Abstract
The effective treatment of wide necked cerebral aneurysms located at vessel bifurcations (WNBAs) remains a significant challenge. Such aneurysm geometries have typically been approached with Y or T stenting configurations of stents and/or flow diverters, often with the addition of endovascular coils. In this study, two WNBAs were virtually treated by a novel T-stenting technique (Flow-T) with a number of braided stents and flow-diverter devices. Multiple possible device deployment configurations with varying device compression levels were tested, using fast-deployment algorithms, before a steady state computational hemodynamic simulation was conducted to examine the efficacy and performance of each scenario. The virtual fast deployment algorithm based on a linear and torsional spring analogy is used to accurately deploy nine stents in two WNBAs geometries. The devices expand from the distal to proximal side of the devices with respect to aneurysm sac. In the WNBAs modelled, all configurations of Flow-T device placement were shown to reduce factors linked with increased aneurysm rupture risk including aneurysm inflow jets and high aneurysm velocity, along with areas of flow impingement and elevated wall shear stress (WSS). The relative position of the flow-diverting device in the secondary daughter vessel in the Flow-T approach was found to have a negligible effect on overall effectiveness of the procedure in the two geometries considered. The level of interventionalist-applied compression in the braised stent that forms the other arm of the Flow-T approach was shown to impact the aneurysm inflow reduction and aneurysm flow pattern more substantially. In the Flow-T approach the relative position of the secondary daughter vessel flow-diverter device (the SVB) was found to have a negligible effect on inflow reduction, aneurysm flow pattern, or WSS distribution in both aneurysm geometries. This suggests that the device placement in this vessel may be of secondary importance. By contrast, substantially more variation in inflow reduction and aneurysm flow pattern was seen due to variations in braided stent (LVIS EVO or Baby Leo) compression at the aneurysm neck. As such we conclude that the success of a Flow-T procedure is primarily dictated by the level of compression that the interventionalist applies to the braided stent. Similar computationally predicted outcomes for both aneurysm geometries studied suggest that adjunct coiling approach taken in the clinical intervention of the second geometry may have been unnecessary for successful aneurysm isolation. Finally, the computational modelling framework proposed offers an effective planning platform for complex endovascular techniques, such as Flow-T, where the scope of device choice and combination is large and selecting the best strategy and device combination from several candidates is vital.
Highlights
Most cerebral aneurysms preferentially occur at vessel bifurcations [1, 2]
Two Wide neck bifurcation aneurysms (WNBAs) geometries located on the Middle Cerebral artery (MCA) that were identified for treatment were segmented from CT angiography imaging data in OsiriX (OsiriX v.4.1.1, Freeware) before being imported into Blender (Blender Foundation, Amsterdam, The Netherlands) as stereolithography (STL) format
The fast virtual deployment algorithm was applied to each device (Stents I-IX) in two WNBA geometries as shown in Table 1 and Figure 1
Summary
With the major advancements in endovascular treatment over the last two decades, various of treatment strategies along with dedicated devices have been developed to deal with bifurcation aneurysms When it comes to treating more difficult Wide neck bifurcation aneurysms (WNBAs), devices such as the pCONus and pCANvas devices (Phenox, Bochum, Germany), the Pulserider (Pulsar Vascular, Los Gatos, California, USA), and the eCLIPs devices (Evasc Medical Systems Corp.) are used to cover the neck of aneurysm and assist aneurysm coiling. Devices such as the WEB (Microvention, Aliso Viejo, California, USA) and Luna/Artisse (Medtronic, Dublin, Ireland) are utilised to disturb intrasaccular flow and are deployed within the aneurysm dome [3]. With the development of new dedicated low-profile devices such as the Baby Leo and LVIS EVO that can be deployed through low-profile 0.17 in microcatheters, Flow-T stenting technique merged as an advancement approach based on the conventional T-stenting [13]
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