Management Of Aneurysms Research Articles

Pterional vs. lateral supraorbital approach in the management of middle cerebral artery aneurysms: insights from a phantom model study

The pterional approach has traditionally been employed for managing middle cerebral artery (MCA) aneurysms. With potential benefits like reduced surgical morbidity and improved postoperative recovery, the lateral supraorbital approach (LSO) should be considered individually based on aneurysm morphology, location and patient-specific variations of the MCA anatomy, which requires considerable technical expertise traditionally acquired through years of experience. The goal of this study was the development and evaluation of a novel phantom simulator in the context of clinical decision-making in the managmement of MCA aneurysms. For this purpose, high-fidelity simulators inclusive of MCA models with identical M1- and bifurcation aneurysms were manufactured employing 3D reconstruction techniques, additive manufacturing and rheological testings. Medical students, neurosurgical residents, and seasoned neurosurgeons (n = 22) tested and evaluated both approaches. Participants’ performances and progress over time were assessed based on objective metrics. The simulator received positive ratings in face and content validity, with mean scores of 4.9 out of 5, respectively. Objective evaluation demonstrated the model’s efficacy as a practical training tool, particularly among inexperienced participants. While requiring more technical expertise, results of the comparative analysis suggest that the LSO approach can improve clipping precision and outcome particularly in patients with shorter than average M1-segments. In conclusion, the employed methodology allowed a direct comparison of the pterional and LSO approaches, revealing comparable success rates via the LSO approach while reducing operation time and complication rate. Future research should aim to establish simulators in the context of clinical decision making.

From Biomechanical Properties to Morphological Variations: Exploring the Interplay between Aortic Valve Cuspidity and Ascending Aortic Aneurysm.

Background: This research explores the biomechanical and structural characteristics of ascending thoracic aortic aneurysms (ATAAs), focusing on the differences between bicuspid aortic valve aneurysms (BAV-As) and tricuspid aortic valve aneurysms (TAV-As) with non-dilated aortas to identify specific traits of ATAAs. Methods: Clinical characteristics, laboratory indices, and imaging data from 26 adult patients operated on for aneurysms (BAV-A: n = 12; TAV-A: n = 14) and 13 controls were analyzed. Biomechanical parameters (maximal aortic diameter, strain, and stress) and structural analyses (collagen fiber organization, density, fragmentation, adipocyte deposits, and immune cell infiltration) were assessed. Results: Significant differences in biomechanical parameters were observed. Median maximal strain was 40.0% (control), 63.4% (BAV-A), and 45.3% (TAV-A); median maximal stress was 0.59 MPa (control), 0.78 MPa (BAV-A), and 0.48 MPa (TAV-A). BAV-A showed higher tangential modulus and smaller diameter, with substantial collagen fragmentation (p < 0.001 vs. TAV and controls). TAV-A exhibited increased collagen density (p = 0.025), thickening between media and adventitia layers, and disorganized fibers (p = 0.036). BAV-A patients had elevated adipocyte deposits and immune cell infiltration. Conclusions: This study highlights distinct pathological profiles associated with different valve anatomies. BAV-A is characterized by smaller diameters, higher biomechanical stress, and significant collagen deterioration, underscoring the necessity for tailored clinical strategies for effective management of thoracic aortic aneurysm.

Management of renal artery aneurysms: A retrospective study.

Although renal artery aneurysms (RAAs) are rare and often asymptomatic with slow growth, their natural progression and optimal management are not well understood. Treatment recommendations for RAAs do exist; however, they are supported by limited data. A retrospective cohort study was conducted to explore the management of patients diagnosed with an RAA at our institution from January 1st, 2013, to December 31st, 2020. Patients were identified through a search of our radiological database, followed by a comprehensive chart review for further assessment. Data collection encompassed patient and aneurysm characteristics, the rationale for initial imaging, treatment, surveillance, and all-cause mortality. One hundred eighty-five patients were diagnosed with or treated for RAAs at our center during this timeframe, with most aneurysms having been discovered incidentally. Average aneurysm size was 1.40cm (±0.05). Of those treated, the mean size was 2.38cm (±0.24). Among aneurysms larger than 3cm in size, comprising 3.24% of the total cases, 83.3% underwent treatment procedures. Only 20% of women of childbearing age received treatment for their aneurysms. There was one instance of aneurysm rupture, with no associated mortality or significant morbidity. Our institution's management of RAAs over the period of the study generally aligned with guidelines. One potential area of improvement is more proactive intervention for women of childbearing age.

Numerical simulation of endovascular treatment options for cerebral aneurysms

AbstractPredicting the long‐term success of endovascular interventions in the clinical management of cerebral aneurysms requires detailed insight into the patient‐specific physiological conditions. In this work, we not only propose numerical representations of endovascular medical devices such as coils, flow diverters or Woven EndoBridge but also outline numerical models for the prediction of blood flow patterns in the aneurysm cavity right after a surgical intervention. Detailed knowledge about the postsurgical state then lays the basis to assess the chances of a stable occlusion of the aneurysm required for a long‐term treatment success. To this end, we propose mathematical and mechanical models of endovascular medical devices made out of thin metal wires. These can then be used for fully resolved flow simulations of the postsurgical blood flow, which in this work will be performed by means of a Lattice Boltzmann method applied to the incompressible Navier–Stokes equations and patient‐specific geometries. To probe the suitability of homogenized models, we also investigate poro‐elastic models to represent such medical devices. In particular, we examine the validity of this modeling approach for flow diverter placement across the opening of the aneurysm cavity. For both approaches, physiologically meaningful boundary conditions are provided from reduced‐order models of the vascular system. The present study demonstrates our capabilities to predict the postsurgical state and lays a solid foundation to tackle the prediction of thrombus formation and, thus, the aneurysm occlusion in a next step.

Current Indications, Trends, and Long-Term Results of 233 Bypasses to Treat Complex Intracranial Aneurysms: A Location-Specific Analysis.

Advances in endovascular flow diverters have led to a secular shift in the management of brain aneurysms, causing debate on current bypass indications. We therefore sought to investigate the long-term results, current indications, and trends of bypasses for brain aneurysms. We retrospectively reviewed bypasses performed between 2005 and 2022 to treat brain aneurysms. Demographic, clinical, and radiological data were collected till the most recent follow-up. Aneurysm occlusion and graft patency was noted on cerebral angiogram in the immediate postoperative, 3-month, and most recent follow-up periods. Clinical outcomes (modified Rankin scores) and complications were assessed at 3 month and most recent follow-up. Trends in bypass volume and graft patency were assessed in 5-year epochs. Results were dichotomized based on aneurysm location to generate location-specific results and trends. Overall, 203 patients (mean age 50 years, 57% female patients) with 207 cerebral aneurysms were treated with 233 cerebral bypasses with a mean follow-up of 2 years. Fusiform morphology was the most common bypass indication. Aneurysm occlusion on immediate postoperative and final follow-up angiogram was 89% (184/207) and 96% (198/207), respectively. Graft patency rate in the immediate postoperative period and most recent follow-up was 95% (222/233) and 92% (215/233), respectively. Of 207 aneurysms, 5 (2%) recurred. Of 203 patients, 81% (165) patients had modified Rankin scores of 0-2 at the 3-month follow-up and 11 patients died (mortality 5%). Although there was a steady decrease in the bypass volume over the study period, the proportion of bypasses for recurrent aneurysms increased serially. Posterior circulation aneurysms had lower rates of aneurysm occlusion and significantly higher incidence of postoperative strokes and deaths (P = .0035), with basilar artery aneurysms having the worst outcomes. Bypass indications have evolved with the inception of novel flow diverters. However, they remain relevant in the cerebrovascular surgeon's armamentarium, and long-term results are excellent.

Preclinical Direct Endoluminal Assessment of Endothelialization After Flow Diversion With Microangioscopy

Background Direct endoluminal imaging, such as with our previously described microangioscope, is an emerging adjunct in endovascular cerebral aneurysm management that enables clinicians to delineate between thrombi and visualize neoepithelialization after stent placement with high resolution. The present study sought to study flow diversion in vivo under direct endoluminal imaging, and to validate our findings with histopathology. Methods In a rabbit model, we implanted each left common carotid artery with a shielded flow diverter (FD) (Medtronic Pipeline Vantage) and nonshielded FD (Medtronic Pipeline Flex) in the right common carotid artery. We studied 9 animals in 3 groups: (1) no periprocedural antiplatelet therapy, (2) aspirin 81 mg daily, and (3) aspirin 81 mg and clopidogrel 75 mg daily. FD thrombosis, stenosis, malapposition, and neoepithelialization were all evaluated by diagnostic cerebral angiography and microangioscopy after 30 days. Diagnostic cerebral angiography and angioscopic video were analyzed by independent evaluators and compared with histopathologic analysis. Results In the aspirin and dual antiplatelet therapy groups, there were no significant observed differences in stent thrombosis, stenosis, malapposition, or neoepithelialization between the shielded and non‐shielded FD groups. There was significantly more thrombus formation in Group 1. Neointimal thickness as measured by the microangioscope was highly correlated with histology (r = 0.72; P = 0.016). Interrater agreement of microangioscope videos was highest for FD thrombosis and stenosis. Conclusion In‐stent thrombosis, stenosis, malapposition, and neopithelialization demonstrated no significant difference between shielded and non‐shielded FDs. Microangioscopy measurements for neointimal thickness were highly correlated with pathology and may be a helpful adjunct to diagnostic cerebral angiography in FD follow‐up.

366 A Case Study: Application of Personalised External Aortic Root Support to Overcome a Failing Ross Procedure

Abstract Aortic root aneurysms are traditionally treated by aortic root replacement surgery alone or in combination with aortic valve replacement in a Modified Bentall procedure. We present a novel surgical approach using a Personalised External Aortic Root Support (PEARS) in the management of an aortic root aneurysm in a 24-year-old male, initially presenting in infancy with mixed aortic valve disease who underwent a free root Ross procedure in 2010 aged 11. Follow-up cardiac magnetic resonance imaging and transthoracic echocardiography showed mild aortic and pulmonary valve regurgitation with aortic root dilatation (51mm). In 2022, Computerised tomography (CT) exhibited dilation of the Sinus of Valsalva (43mm) and ascending aorta (56 mm). MDT review deemed redo valve-sparing root replacement appropriate as the ascending aorta was &amp;gt;55mm with an approximate 8mm increase over three years. As the young patient wished to avoid warfarinisation and the autograft valve maintained good function, a reduction PEARS was considered. In September 2023, a reduced aortic PEARS graft (80% reduction) was implemented along with a redo of the right ventricle to pulmonary artery conduit. Whilst applying the PEARS it was noted that there was a retroaortic circumflex artery, care was taken to mobilise this aberrant vessel to avoid compression by the graft. Cardiopulmonary bypass and cross-clamp times were 180 and 116 minutes respectively. Intraoperative transoesophageal echocardiography confirmed good bi-ventricular function with no pulmonary regurgitation additionally on postoperative CT the aortic diameter was 38mm. In conclusion, application of a reduction PEARS is a potential alternative to a valve-sparing aortic root replacement method in young patients.

Trans-catheter procedures in the management of renal artery aneurysm

Background The endovascular approach has emerged as the preferred method for managing renal artery aneurysms (RAAs), particularly in cases with intricate anatomical features, as a viable alternative to surgical intervention. Aim The objective of this research was to assess the significance of trans-catheter operations in the treatment of RAAs, with a particular focus on the management of symptoms. Patients and methods This prospective minimally invasive was carried out on 30 patients with RAA aged from 6 to 67 years old, diagnosed by various radiological modalities (ultrasonography, computed tomography, or MRI) and underwent 30 arteriographies for RAA who were managed by Trans-catheter procedures (especially selective embolization with coils). All patients undergo follow-up by clinical assessment, medical imaging, and laboratory investigations. Results Out of the total 28 RAAs that were treated, a significant majority of 93.3% were effectively embolized and showed no symptoms of recurrence during the subsequent follow-up period. One case (3.3%) of RAA did not achieve effective embolization, resulting in failed embolization. Additionally, another case (3.3%) of RAA had recurrence during follow-up despite initial successful closure. Minor issues occurred in seven instances, accounting for 23.3% of the total occurrences, while significant complications were observed in only one instance, representing 3.3% of the total occurrences. Conclusions The endovascular approach is a very safe and successful method for managing RAAs, whether in planned or emergent medical scenarios. This approach preserves renal function and minimizes invasiveness, while also demonstrating low rates of both severe and minor complications.

595 Dilemma in the Management of Saccular Aortic Aneurysms

595 Dilemma in the Management of Saccular Aortic Aneurysms

Surgical Management of Giant Abdominal Aortic Aneurysm in Marfan Syndrome – Case Report and Review of Literature

Surgical Management of Giant Abdominal Aortic Aneurysm in Marfan Syndrome – Case Report and Review of Literature

Microsurgical clipping of unruptured intracranial aneurysms: Clinical and radiological outcomes

Background and objectivesThe prevalence of unruptured intracranial aneurysms is 1–3%. The annual rupture rate increases in patients with multiple aneurysms that presented a previous hemorrhage from another aneurysm. ObjectivesTo evaluate outcomes of clipping unruptured aneurysms, comparing patients with single or multiple aneurysms clipped, describe the complications related to surgery and to identify risk factors predicting an unfavorable outcome. Materials and methodsRetrospective study including patients who underwent clipping of unruptured aneurysms between 2020–2023 at our center. Occlusion rate, complications, and functional outcome were analyzed. Risk factors for poor prognosis are identified using univariate model. Results82 patients with 114 aneurysms were treated with microsurgery. Multiple aneurysms were clipped in 22 patients. A mini-open approach was used in 86,5% of cases. Complete occlusion in angio3D was found in 78.6% of clipped aneurysms. Complication rate was 12.2%, including asymptomatic cases. Mortality was 0%. The probability of 1 point mRS worsening was 7.3% and 2 or more points was 1.2%, with a good functional outcome in 98.9%. Clipping multiple aneurysms, miniopen approaches, or surgery in patients with previous subarachnoid hemorrhage did not increase the risk of complications. Posterior circulation aneurysms surgery increased the risk of ischemia. ConclusionsThe management for unruptured intracranial aneurysms should be multimodal and based on clinical and radiological outcomes. Microsurgery is a valid and safe technique, with 0% mortality and bleeding rates and 1,2% rate of severe morbidity in our series.

The gender divide in abdominal aortic aneurysm management: A call for equitable screening practices

The gender divide in abdominal aortic aneurysm management: A call for equitable screening practices

Critical insights into the diagnosis and management of post-myocardial infarction left ventricular aneurysm of the inferior wall: a case report and brief review.

Critical insights into the diagnosis and management of post-myocardial infarction left ventricular aneurysm of the inferior wall: a case report and brief review.

Innovation in pathogenesis and management of aortic aneurysm.

Aortic aneurysm (AA) refers to the persistent dilatation of the aorta, exceeding three centimeters. Investigating the pathophysiology of this condition is important for its prevention and management, given its responsibility for more than 25000 deaths in the United States. AAs are classified based on their location or morphology. various pathophysiologic pathways including inflammation, the immune system and atherosclerosis have been implicated in its development. Inflammatory markers such as transforming growth factor β, interleukin-1β, tumor necrosis factor-α, matrix metalloproteinase-2 and many more may contribute to this phenomenon. Several genetic disorders such as Marfan syndrome, Ehler-Danlos syndrome and Loeys-Dietz syndrome have also been associated with this disease. Recent years has seen the investigation of novel management of AA, exploring the implication of different immune suppressors, the role of radiation in shrinkage and prevention, as well as minimally invasive and newly hypothesized surgical methods. In this narrative review, we aim to present the new contributing factors involved in pathophysiology of AA. We also highlighted the novel management methods that have demonstrated promising benefits in clinical outcomes of the AA.

Variability patterns in dual antiplatelet therapy following endovascular repair of intracranial aneurysms: Insight into regimen heterogeneity and the need for a consensus.

This comprehensive review delves into the evolving field of neurointervention for intracranial aneurysms, exploring the critical adjunct of Dual Antiplatelet Therapy (DAPT) to endovascular coiling, stent-assisted coiling (SAC), flow-diversion stents, and flow-disruption (intrasaccular) devices. Despite growing evidence supporting the success of DAPT in reducing thromboembolic events, the lack of consensus on optimal regimens, doses, and duration is evident. Factors contributing to this variability include genetic polymorphisms affecting treatment response and ongoing debates regarding the clinical significance of hemorrhagic complications associated with DAPT. This review analyzes pre- and post-procedural antiplatelet usage across various interventions. The imperative lies in ongoing research to define optimal DAPT durations, ensuring a nuanced approach to the delicate balance between thrombosis and hemorrhage in intracranial aneurysm management.

Flow Diverter

The flow diverter is a relatively new but revolutionary technology in the realm of Endo vascular management of complex cerebral aneurysms. The traditional approach in the past has been stent deployment assisted coil embolisation. However, this maybe associated with partial occlusion or late recanalisation of the aneurysm. While planning the procedure for any cerebral aneurysm, the neurosurgeon needs to consider the morphology of the intracranial aneurysm as well as its proximity to the vascular branches and perforators. Giant (&gt;25mm diameter), large (&gt;10mm diameter), wide necked and fusiform aneurysms are the most challenging ones to treat.(1) The flow diverter works on the following principles (a)the stent deployed disrupts the blood flow from the parent vessel into the aneurysm (b) the stent works like a scaffolding for the growth of endothelial cells and separates the aneurysm from the parent vessel and gradually blocks it.(2) It is inducing endoluminal reconstruction in contrast to endosaccular filling in the older procedures. Moreover, it spares the origin of perforators from getting occluded. The sac gradually shrinks and finally collapses. This has excellent outcomes in comparison to conventional procedures for large or wide-necked aneurysms. This fascinating, innovative technology is associated with lesser complications and higher success rates. It is backed by landmark trials including the ‘Pipeline Embolisation Device for the Intracranial treatment of Aneurysms (PITA)’ trial and the ‘Pipeline for Uncoilable or Failed Aneurysms (PUFs) trial.(1) The device has thrombogenic potential and the patient needs to be on anti platelet therapy to prevent thromboembolism and late in-stent stenosis. A diversified complex case of multiple giant internal carotid artery aneurysms managed by latest phenomenal advanced technique of flow diversion in Neurointervention spectrum, that is, FLOW DIVERTER (FD). This young lady presented with sudden onset right sided complete opthalmoplegia and headache. Her investigations revealed bilateral ICA large to giant aneurysms. Considering all aspects of her case, she was counselled and planned for FD placement with some coils.

Pharmaceutical Modulation of Intracranial Aneurysm Development and Rupture.

Management of intracranial aneurysms (IAs) is determined by patient age, risk of rupture, and comorbid conditions. While endovascular and microsurgical interventions offer solutions to mitigate the risk of rupture, pharmacological management strategies may complement these approaches or serve as alternatives in appropriate cases. The pathophysiology of IAs allows for the targeting of inflammation to prevent the development and rupture of IAs. The aim of this review is to provide an updated summary of different pharmaceutical management strategies for IAs. Acetylsalicylic acid and renin-angiotensin-aldosterone system (RAAS) inhibitor antihypertensives have some evidence supporting their protective effect. Studies of selective cyclooxygenase-2 (COX-2) inhibitors, statins, ADP inhibitors, and other metabolism-affecting drugs have demonstrated inconclusive findings regarding their association with aneurysm growth or rupture. In this manuscript, we highlight the evidence supporting each drug's effectiveness.

Interpretation of Chinese guideline for the clinical management of patients with unruptured intracranial aneurysms (2024)

With the popularization of cerebrovascular imaging technology, the clinical detection rate of unruptured intracranial aneurysm (UIA) is increasing. UIA has a low risk of rupture, but once ruptured, it can seriously affect human health. The treatment of UIA is highly controversial and has attracted widespread clinical attention. The Society of Neurosurgery of the Chinese Medical Association, the Society of Cerebrovascular Surgery of the Chinese Stroke Association, the National Center for Neurological Diseases, and the National Center for Clinical Research on Neurological Diseases jointly formulate "Chinese guideline for the clinical management of patients with unruptured intracranial aneurysm management (2024)", which adopts a modular format, highlighting management recommendations and indicating current research deficiencies and future research directions. It provides comprehensive clinical management recommendations on UIA epidemiology, population screening, clinical imaging and diagnosis, rupture risk assessment, treatment decisions and choices, postoperative follow-up, and long-term management. The evidence sources are divided into the Chinese population and other populations, which helps guide clinical practice in China.

The Outcome after Surgical Management of Ruptured Versus Unruptured Anterior Circulation Aneurysms.

The present article aimed to review the safety and the clinical and radiological outcomes of clipped ruptured and unruptured anterior circulation aneurysms. The study investigated the relative articles involving the outcome after surgical management of ruptures versus unruptured anterior circulation aneurysms through electronic databases from January 1980 to January 2023. The primary outcomes were mortality and modified Rankin scale (mRS) >3. Information on mRS >3 was found in six articles totalizing 2096 patients, of whom 130 subjects had ruptured and unruptured aneurysms. Data about mortality was provided by eight studies totalizing 2454 participants, of whom 140 subjects had ruptured and unruptured aneurysms. The current meta-analysis indicates that surgical clipping is a safe procedure for both ruptured and unruptured aneurysms of anterior circulation.

Intracranial Aneurysms Managed by Parent Artery Reconstruction Using Tubridge Flow Diverter study: 1-year outcomes.

Previous randomized controlled trials have reported a significantly higher occlusion rate of large and giant aneurysms when utilizing the Tubridge flow diverter (FD). In the present trial, the safety and efficacy of the Tubridge FD in treating unruptured internal carotid artery (ICA) or vertebral artery (VA) aneurysms were assessed in a real-world setting. The Intracranial Aneurysms Managed by Parent Artery Reconstruction Using Tubridge Flow Diverter (IMPACT) study is a prospective, multicenter, single-arm clinical trial assessing the efficacy of the Tubridge FD in the management of unruptured aneurysms located in the ICA or VA. The primary endpoint was the complete occlusion (Raymond-Roy class 1) rate at the 1-year follow-up. The secondary endpoints included the technical success rate, the successful occlusion rate of the aneurysm, which is the degree of aneurysm embolization scored as Raymond-Roy class 1 or 2, major (> 50%) in-stent stenosis, and incidence of disabling stroke or neurological death associated with the target aneurysms. This study included 14 interventional neuroradiology centers, with 200 patients and 240 aneurysms. According to angiographic core laboratory assessment, 205 (85.4%) aneurysms were located in the ICA, 34 (14.2%) in the VA, and 1 (0.4%) in the middle cerebral artery. Additionally, 189 (78.8%) aneurysms were small (< 10 mm). At the 12-month follow-up, the total occlusion rate was 79.0% (166/210, 95% CI 72.91%-84.34%). Additionally, the occurrence of disabling stroke or neurological death related to the specified aneurysms was 1% (2/200). The 1-year results from the IMPACT trial affirm the safety record of use of the Tubridge FD in the treatment of intracranial aneurysms in real-world scenarios. These results reveal low morbidity and mortality rates of 3.5% and 1.5%, respectively. Furthermore, they provide evidence of the effectiveness of the Tubridge FD, as demonstrated by the complete occlusion achieved in 166 of 210 (79%) cases.