Safety and efficacy of dual lumen balloon catheters for the Treatment of cerebral vascular malformations: A systematic review, pooled analysis, and meta-analysis

BACKGROUND

There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs).

METHODS

In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome.

RESULTS

The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74-87.8%]) and in 45/77 treated AVMs (58.4%, [46.7-69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8-7.7%]), five technical failures (2.4%, [0.9-5.8%]), 14 reflux events (6.7%, [3.9-11.2%]), two entrapment events (1%, [0.2-3.8%]) and 0 deaths (mortality rate 0%, [0-2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5-14.3], p = .008).

CONCLUSION

Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs.

REGISTRATION-URL

https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096.

De novo brain AVM following radiotherapy for cerebral cavernous malformation in a child: A 15-year clinical course

Multiple de novo brain arteriovenous malformations (bAVM) have been reported in the literature, raising questions about the contended purely congenital nature of these lesions. We present the 15-year course of a pediatric patient, who initially presented at age 5 with a thalamic cavernous malformation and was treated with radiosurgery, and then subsequently developed a thalamic de novo bAVM immediately adjacent to the initial lesion location, discovered 2 years later. Treatment of the bAVM entailed two transarterial embolizations and one radiosurgery session which ultimately led to complete angiographic resolution. Finally, this patient's course was complicated by intraparenchymal hemorrhage and acute obstructive hydrocephalus, and further imaging revealed two newly formed cavernous malformations, also associated with the initial lesion's location, that have remained stable since their formation. This case likely represents the second-hit model for the formation of vascular malformations, as sparsely supported by the current literature. According to this, genetically aberrant, yet quiescent, brain areas might promote the de novo formation of vascular malformations after brain injury, including radiation.

Abstract P515: Early Neurological Deterioration in Minor Stroke Symptom Large Vessel Occlusion Patients

Background: 30% of minor stroke symptom (MSS) patients (NIHSS=<5) have underlying large vessel occlusions (LVO). MSS patients are less likely to receive endovascular therapy (EVT) and thrombolytic therapy. 20-25% of patients with LVO suffer early neurological deterioration (END), ≥ 4 points decrease on NIHSS, which is associated with worse outcomes. The predictability of END is currently unclear and there is need for elucidation on the factors which precipitate rapid decline.

Methods: Retrospective review of MSS-LVO patients across two multi-hospital centers from June 2015 thru June 2018 was conducted. Patients who underwent immediate EVT without signs of deterioration were excluded. Baseline characteristics, management, and outcomes were compared with t-tests, Mann-Whitney U, Chi-square, Fisher’s exact test, and Fisher-Freeman-Halton test for continuous and categorical variables, as appropriate using SPSS Software.

Results: Of the 45 MSS-LVO patients who were included, 12 suffered END. Demographics and baseline characteristics were not significantly different across groups. Weakness was more often a presenting symptom in the No-END cohort (84.8% vs 41.7% in END group, p=0.01). The END group showed a lower diastolic BP at the time of the highest NIHSS (86mmHg vs 72mmHg in END group, p= 0.03). The highest BP was comparable across groups (180/84 in the No END group vs 182/91 in END group, p>0.05); although in the END group, the high BP correlated with a higher NIHSS (3 vs 0 in No END group, p=0.01). Patients in the END group were more likely to receive tpA (58.3% vs 15.2% in No END group, p=0.01). The 24-hour NIHSS was greater in the END group (2.5 vs. 0, p=0.02). 84.4% of patients in the No END group had good functional outcome at 3-5 days (mRS 0-2), compared to 45.5% of the END patients (p=0.02). 25% of the END group had in-hospital mortality, while there were no deaths in the No END group. Fewer patients were discharged home (72.7% in No END vs 58.3% in END group, p=0.04).

Conclusion: END in MSS patients is associated with worse outcomes at 3-5 days and higher in-hospital mortality. Presenting symptoms and BP fluctuations may be factors in predicting END. Further studies are needed to elucidate the risk factors associated with END in MSS-LVO patients.

Residuals, recurrences and re-treatment after endovascular repair of intracranial aneurysms: A retrospective methodological comparison

OBJECTIVE

Incomplete aneurysm occlusions and re-treatment rates of 52 and 10-30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia.

METHODS

Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion.

RESULTS

Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05).

CONCLUSIONS

Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.

Abstract WMP34: One Year Follow-Up on the Utility of the Penumbra SMART COIL System for Treatment of Intracranial Aneurysms and Malformations in 500 Patients

Introduction: The Penumbra SMART COIL System includes a novel generation of embolic coils comprised of complex and WAVE shape properties with varying levels of softness to promote dense packing and durable long-term occlusion. We report an interim analysis of the first 500 patients enrolled in the SMART registry to assess the utility of the SMART COIL System in the treatment of intracranial aneurysms and other malformations.

Methods: The SMART registry is a prospective, multi-center registry study. Procedures must employ ≥75% of the Smart, PC400, or POD coils to meet the registry criteria. SMART registry endpoints include retreatment rates through one year follow-up, procedural device-related serious adverse events (SAE), the ability to achieve adequate occlusion at immediate post-procedure, and the number of times re-access with guidewire was required due to catheter kickout.

Results: The interim analysis of the first 500 patients enrolled (70.6% female; mean age 60.0±13.2 years) includes cerebral aneurysms (91.0%, 454/499), of which 30.4% were ruptured; arteriovenous malformations (1.4%); fistulae (4.4%); and other lesions (3.2%). Aneurysms were small (87.9%), large (11.9%), and giant (0.2%); 64.3% (275/428) were wide-neck. Stent-assisted coiling was performed in 30.2% of patients and balloon-assisted coiling in 20.2% of patients. Median packing density for all aneurysms was 29.3% (IQR 21.3-38.4). In aneurysm patients, Raymond Class I and II was observed in 79.5% (357/449) at immediate post-procedure, and 88.8% (229/258) at one year follow-up. In all patients, the retreatment rate through one year follow-up was 6.7% (19/282). Procedural device-related SAE were observed in 3.2% subjects (16/500). One year follow-up data collection is ongoing.

Conclusion: Interim Results suggest that the SMART COIL System achieves adequate embolization in a variety of neurovascular lesions with low retreatment rates over one year.

Abstract TP38: Re-Occlusion During Endovascular Therapy for Acute Stroke Patients With Large Vessel Occlusion

Introduction: Endovascular Therapy (EVT) has demonstrated significant benefits for selected acute ischemic stroke (AIS) with emergent large vessels occlusion (ELVO). Early recanalization is one of the most significant predictors of favorable outcome. However, re-occlusion during the procedure remains a challenge and may prolong the time needed for recanalization in a subset of patients. We planned to explore the clinical, radiographic and laboratory features that are associated with intra-procedural re-occlusion.

Method: We retrospectively reviewed consecutive patients who received EVT for ELVO in a single academic health system. Re-occlusion was defined if the occluded target vessel recanalized with TICI ≥2, but became TICI<2 on repeated diagnostic angiography. T test/Wilcoxon test and Chi-square were used to compare risks factors, atherosclerotic plaque burden, and coagulation profile (obtained prior to procedure) between patients with and without re-occlusion.

Results: Among 265 patients (male 46.4%, mean age 69 ±14.4 year old), 25 patients had re-occlusion intra-operatively. The history of cardiovascular risks factors (HTN, HLD, DM, smoking, atrial fibrillation), prior use of antiplatelets or antithrombotics, the number of cerebral arteries with atherosclerotic lesions, and the level of platelets, PT, PTT, INR, LDL and HbA1c were similar between patients with and without re-occlusion. Compared to patients without re-occlusion, those with re-occlusion had a higher proportion of stroke with the etiology of large artery atherosclerosis (34.8% vs 3.2%, p<0.001), and tended to have a longer time from last know well to groin puncture (498 ± 411 vs 408±328 minutes, p=0.15).

Conclusion: Large artery atherosclerotic disease was a more common stroke etiology in patients with re-occlusion during thrombectomy for ELVO. Underlying vasculopathy and plaque rupture may have precipitated the thrombotic process.