1
|
Dong L, Wang C, Wei D, Peng Q, Wu X, Chen X, Li M, Li T, Liu H, Zhao Y, Duan R, Jin W, Zhang Y, Wang Y, Lv M. Spontaneous delayed migration or shortening after pipeline embolization device treatment of intracranial aneurysm: incidence, management, and risk factors. J Neurointerv Surg 2024:jnis-2024-021535. [PMID: 38580442 DOI: 10.1136/jnis-2024-021535] [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: 01/24/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Studies reporting spontaneous delayed migration or shortening (SDMS) after treatment with the Pipeline Embolization Device (PED) are limited. This study aimed to evaluate the incidence of SDMS after PED treatment, propose management strategies, and identify the risk factors contributing to its occurrence. METHODS We retrospectively reviewed consecutive patients with an intracranial aneurysm (IA) treated with PEDs at three institutions. SDMS was classified as type I or II based on whether the PED covered the aneurysm neck. RESULTS The total cohort comprised 790 patients. SDMS was identified in 24 (3.04%) patients. Eighteen of the 24 patients had type I SDMS and did not require retreatment, while the remaining six patients had type II SDMS and all received retreatment. Multivariate logistic regression showed that the difference between the proximal and distal parent artery diameters (DPAD) (adjusted OR 2.977; 95% CI 1.054 to 8.405; P=0.039) and device tortuosity index (DTI) (adjusted OR 8.059; 95% CI 2.867 to 23.428; P<0.001) were independent predictors of SDMS after PED treatment, while the difference in length (DL) (adjusted OR 0.841; 95% CI 0.738 to 0.958; P=0.009) and PED plus coiling (adjusted OR 0.288; 95% CI 0.106 to 0.785; P=0.015) were protective factors. CONCLUSION The incidence of SDMS after PED treatment of IA was 3.04%. For patients with type I SDMS with incomplete aneurysm occlusion we recommend continuous imaging follow-up while, for patients with type II SDMS, we recommend aggressive retreatment. The DPAD and DTI were independent risk predictors of SDMS after PED treatment, while the DL and PED plus coiling were protective factors.
Collapse
Affiliation(s)
- Linggen Dong
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dachao Wei
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qichen Peng
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinzhi Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiheng Chen
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mingtao Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Tong Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - He Liu
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Ran Duan
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Weitao Jin
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ming Lv
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
2
|
Nariai Y, Takigawa T, Hyodo A, Suzuki K. Acute Distal Migration and Shortening of the Flow-Redirection Endoluminal Device: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:132-138. [PMID: 37546345 PMCID: PMC10400909 DOI: 10.5797/jnet.cr.2023-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/08/2023] [Indexed: 08/08/2023]
Abstract
Objective The flow diverter (FD) is a promising device. Apart from two main complications, hemorrhagic and ischemic ones, stent migration is reportedly an unusual complication. In particular, distal migration of the FD has rarely been reported. We report a case of asymptomatic acute distal migration of the flow-redirection endoluminal device (FRED). Case Presentation A 50-year-old woman was incidentally diagnosed with an unruptured right internal carotid-ophthalmic artery aneurysm with a maximum diameter of 8.0 mm, and she subsequently underwent endovascular treatment with FRED. Based on the vessel diameter (3.8 mm proximal and 3.6 mm distal to the aneurysm), a 4.0-mm-diameter and 18-mm-long FRED was deployed without postoperative complications. However, on MRA 12 months after treatment, the aneurysm was not occluded; angiography showed distal migration of the FRED. The postoperative MRA and skull X-ray images were retrospectively reviewed to determine the period of the migration. The skull X-ray images and the signal loss area due to the FRED on MRA 1 day after the treatment had already demonstrated the migration of the FRED. In the second treatment, a 4.0-mm-diameter and 23-mm-long FRED was deployed in an overlapping fashion up to the proximal part of the carotid siphon. Prompt identification of distal migration of the FD without neurologic signs could be challenging. Conclusion It is important to follow up meticulously with MRA and skull X-ray images after FD treatment for detecting stent migrations as early as possible.
Collapse
Affiliation(s)
- Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Kamagaya General Hospital, Kamagaya, Chiba, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
| |
Collapse
|
3
|
Wang T, Ugurlu H, Yan Y, Li M, Li M, Wild AM, Yildiz E, Schneider M, Sheehan D, Hu W, Sitti M. Adaptive wireless millirobotic locomotion into distal vasculature. Nat Commun 2022; 13:4465. [PMID: 35915075 PMCID: PMC9343456 DOI: 10.1038/s41467-022-32059-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/14/2022] [Indexed: 11/23/2022] Open
Abstract
Microcatheters have enabled diverse minimally invasive endovascular operations and notable health benefits compared with open surgeries. However, with tortuous routes far from the arterial puncture site, the distal vascular regions remain challenging for safe catheter access. Therefore, we propose a wireless stent-shaped magnetic soft robot to be deployed, actively navigated, used for medical functions, and retrieved in the example M4 segment of the middle cerebral artery. We investigate shape-adaptively controlled locomotion in phantoms emulating the physiological conditions here, where the lumen diameter shrinks from 1.5 mm to 1 mm, the radius of curvature of the tortuous lumen gets as small as 3 mm, the lumen bifurcation angle goes up to 120°, and the pulsatile flow speed reaches up to 26 cm/s. The robot can also withstand the flow when the magnetic actuation is turned off. These locomotion capabilities are confirmed in porcine arteries ex vivo. Furthermore, variants of the robot could release the tissue plasminogen activator on-demand locally for thrombolysis and function as flow diverters, initiating promising therapies towards acute ischemic stroke, aneurysm, arteriovenous malformation, dural arteriovenous fistulas, and brain tumors. These functions should facilitate the robot’s usage in new distal endovascular operations. Accessibility into the distal vascular systems to treat various diseases remains challenging using medical catheters. Here, Wang et al. demonstrate that a stent-shaped wireless magnetic soft robot enables adaptive locomotion and medical functions into these distal vascular regions.
Collapse
Affiliation(s)
- Tianlu Wang
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.,Department of Information Technology and Electrical Engineering, ETH Zurich, 8092, Zurich, Switzerland
| | - Halim Ugurlu
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.,Clinic for Neuroradiology, Klinikum Stuttgart, 70174, Stuttgart, Germany.,Department of Biophysics, Aydın Adnan Menderes University, Graduate School of Health Sciences, 09010, Aydın, Turkey
| | - Yingbo Yan
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Mingtong Li
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Meng Li
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Anna-Maria Wild
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Erdost Yildiz
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Martina Schneider
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Devin Sheehan
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany
| | - Wenqi Hu
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany.
| | - Metin Sitti
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, 70569, Stuttgart, Germany. .,Department of Information Technology and Electrical Engineering, ETH Zurich, 8092, Zurich, Switzerland. .,School of Medicine and College of Engineering, Koç University, 34450, Istanbul, Turkey.
| |
Collapse
|
4
|
Nariai Y, Takigawa T, Hyodo A, Suzuki K. Distal migration of the flow-redirection endoluminal device immediately after treatment: A case report and literature review. Surg Neurol Int 2022; 13:81. [PMID: 35399895 PMCID: PMC8986641 DOI: 10.25259/sni_1279_2021] [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: 12/31/2021] [Accepted: 02/16/2022] [Indexed: 12/02/2022] Open
Abstract
Background: A flow diverter (FD) has been a promising endovascular therapeutic modality for challenging intracranial aneurysms. However, stent migration has been an unusual complication. Until recently, among some types of FDs, the migration of the flow-redirection endoluminal device (FRED; MicroVention Inc., Aliso Viejo, CA, USA) has almost never been reported. Herein, we report a case of acute distal migration of a single FRED secondary to in-stent thrombi with symptomatic ischemic stroke and review the literature on the distal migration of FDs. Case Description: A 35-year-old woman was diagnosed with a left unruptured internal carotid-ophthalmic artery aneurysm. A 3.5 mm diameter and 17 mm long FRED was adequately deployed. The patient awoke from general anesthesia without neurological deficits. However, shortly after the procedure, the patient presented with conjugate deviation toward the left side, right severe hemiparesis, and total aphasia. Although the symptoms gradually improved, angiography was performed. Angiography revealed some in-stent thrombi and distal migration of the FRED, and initially, one of the left M2 inferior trunk branches was occluded by an embolic thrombus. However, the thrombus spontaneously migrated distally without any specific treatment. Finally, despite leaving the migrated stent in situ, the flow almost completely improved, and the patient’s neurologic deficits disappeared. Magnetic resonance imaging following treatment revealed only a small cerebral infarction in the left temporo-occipital area. Conclusion: Distal migration of an FD in an acute setting, including the FRED, may occur even following appropriate placement. In-stent thrombosis can cause distal stent migration and thromboembolic stroke.
Collapse
|
5
|
Winters H, Schüngel MS, Scherlach C, Mucha D, Thalwitzer J, Härtig W, Donitza A, Bailis N, Maybaum J, Hoffmann KT, Quäschling U, Schob S. First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating. Front Neurol 2021; 12:724705. [PMID: 34594297 PMCID: PMC8476967 DOI: 10.3389/fneur.2021.724705] [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: 06/14/2021] [Accepted: 08/12/2021] [Indexed: 12/23/2022] Open
Abstract
Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter. Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM). Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity. Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.
Collapse
Affiliation(s)
- Helge Winters
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany.,Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Germany
| | | | - Cordula Scherlach
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Dirk Mucha
- Institut für Radiologie und Neuroradiologie, Heinrich-Braun- Klinikum, Zwickau, Germany
| | - Jörg Thalwitzer
- Institut für Radiologie und Neuroradiologie, Klinikum Chemnitz gGmbH, Chemnitz, Germany
| | - Wolfgang Härtig
- Paul-Flechsig-Institut für Hirnforschung, Universität Leipzig, Leipzig, Germany
| | - Aneta Donitza
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
| | - Nikolaos Bailis
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Jens Maybaum
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Karl Titus Hoffmann
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Institut für Neuroradiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Stefan Schob
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle, Halle (Saale), Germany
| |
Collapse
|