care 2022; 30:839-850. [PMID: 35068427 PMCID: PMC9398066 DOI: 10.3233/thc-213216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND: Hemodynamics and their clinical outcome of cerebral aneurysms treated with flow diverter (FD) stents have thus far been investigated using computational fluid dynamics (CFD) simulations. Although human blood is characterized as a non-Newtonian patientspecific fluid, non-patient-specific blood properties (PSBP) were applied in most extant studies. OBJECTIVE: To investigate the hemodynamic effects caused by PSBPs in aneurysms treated with FD stents. METHODS: We measured blood properties (density and viscosity) for 12 patients who underwent FD stent deployment. We conducted CFD simulations with the measured PSBPs and non-PSBPs quoted from previous studies. The average blood flow velocity and wall shear stress within the aneurysms were calculated and two simulation patterns were compared. RESULTS: The velocity and wall shear stress changed by 2.93% and 3.16% on average, respectively, without an FD stent deployed. Conversely, with the FD stents deployed, the change rates increased to 11.1% and 9.06% on average, respectively. CONCLUSIONS: The change in hemodynamic parameters if PSBPs are considered, may not be negligible when conducting CFD simulations of FD stent deployed aneurysms To obtain an adequate hemodynamic environment for cerebral aneurysms with FD stents deployed, it is recommended to use PSBPs for CFD simulations.
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Affiliation(s)
- Yuya Uchiyama
- Graduate School of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Soichiro Fujimura
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- Department of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
| | - Hiroyuki Takao
- Graduate School of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Takashi Suzuki
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Katharina Otani
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
- Siemens Healthcare Japan K.K., Shinagawa-ku, Tokyo, Japan
| | - Kostadin Karagiozov
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Koji Fukudome
- Department of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
| | - Hideki Yamamoto
- Faculty of Environmental and Urban Engineering, Kansai University Fukita-shi, Osaka, Japan
| | - Makoto Yamamoto
- Department of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Tokyo, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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Janot K, Fahed R, Rouchaud A, Zuber K, Boulouis G, Forestier G, Mounayer C, Piotin M. Parent Artery Straightening after Flow-Diverter Stenting Improves the Odds of Aneurysm Occlusion. AJNR Am J Neuroradiol 2022; 43:87-92. [PMID: 34794946 PMCID: PMC8757548 DOI: 10.3174/ajnr.a7350] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/16/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND PURPOSE Intracranial stents for the treatment of aneurysms can be responsible for parent artery straightening, a phenomenon with potential consequences for aneurysmal occlusion. We aimed to evaluate parent artery straightening following flow-diverter stent placement in patients with intracranial aneurysms and explored the association between parent artery straightening and subsequent aneurysm occlusion. MATERIALS AND METHODS All patients treated with flow-diverter stents for anterior circulation aneurysms located downstream from the carotid siphon between January 2009 and January 2018 were screened for inclusion. Parent artery straightening was defined as the difference (α-β) in the parent artery angle at the neck level before (α angle) and after flow-diverter stent deployment (β angle). We analyzed the procedural and imaging factors associated with parent artery straightening and the associations between parent artery straightening and aneurysmal occlusion. RESULTS Ninety-five patients met the inclusion criteria (n = 64/95 women, 67.4%; mean age, 54.1 [SD, 11.2] years) with 97 flow-diverter stents deployed for 99 aneurysms. Aneurysms were predominantly located at the MCA bifurcation (n = 44/95, 44.4%). Parent artery straightening was found to be more pronounced in patients treated with cobalt chromium stents than with nitinol stents (P = .02). In multivariate analysis, parent artery straightening (P = .04) was independently associated with aneurysm occlusion after flow-diverter stent deployment. CONCLUSIONS The use of flow-diverter stents for distal aneurysms induces a measurable parent artery straightening, which is associated with higher occlusion rates. Parent artery straightening, in our sample, appeared to be more prominent with cobalt chromium stents than with nitinol stents. This work highlights the necessary trade-off between navigability and parent artery straightening and may help tailor the selection of flow-diverter stents to aneurysms and parent artery characteristics.
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Affiliation(s)
- K. Janot
- From the Department of Interventional Neuroradiology (K.J., G.B.), University Hospital of Tours, Tours, France
| | - R. Fahed
- Department of Interventional Neuroradiology (R.F., M.P.)
| | - A. Rouchaud
- Department of Interventional Neuroradiology (A.R., G.F., C.M.), Dupuytren University Hospital, Limoges, Franc
| | - K. Zuber
- Research and Biostatistics Unit (K.Z.), Rothschild Foundation Hospital, Paris, France
| | - G. Boulouis
- From the Department of Interventional Neuroradiology (K.J., G.B.), University Hospital of Tours, Tours, France
| | - G. Forestier
- Department of Interventional Neuroradiology (A.R., G.F., C.M.), Dupuytren University Hospital, Limoges, Franc
| | - C. Mounayer
- Department of Interventional Neuroradiology (A.R., G.F., C.M.), Dupuytren University Hospital, Limoges, Franc
| | - M. Piotin
- Department of Interventional Neuroradiology (R.F., M.P.)
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Shiozaki S, Otani T, Fujimura S, Takao H, Wada S. Computational modeling of braided-stent deployment for interpreting the mechanism of stent flattening. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3335. [PMID: 32212324 DOI: 10.1002/cnm.3335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/20/2020] [Accepted: 03/16/2020] [Indexed: 06/10/2023]
Abstract
This study develops a computational model of the braided stent for interpreting the mechanism of stent flattening during deployment into curved arteries. Stent wires are expressed using Kirchhoff's rod theory and their mechanical behavior is treated using a corotational beam formulation. The equation of motion of the braided stent is solved in a step-by-step manner using the resultant elastic force and mechanical interactions of wires with friction. Examples of braided-stent deployment into idealized arteries with various curvatures are numerically simulated. In cases of low curvature, the braided stent expands from a catheter by releasing the bending energy stored in stent wires, while incomplete expansion is found at both stent ends (ie, the fish-mouth phenomenon), where relatively little bending energy is stored. In cases of high curvature, much torsional energy is stored in stent wires locally in the midsection of the curvature and the bending energy for stent self-expansion is not fully released even after deployment, leading to stent flattening. These findings suggest that the mechanical state of the braided stent and its transition during deployment play an important role in the underlying mechanism of stent flattening. NOVELTY STATEMENT: This study developed a computational mechanical model of the braided stent for interpreting stent flattening, which is a critical issue observed during deployment into highly curved arteries. Mechanical behaviors of the stent wires are appropriately treated by corotational beam element formulation with considering multiple contacts. We conducted numerical examples of the stent deployment into curved arteries and found that the mechanical state of the braided stent during deployment associated with occurrences of the stent flattening. We believe this finding gives new insight into the mechanism of stent flattening and would advance the design of the stent and its deployment protocol.
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Affiliation(s)
- Shunya Shiozaki
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Toyonaka, Japan
| | - Tomohiro Otani
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Toyonaka, Japan
| | - Soichiro Fujimura
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Japan
- Graduate School of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Japan
| | - Hiroyuki Takao
- Department of Innovation for Medical Information Technology, The Jikei University School of Medicine, Minato-ku, Japan
- Graduate School of Mechanical Engineering, Tokyo University of Science, Katsushika-ku, Japan
- Department of Neurosurgery, The Jikei University School of Medicine, Minato-ku, Japan
| | - Shigeo Wada
- Department of Mechanical Science and Bioengineering, Graduate School of Engineering Science, Osaka University, Toyonaka, Japan
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Bonafe A, Perez MA, Henkes H, Lylyk P, Bleise C, Gascou G, Sirakov S, Sirakov A, Stockx L, Turjman F, Petrov A, Roth C, Narata AP, Barreau X, Loehr C, Berlis A, Pierot L, Miś M, Goddard T, Clifton A, Klisch J, Wałęsa C, Dall'Olio M, Spelle L, Clarencon F, Yakovlev S, Keston P, Nuzzi NP, Dima S, Wendl C, Willems T, Schramm P. Diversion-p64: results from an international, prospective, multicenter, single-arm post-market study to assess the safety and effectiveness of the p64 flow modulation device. J Neurointerv Surg 2021; 14:898-903. [PMID: 34782399 PMCID: PMC9380510 DOI: 10.1136/neurintsurg-2021-017809] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/21/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The use of flow diversion to treat intracranial aneurysms has increased in recent years. OBJECTIVE To assess the safety and angiographic efficacy of the p64 flow modulation device. METHODS Diversion-p64 is an international, prospective, multicenter, single-arm, study conducted at 26 centers. The p64 flow modulation device was used to treat anterior circulation aneurysms between December 2015 and January 2019. The primary safety endpoint was the incidence of major stroke or neurologic death at 3-6 months, with the primary efficacy endpoint being complete aneurysm occlusion (Raymond-Roy Occlusion Classification 1) on follow-up angiography. RESULTS A total of 420 patients met the eligibility criteria and underwent treatment with the p64 flow modulation device (mean age 55±12.0 years, 86.2% female). Mean aneurysm dome width was 6.99±5.28 mm and neck width 4.47±2.28 mm. Mean number of devices implanted per patient was 1.06±0.47, with adjunctive coiling performed in 14.0% of the cases. At the second angiographic follow-up (mean 375±73 days), available for 343 patients (81.7%), complete aneurysm occlusion was seen in 287 (83.7%) patients. Safety data were available for 413 patients (98.3%) at the first follow-up (mean 145±43 days) with a composite morbidity/mortality rate of 2.42% (n=10). CONCLUSIONS Diversion-p64 is the largest prospective study using the p64 flow modulation device. The results of this study demonstrate that the device has a high efficacy and carries a low rate of mortality and permanent morbidity.
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Affiliation(s)
- Alain Bonafe
- Department of Neuroradiology, Hopital Gui de Chauliac, Montpellier, France
| | - Marta Aguilar Perez
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Baden-Württemberg, Germany
| | - Pedro Lylyk
- Departamento de Neurociencias, ENERI, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Carlos Bleise
- Departamento de Neurociencias, ENERI, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Gregory Gascou
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Stanimir Sirakov
- Department of Radiology, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Alexander Sirakov
- Department of Radiology, University Hospital St Ivan Rilski, Sofia, Bulgaria
| | - Luc Stockx
- Neuroradiology, Ziekenhuis Oost-Limburg - Campus Sint Jan, Genk, Belgium
| | - Francis Turjman
- Department of Interventional Neuroradiology, Hôpital Neurologique Pierre Wertheimer, Lyon, France
| | - Andrey Petrov
- Department of Vascular Neurosurgery, Russian Polenov Neurosurgical Institute, Federal Almazov North West Medical Research Centre, St Petersburg, Russian Federation
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Ana-Paula Narata
- Department of Interventional Neuroradiology, Regional University Hospital, Tours, France
| | - Xavier Barreau
- Department of Neuroradiology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest GmbH Behandlungszentrum Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Nordrhein-Westfalen, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Augsburg, Augsburg, Bayern, Germany
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison Blanche, Reims, France
| | - Marcin Miś
- Department of General Radiology, Interventional Radiology, and Neuroradiology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
| | - Tony Goddard
- Department of Neuroradiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andy Clifton
- Department of Neuroradiology, St George's Hospital, London, UK
| | - Joachim Klisch
- Department of Neuroradiology, HELIOS Klinikum Erfurt, Erfurt, Thüringen, Germany
| | - Cezary Wałęsa
- Neuroradiology, Regionalny Szpital Specjalistyczny im dr Wl Bieganskiego, Grudziadz, Poland
| | - Massimo Dall'Olio
- Neuroradiology, Ospedale Bellaria Carlo Alberto Pizzardi, Bologna, Italy
| | - Laurent Spelle
- Department of Interventional Neuroradiology, BICETRE HOSPITAL - APHP, Le Kremlin-Bicetre, France.,Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicetre, France
| | - Frédéric Clarencon
- Department of Neuroradiology, Hôpital Universitaire Pitié Salpêtrière Service de Neuroradiologie Interventionnelle, Paris, Île-de-France, France
| | - Sergey Yakovlev
- Neuroradiology, Burdenko Neurosurgical Clinic, Moskva, Russian Federation
| | - Peter Keston
- Department of Clinical Neuroscience, NHS Lothian, Edinburgh, UK
| | - Nunzio Paolo Nuzzi
- Neuroradiologia Interventistica, IRCCS Istituto Clinico Humanitas, Rozzano, Lombardia, Italy
| | - Stefanita Dima
- Clinica de Neurochirurgie si Terapie Endovasculara Neurolife, Life Memorial Hospital, Bucharest, Romania
| | - Christina Wendl
- Institut für Röntgendiagnostik, Universitatsklinikum Regensburg, Regensburg, Bayern, Germany
| | | | - Peter Schramm
- Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lubeck, Schleswig-Holstein, Germany
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Gyürki D, Csippa B, Paál G, Szikora I. Impact of Design and Deployment Technique on the Hydrodynamic Resistance of Flow Diverters : An in Vitro Experimental Study. Clin Neuroradiol 2021; 32:107-115. [PMID: 34686884 PMCID: PMC8894302 DOI: 10.1007/s00062-021-01106-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/22/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Despite the high efficacy of flow diverters (FD) in treating sidewall intracranial aneurysms, failures are reported. One of the physical factors determining efficacy is the flow reducing capacity of the FD that is currently unknown to the operator. Our aim was to measure the flow reducing capacity expressed as the hydrodynamic resistance (HR), the metallic surface area (MSA) and pore density (PD) of two different FD designs and quantitatively investigate the impact of sizing and the deployment technique on these parameters. METHODS Altogether 38 Pipeline (Medtronic) and P64 (Phenox) FD‑s were implanted in holder tubes by a neurointerventionist in nominally sized, oversized and longitudinally compressed or elongated manners. The tubes were placed in a flow model with the flow directed across the FD through a side hole on the tube. HR was expressed by the measured pressure drop as the function of the flow rate. Deployed length, MSA and PD were also measured and correlated with the HR. RESULTS Both PD and MSA changed with varying deployment length, which correlates well with the change in HR. Oversizing the device by 1 mm in diameter has reduced the HR on average to one fifth of the original value for both manufacturers. CONCLUSION This study demonstrates experimentally that different FD designs have different flow diverting capacities (HR). Parameters are greatly influenced by radial sizing and longitudinal compression or elongation during implantation. Our results might be useful in procedure planning, predicting clinical outcome, and in patient-specific numerical flow simulations.
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Affiliation(s)
- Dániel Gyürki
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Műegyetem rkp. 3., D building, 3rd floor, 1111, Budapest, Hungary.
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Műegyetem rkp. 3., D building, 3rd floor, 1111, Budapest, Hungary
| | - György Paál
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, Műegyetem rkp. 3., D building, 3rd floor, 1111, Budapest, Hungary
| | - István Szikora
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
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Hemodynamic Investigation of the Effectiveness of a Two Overlapping Flow Diverter Configuration for Cerebral Aneurysm Treatment. Bioengineering (Basel) 2021; 8:bioengineering8100143. [PMID: 34677216 PMCID: PMC8533189 DOI: 10.3390/bioengineering8100143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/12/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022] Open
Abstract
Flow diverters (FDs) are widely employed as endovascular treatment devices for large or wide-neck cerebral aneurysms. Occasionally, overlapped FDs are deployed to enhance the flow diversion effect. In this study, we investigated the hemodynamics of overlapping FDs via computational fluid dynamics (CFD) simulations. We reproduced the arterial geometry of a patient who had experienced the deployment of two overlapping FDs. We utilized two stent patterns, namely the patterns for one FD and two overlapping FDs. We calculated the velocity, mass flow rate, wall shear stress, and pressure loss coefficient as well as their change rates for each pattern relative to the no-FD pattern results. The CFD simulation results indicated that the characteristics of the blood flow inside the aneurysm were minimally affected by the deployment of a single FD; in contrast, the overlapping FD pattern results revealed significant changes in the flow. Further, the velocity at an inspection plane within the aneurysm sac decreased by up to 92.2% and 31.0% in the cases of the overlapping and single FD patterns, respectively, relative to the no-FD pattern. The simulations successfully reproduced the hemodynamics, and the qualitative and quantitative investigations are meaningful with regard to the clinical outcomes of overlapped FD deployment.
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Safety Evaluation and Flow Modification in the Anterior Cerebral Artery after Pipeline Embolization Device Deployment across the Internal Carotid Artery Terminus. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6657595. [PMID: 34471639 PMCID: PMC8405287 DOI: 10.1155/2021/6657595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 02/26/2021] [Accepted: 07/31/2021] [Indexed: 11/24/2022]
Abstract
Method The clinical and imaging data of PEDs in the postmarket multicenter registry study (PLUS) in China were retrospectively analyzed, and patients were divided into two groups on the basis of the follow-up angiographic results: group 1 (no significant change in A1 blood flow) and group 2 (A1 occlusion or decreased blood flow). We collected patients' baseline data and evaluated the following imaging indicators: diameter and ratio of bilateral A1, M1, and internal carotid artery (ICA) vessels before stenting and the ratio of the PED size (sPED) to the ipsilateral ICA (I-ICA) diameter on the implantation side. Results A total of 1171 patients were included, of whom 48 met the inclusion criteria (17 in group 1 and 31 in group 2). In group 2, three patients experienced neurological deterioration at follow-up. From the univariate analysis of outcomes, single PED without coils, incomplete aneurysm occlusion (IAO), maximum aneurysm diameter, aneurysms involving the ICA bifurcation (ICAb), and large sPED/I-ICA diameter ratio were included in the multivariate analysis (P < 0.20). The multivariate regression analysis results showed that the ratio of sPED/I-ICA diameter was the factor influencing A1 vessel occlusion. The area under the ROC curve was 73.2%. When the sPED/I-ICA diameter ratio was 1.14, sensitivity was 70.6%, and specificity was 77.4%. Conclusion When an oversized PED is placed from M1 to the ICA, the higher porosity formed at the covered A1 orifice is conducive to maintaining stable A1 blood flow and reducing the risk of A1 vessel occlusion. This trial is registered with ClinicalTrials.gov identifier: NCT03831672.
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40
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Kim S, Yang H, Hong I, Oh JH, Kim YB. Computational Study of Hemodynamic Changes Induced by Overlapping and Compacting of Stents and Flow Diverter in Cerebral Aneurysms. Front Neurol 2021; 12:705841. [PMID: 34408723 PMCID: PMC8365227 DOI: 10.3389/fneur.2021.705841] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The flow diversion effect of an intracranial stent is closely related to its metal coverage rate (MCR). In this study, the flow diversion effects of Enterprise and low-profile visualized intraluminal support (LVIS) stents are compared with those of a Pipeline flow diverter, focusing on the MCR change. Moreover, the changes in the flow diversion effect caused by the additional manipulations of overlapping and compaction are verified using computational fluid dynamics (CFD) analysis. Methods: CFD analysis was performed using virtually generated stents mounted in an idealized aneurysm model. First, the flow diversion effects of single Enterprise, LVIS, and Pipeline devices were analyzed. The Enterprise and LVIS were sequentially overlapped and compared with a Pipeline, to evaluate the effect of stent overlapping. The effect of compacting a stent was evaluated by comparing the flow diversion effects of a single and two compacted LVIS with those of two overlapped, uncompacted LVIS and uncompacted and compacted Pipeline. Quantitative analysis was performed to evaluate the hemodynamic parameters of energy loss, average velocity, and inflow rate. Results: Statistically significant correlations were observed between the reduction rates of the hemodynamic parameters and MCR. The single LVIS without compaction induced a reduction in all the hemodynamic parameters comparable to those of the three overlapped Enterprise. Moreover, the two overlapped, uncompacted LVIS showed a flow diversion effect as large as that induced by the single uncompacted Pipeline. Compacted stents induced a better flow diversion effect than uncompacted stents. The single compacted LVIS induced a flow diversion effect similar to that induced by the two uncompacted LVIS or single uncompacted Pipeline. Conclusions: The MCR of a stent correlates with its flow diversion effect. Overlapping and compaction can increase the MCR of an intracranial stent and achieve a flow diversion effect as large as that observed with a flow diverter.
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Affiliation(s)
- Sunghan Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.,Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeondong Yang
- Department of Mechanical Engineering and BK21 FOUR ERICA-ACE Center, Hanyang University, Ansan, South Korea
| | - Ineui Hong
- Department of Mechanical Engineering and BK21 FOUR ERICA-ACE Center, Hanyang University, Ansan, South Korea
| | - Je Hoon Oh
- Department of Mechanical Engineering and BK21 FOUR ERICA-ACE Center, Hanyang University, Ansan, South Korea
| | - Yong Bae Kim
- Department of Neurosurgery, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Porto GBF, Al Kasab S, Sattur MG, Almallouhi E, Lajthia O, Casey MA, Starke RM, Lanzino G, Ogilvy CS, Thomas AJ, Kim L, James RF, Levitt M, Spiotta AM. Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review. World Neurosurg 2021; 154:e421-e427. [PMID: 34284157 DOI: 10.1016/j.wneu.2021.07.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA. METHODS A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up. RESULTS A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access. CONCLUSION Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.
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Affiliation(s)
- Guilherme B F Porto
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mithun G Sattur
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Orgest Lajthia
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael A Casey
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert M Starke
- Department of Neurosurgery, Division of Neuroendovascular Surgery, University of Miami, Miami, Florida, USA
| | - Giuseppe Lanzino
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Louis Kim
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Robert F James
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Michael Levitt
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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In-silico trial of intracranial flow diverters replicates and expands insights from conventional clinical trials. Nat Commun 2021; 12:3861. [PMID: 34162852 PMCID: PMC8222326 DOI: 10.1038/s41467-021-23998-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 05/25/2021] [Indexed: 01/18/2023] Open
Abstract
The cost of clinical trials is ever-increasing. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower these costs. We present the flow diverter performance assessment (FD-PASS) in-silico trial, which models the treatment of intracranial aneurysms in 164 virtual patients with 82 distinct anatomies with a flow-diverting stent, using computational fluid dynamics to quantify post-treatment flow reduction. The predicted FD-PASS flow-diversion success rates replicate the values previously reported in three clinical trials. The in-silico approach allows broader investigation of factors associated with insufficient flow reduction than feasible in a conventional trial. Our findings demonstrate that in-silico trials of endovascular medical devices can: (i) replicate findings of conventional clinical trials, and (ii) perform virtual experiments and sub-group analyses that are difficult or impossible in conventional trials to discover new insights on treatment failure, e.g. in the presence of side-branches or hypertension. In-silico trials rely on virtual populations and interventions simulated using patient-specific models and may offer a solution to lower costs. Here, the authors present the flow diverter performance assessment in-silico trial, which models the treatment of intracranial aneurysms with a flow-diverting stent.
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Bhogal P, Makalanda H, Wong K, Keston P, Downer J, Du Plessis JC, Nania A, Simonato D, Fuschi M, Chong W, O'Reilly S, Rennie I. The Silk Vista Baby - The UK experience. Interv Neuroradiol 2021; 28:201-212. [PMID: 34078155 DOI: 10.1177/15910199211024061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB) flow diverter (FDS) is the only FDS deliverable via a 0.017 inch microcatheter and is specifically designed for the distal vasculature. We sought to evaluate the safety and efficacy of the SVB. MATERIALS AND METHODS We performed a retrospective review to identify SVB cases at 4 tertiary neurosurgical centres within the U.K. Clinical, procedural, angiographic and follow-up data were collected. RESULTS We identified 60 patients (35 female, 58%) of average age 54 ± 10.5 (range 30-72) with 61 aneurysms, 50 (81.9%) located in the anterior circulation. The majority of the aneurysms treated were unruptured (46, 75.4%) and saccular (46, 75.4%). Dome size was 6.2 ± 6.2 mm (range 1-36mm) and parent vessel diameter was 2.3 ± 0.4 mm (range 1.2-3.3 mm).An average number of 1.07 devices were implanted. Coils or other devices were implanted in 14 aneurysms (23.3%). At last angiographic follow-up (n = 55), 7.5 ± 4.2 months post-procedure, 32 aneurysms (57.1%) were graded as RRC I, 7 (12.5%) RRC II, and 17 RRC III (30.4%).Clinical complications, excluding death, were seen in 4 patients (6.8%) including 1 delayed aneurysm rupture and 3 symptomatic ischaemic events. Only one patient had permanent morbidity (mRS 1). 3 patients died during follow-up (5.1%); 2 deaths were related to the aneurysms (3.4%) - one ruptured dissecting MCA aneurysm, and one giant partially thrombosed posterior circulation aneurysm. 93% of patients were mRS ≤ 2 at last follow-up. CONCLUSION The SVB has high rates of technical success and an acceptable safety profile. Distal aneurysms may occlude slower due to relative oversizing of the devices.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, London, UK
| | | | - K Wong
- The Royal London Hospital, London, UK
| | - P Keston
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J Downer
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - J C Du Plessis
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - A Nania
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - D Simonato
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - M Fuschi
- Department of Interventional Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - W Chong
- Department of Interventional Neuroradiology, University Hospitals Coventry and Warwickshire, Warwickshire, UK
| | - S O'Reilly
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
| | - I Rennie
- Department of Interventional Neuroradiology, The Royal Victoria Hospital, Belfast, UK
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Miller TR, Wessell A, Jindal G, Malhotra A, Simard JM, Gandhi D. The utility of platelet inhibition testing in patients undergoing Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2021; 14:neurintsurg-2021-017681. [PMID: 34078649 DOI: 10.1136/neurintsurg-2021-017681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 05/20/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The utility of using the VerifyNow P2Y12 platelet inhibition assay in patients undergoing Pipeline embolization of intracranial aneurysms remains controversial. As we have routinely employed the assay for patients undergoing flow diversion, we elected to explore the relationship between P2Y12 hyporesponse as indicated by a P2Y12 Reaction Units (PRU) value >200 and treatment outcomes, including intraprocedural platelet aggregation and ischemic complications. METHODS All successful intracranial aneurysm Pipeline treatments performed at our institution from November 2011 to May 2019 were included. The rate of P2Y12 hyporesponse and treatment outcomes were evaluated. Multivariable logistic regression was utilized to determine independent predictors of treatment outcomes. RESULTS 333 qualifying treatments were performed in 297 patients. Clopidogrel hyporesponse was initially noted in 24%, falling to 17% by day-of-procedure by dose titration. A glycoprotein (GP) IIb/IIIa inhibitor was administered prophylactically in 3% of cases for persistent, profound hyporesponse. 27 (8.1%) patients developed acute platelet aggregation; only 6 demonstrated day-of-procedure P2Y12 hyporesponse. Day-of-procedure hyporesponse was not associated with intraprocedural platelet aggregation or ischemic complications. Greater Pipeline embolization device (PED) diameter was associated with a reduced odds of platelet aggregation (OR 0.38, 95% CI 0.17 to 0.85; p=0.019). Antiplatelet non-compliance (OR 25.20, 95% CI 3.86 to 164.61; p=0.001) and treatment of posterior circulation aneurysms (OR 5.23, 95% CI 1.22 to 22.33; p=0.026) were the only independent predictors of ischemic complications. CONCLUSIONS P2Y12 hyporesponse was not associated with acute platelet aggregation or ischemic complications in our patients undergoing Pipeline embolization of intracranial aneurysms, possibly due to aggressive management of the hyporesponse using clopidogrel dose titration and/or GP IIb/IIIa inhibitor administration.
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Affiliation(s)
- Timothy R Miller
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron Wessell
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gaurav Jindal
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - J Marc Simard
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Dheeraj Gandhi
- Diagnostic Radiology, Neuroradiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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den Bergh FRAV, De Beule T, van Rooij WJ, Voormolen MH, Van der Zijden T, Stockx L, van Zwam WH, Fransen H. The p48 flow diverter: First clinical results in 25 aneurysms in three centers. Interv Neuroradiol 2021; 27:339-345. [PMID: 33164617 PMCID: PMC8190948 DOI: 10.1177/1591019920972213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/13/2020] [Accepted: 10/18/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75-3mm. We report our first clinical experiences. METHODS Between March 2018-January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29-73 years). RESULTS In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9-34.2%) and mortality was 4.5% (1 of 22, 95%CI <0.01-23.5%). Most complications were procedure-related and not device-specific. Of 22 patients with 25 aneurysms treated with p48, 18 patients with 20 aneurysms had angiographic follow-up after 5-18 months. Of 19 aneurysms, 10 were occluded and 7 showed a remnant. Two aneurysms were open after 6 months. Three aneurysms were still not occluded after 12, 14, and 18 months and these 3 were retreated. Retreatment rate was 16% (3 of 19) and the adequate occlusion rate was 90% (17 of 19). CONCLUSIONS Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately.
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Affiliation(s)
- FRA Van den Bergh
- Department of Radiology, Algemeen Ziekenhuis St Lucas, Gent, Belgium
| | - T De Beule
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - WJ van Rooij
- Department of Radiology, Algemeen Ziekenhuis Turnhout, Turnhout, Belgium
| | - MH Voormolen
- Department of Radiology, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - T Van der Zijden
- Department of Radiology, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - L Stockx
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - WH van Zwam
- Department of Radiology, Maastricht Universiteit Medisch Centrum, Maastricht, the Netherlands
| | - H Fransen
- Department of Radiology, Algemeen Ziekenhuis St Lucas, Gent, Belgium
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Zhang M, Tupin S, Li Y, Ohta M. Association Between Aneurysmal Haemodynamics and Device Microstructural Characteristics After Flow-Diversion Treatments With Dual Stents of Different Sizes: A Numerical Study. Front Physiol 2021; 12:663668. [PMID: 34113263 PMCID: PMC8185279 DOI: 10.3389/fphys.2021.663668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives Treating intracranial aneurysms with flow-diverting stents sometimes requires deployment of a second device. Herein we quantify the sizing effects of devices in dual-stent treatments upon the final stent microstructure and the post-treatment aneurysmal haemodynamics. Methods Fifteen sidewall ICA aneurysm geometries were included. Using a virtual stenting technique, we implanted either one or two stents for each aneurysm treatment considered, with each stent specified as one of two different sizes, yielding a total of two single-stent and fouir dual-stent treatment scenarios for each aneurysm. Three stent microstructural parameters and nine aneurysmal haemodynamic parameters were quantified and systematically compared across the 90 treatment scenarios. Results Deployment of a second stent further reduced the aneurysmal inflow rate (IR) and energy loss (EL) by, respectively, 14 ± 11% (p = 0.001) and 9 ± 12% (p = 0.056), relative to the untreated condition. Sizing effects of the earlier-deployed stent led to largest differences of 6.9% for the final IR reduction and 11.1% for the EL, whereas sizing effects from the later-deployed stent were minor (≤2.1%). The change in stent pore size was the only microstructural parameter demonstrating a strong correlation with the reduction in the post-treatment aneurysmal haemodynamics, in terms of the IR (r = 0.50, p < 0.001) and pressure drop (r = 0.63, p < 0.001). Conclusion Size of the earlier-deployed stent has substantial effects on the final haemodynamic outcomes after dual-stent treatment. The average pore size of stent wires at the aneurysm orifice shows promise as a potential index for predicting the efficacy of flow-diversion treatments.
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Affiliation(s)
- Mingzi Zhang
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Simon Tupin
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Yujie Li
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan
| | - Makoto Ohta
- Biomedical Flow Dynamics Laboratory, Institute of Fluid Science, Tohoku University, Sendai, Japan.,ElyTMaX, CNRS-Université de Lyon-Tohoku University, International Joint Unit, Tohoku University, Sendai, Japan
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47
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Poker A, Öcal O, Öztürk E, Arat A. Propensity Score Analysis of Flow Diverters Placed in Scaffolding Stents. AJNR Am J Neuroradiol 2021; 42:1093-1098. [PMID: 33664116 DOI: 10.3174/ajnr.a7040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/09/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow-diverter deployment within a stent remains controversial, but flow-diverter deployment within a scaffolding stent has been performed occasionally. To date, an analysis of this scaffolding technique has not been reported. We aimed to evaluate whether the scaffolding technique adversely affects the outcomes of flow diversion. MATERIALS AND METHODS Patients who had undergone intracranial aneurysm treatment using a Silk flow diverter with (scaffolding group) or without (bare flow-diverter group) a scaffolding stent were identified retrospectively and compared. Propensity score matching was used to match the aneurysms in both groups for variables with a significant difference between groups. Aneurysm occlusion rates and clinical outcomes were compared. RESULTS There were 84 patients (105 aneurysms) in the bare flow-diverter group and 21 patients (22 aneurysms) in the scaffolding group (using 20 LEO stents and 1 Enterprise stent). The aneurysms in the scaffolding group were larger (mean, 13.1 [SD, 10.7] versus 7 [SD, 4.5] mm, P = .001) and more likely to be fusiform (40.9% versus 5.7%, P < .001) than in the bare flow-diverter group. After 2:1 propensity score matching, 24 aneurysms in the bare flow-diverter group and 15 in the scaffolding group were matched. Aneurysm occlusion rates did not significantly differ between groups at 1-3 months (41.2 versus 33.3%, P > .99), 3-6 months (55.5 versus 75.0%, P = .44), 7-12 months (65.0 versus 90.0%, P = .21), or beyond 1 year (73.6 versus 91.6%, P = .36). There was no difference in complication rates between the groups (P > .99). CONCLUSIONS Placement of a scaffolding stent before flow diversion does not adversely affect aneurysm occlusion or complication rates.
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Affiliation(s)
- A Poker
- From the Department of Radiology (A.P., O.Ö., A.A.), Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - O Öcal
- From the Department of Radiology (A.P., O.Ö., A.A.), Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - E Öztürk
- Department of Biostatistics (E.Ö.), Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - A Arat
- From the Department of Radiology (A.P., O.Ö., A.A.), Faculty of Medicine, Hacettepe University, Ankara, Turkey
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48
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Maragkos GA, Dmytriw AA, Salem MM, Tutino VM, Meng H, Cognard C, Machi P, Krings T, Mendes Pereira V. Overview of Different Flow Diverters and Flow Dynamics. Neurosurgery 2020; 86:S21-S34. [PMID: 31838536 DOI: 10.1093/neuros/nyz323] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.
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Affiliation(s)
- Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Hui Meng
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hopitalier de Toulouse, Toulouse, France
| | - Paolo Machi
- Department of Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Vitor Mendes Pereira
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
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Limbucci N, Leone G, Renieri L, Nappini S, Cagnazzo F, Laiso A, Muto M, Mangiafico S. Expanding Indications for Flow Diverters: Distal Aneurysms, Bifurcation Aneurysms, Small Aneurysms, Previously Coiled Aneurysms and Clipped Aneurysms, and Carotid Cavernous Fistulas. Neurosurgery 2020; 86:S85-S94. [PMID: 31838532 PMCID: PMC6911737 DOI: 10.1093/neuros/nyz334] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/06/2019] [Indexed: 11/23/2022] Open
Abstract
Flow diverter devices have gained wide acceptance for the treatment of unruptured intracranial aneurysms. Most studies are based on the treatment of large aneurysms harboring on the carotid syphon. However, during the last years the “off-label” use of these stents has widely grown up even if not supported by randomized studies. This review examines the relevant literature concerning “off-label” indications for flow diverter devices, such as for distal aneurysms, bifurcation aneurysms, small aneurysms, recurrent aneurysms, and direct carotid cavernous fistulas.
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Affiliation(s)
- Nicola Limbucci
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Giuseppe Leone
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy.,Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
| | - Leonardo Renieri
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Sergio Nappini
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Federico Cagnazzo
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Antonio Laiso
- Neurovascular Interventional Unit, Careggi University Hospital, Florence, Italy
| | - Mario Muto
- Department of Neuroradiology, Cardarelli Hospital, Naples, Italy
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50
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Bonney PA, Connor M, Fujii T, Singh P, Koch MJ, Stapleton CJ, Mack WJ, Walcott BP. Failure of Flow Diverter Therapy: Predictors and Management Strategies. Neurosurgery 2020; 86:S64-S73. [PMID: 31838530 DOI: 10.1093/neuros/nyz305] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/15/2019] [Indexed: 11/14/2022] Open
Abstract
Flow diversion is a safe and effective treatment for many types of brain aneurysms. Even so, there remain some aneurysms that persist despite initial treatment. In studies with the longest follow-up (5 yr), at least 5% of aneurysms persist with this treatment modality. As the cumulative experience and clinical indications for flow diversion continue to expand, the anatomic and functional characteristics that are associated with aneurysm persistence are increasingly described. Identification of these factors preoperatively can help to guide initial treatment decisions, enhance monitoring protocols in the follow-up period, and establish best practices for re-treatment when necessary. Herein, we review published clinical series and provide examples to highlight variables implicated in aneurysm persistence after treatment with flow diversion.
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Affiliation(s)
- Phillip A Bonney
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Michelle Connor
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Tatsuhiro Fujii
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Parampreet Singh
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Matthew J Koch
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Christopher J Stapleton
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - William J Mack
- Department of Neurological Surgery, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Brian P Walcott
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois.,University of Chicago Pritzker School of Medicine, Chicago, Illinois
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