Rate Of Complete Aneurysm Occlusion Research Articles

The safety and efficiency of SMART coil for brain aneurysm: A systematic review and meta-analysis.

The SMART coil system is a relatively new generation of embolic coils consisting of a bare platinum coil, a detachment pusher, and a detachment handle. This study investigated the safety and efficiency of the SMART coil system in treating cerebral aneurysms. PubMed/Medline, Embase, Web of Science, and Scopus were searched until October, 1st 2023. Non-English language, non-human studies, and non-original studies were excluded. A total of 7 studies were included. The results of our study reflected complete aneurysm occlusion (mRRC1) rate of 45% (95% CI, 0.35-0.56), neck remnant aneurysm (mRRC2) rate of 36% (95% CI, 0.30-0.42), and residual aneurysm (mRRC3) rate of 22% (95% CI, 0.12-0.38) during post-procedural assessment. Moreover, considering longest follow-up, our study showed complete aneurysm occlusion (mRRC1) rate of 66% (95% CI, 0.43-0.84), neck remnant aneurysm (mRRC2) rate of 27% (95% CI, 0.13-0.49), and residual aneurysm (mRRC3) rate of 9% (95% CI, 0.04-0.20). In addition, recanalization and retreatment rates were reported 10% (95% CI, 0.06-0.17) and 9% (95% CI, 0.06-0.12), respectively. The rates of adverse and serious adverse events were 9% (95% CI, 0.07-0.10) and 6% (95% CI, 0.01-0.22), respectively. Three studies reported a stroke rate which was 2% (95% CI, 0.00-0.13), and five studies reported a mortality rate which was 6% (95% CI, 0.03-0.11). The findings suggested that the SMART coil can be a safe and efficient treatment in patients with intracranial aneurysms compared to other available treatment methods.

Anterior circulation location-specific results for stent-assisted coiling – carotid versus distal aneurysms: 1-year outcomes from the Neuroform Atlas Stent Pivotal Trial

BackgroundThe Neuroform Atlas Stent System is an established treatment modality for unruptured anterior and posterior circulation intracranial aneurysms. Location-specific results are needed to guide treatment decision-making. However, it is unclear...

Lower-Ischemic-Risk Profile of Coated Flow Redirection Endoluminal Device X Compared With Uncoated Flow Redirection Endoluminal Device Flow Diverter in the Treatment of Unruptured Intracranial Aneurysms.

Flow Redirection Endoluminal Device (FRED) X is a new generation flow diverter with an antithrombotic surface coating. This study compares the procedural safety and short-term efficacy of FRED X with its uncoated predecessor, the FRED. Patients treated with FRED and FRED X devices for unruptured aneurysms between 2013 and 2023 at 3 neurovascular centers were retrospectively reviewed. The procedural ischemic event rate was the safety end point, and the complete aneurysm occlusion rate at 1 year was the efficacy end point. Multivariable regression adjustment and 1:1 propensity score matching were performed to control for potential confounding. The FRED X group (137 patients) had a higher prevalence of recurrent and bifurcation aneurysms and fewer aneurysms with branch involvement than the FRED X group (156 patients). The ischemic event rate was lower in FRED X (1/156 [0.6%]) than in FRED (7/137 [5.1%]), which was significant after multivariable adjustment (odds ratio: 8.8, 95% CI: 1.1-72.7, P = .04), and tended to be significant in the propensity score analysis (P = .07). Morbidity was comparable between FRED (2.2%) and FRED X (0%, P = .10). The complete occlusion rates of FRED vs FRED X were 73/117 (62.4%) vs 39/54 (72.2%) aneurysms at 6 months (P = .21) and 52/74 (70.3%) vs 27/37 (73.0%) at 12 months (P = .77). Hemorrhagic complications, in-stent stenosis, and clinical events during follow-up and retreatments were not significantly different between groups. This study indicates an improved ischemic risk profile of FRED X while maintaining a favorable efficacy profile, warranting further study and translation into clinical use.

Performance assessment of the Surpass Evolve flow diverter for the treatment of intracranial aneurysms: A systematic review and meta-analysis.

The Surpass Evolve (SE) has emerged as a promising alternative treatment from the flow diverter series. The utilization of the SE has gradually increased, however, there is a scarcity of comprehensive data on the solidity of this technology in the endovascular treatment of intracranial aneurysms (IAs). This meta-analysis aimed to evaluate the safety and effectiveness of the SE flow diverter. A systematic literature search from inception to April 2024 was conducted across five databases for studies involving IAs treated with the SE. The primary effectiveness outcome was the proportion of complete aneurysm occlusion at the final follow-up, and the primary safety outcome comprised a composite of early and delayed complications. Subgroup analyses based on aneurysm size, anatomical location, and rupture status were also conducted. Our analysis included nine studies with 645 patients and 722 IAs. Effectiveness outcomes revealed an overall complete aneurysm occlusion rate of 69% (95% confidence interval (CI) = 58%-78%; I2 = 72%) and a favorable aneurysm occlusion rate of 91% (95% CI = 82%-96%; I2 = 49%). Safety outcomes demonstrated an overall complications rate of 6% (95% CI = 3%-12%; I2 = 66%), with an early complications rate of 6% (95% CI = 4%-11%; I2 = 0%), and a delayed complications rate of 0% (95% CI = 0%-7%; I2 = 0%). Our findings suggest a favorable outcome with a high rate of complete aneurysm occlusion at the last follow-up, with acceptable rates of neurological complications. Future research efforts should focus on larger, prospective studies with standardized outcome measures to further elucidate the clinical utility of the SE flow diverter in the management of IAs.

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

ObjectTreatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms. MethodsBetween January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated. ResultsAll 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months. ConclusionsEndovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Clinical Outcome of Pipeline Embolization Device with and without Coil to Treat Intracranial Aneurysm: A Systematic Review and Meta-Analysis.

The use of a Pipeline Embolization Device (PED) in combination with coils (PEDC) to treat intracranial aneurysms remains unclear as to whether it offers significant benefits for the patients since the results have varied. This study aimed to investigate the clinical outcome of PEDC compared to PED in treating intracranial aneurysms. We systematically searched the articles from PubMed, Web of Science, and the Cochrane Library databases published before January 25, 2024. We selected studies comparing PEDC vs. PED to treat intracranial aneurysms. Patients treated with PEDC but using dense coiling were excluded from the study. The clinical outcomes observed in this meta-analysis were intraprocedural complications, postoperative complications (stenosis, stroke, hemorrhage, mortality), favorable outcome (mRS ≤ 2), complete occlusion rate, and retreatment rate. Forest plot was used to analyze pooled Odds Ratio (OR) of clinical outcomes. A total of 3001 subjects from nine observational studies were included. PEDC was mainly used to treat larger aneurysms. PEDC has a significantly higher complete occlusion rate at 6 months [OR= 2.66, 95% CI(1.26, 5.59), p= 0.01], a lower retreatment rate [OR= 0.18, 95% CI(0.05, 0.07), p= 0.010], higher stroke-related complications [OR= 1.66, 95% CI(1.16, 2.37), p= 0.005], and higher hemorrhage-related complications [OR= 1.98, 95% CI(1.22, 3.21), p = 0.005]. There was no significant difference in intraprocedural complications, stenosis-related complications, mortality, favorable outcomes, and complete occlusion at the end of the study. No randomized controlled trials have been performed comparing PEDC and PED. Considering that all the included studies were observational, the patients' baseline characteristics were not completely balanced. This meta-analysis study showed that PEDC in large intracranial aneurysms induces a faster complete occlusion rate at 6 months and a lower retreatment rate. However, it increases the risk of stroke-related postoperative complications, and the faster complete aneurysm occlusion rate found in this study did not correlate with a reduction in long-term aneurysm or distal artery ruptures. Thus, this study suggests the need to find a better strategy to improve long-term hemorrhage-related complications in large intracranial aneurysms. F = female; FDDs = flow-diverter devices; M = male; NOS = Newcastle-Ottawa Scale; PED = pipeline embolization device; PEDC = pipeline embolization device in combination with coils.

Pure arterial malformation of the fetal PCA treated with flow diverter stent-case report and literature review.

Thirty-three-year-old female underwent diagnostic work-up for chronic headaches. Cerebral DSA on the right side showed fetal posterior cerebral artery (PCA) with unusually shaped arterial malformation on its proximal part. Malformation was formed by multiple convolutions and loops with no arteriovenous shunting. During endovascular procedure, flow diverter stent was placed in the right C6 segment. Patient was put on double antiaggregation therapy. Four weeks after procedure, patient was admitted to ER with signs of dyphasia. No recent ischemic lesions were detected on emergent magnetic resonance. Dyphasia resolved spontaneously. On follow-up magnetic resonance angiography 5 years after the procedure, main portion of malformation has diminished with slightly filling of posterior part supplied by right P1. Here, reported finding is consistent with previously described pure arterial malformation (PAM). Main intention of our treatment was to induce malformation remodeling with flow diverter placement. Two main risks arise when using flow diverters on fetal PCA region. Firstly, there is possibility of occluding fetal PCA alongside malformation. On the contrary, high flow through fetal PCA could hinder malformation thrombosis. Some case series reported high rate of fetal PCA occlusion without ischemic sequelae in the PCA teritory. Others consider flow diverters highly ineffective treatment for the fetal PCA aneurysms due to low rate of complete aneurysm occlusion. We presented first reported case in which flow diverter was used to treat PAM. Slow malformation thrombosis leaves enough time for collateral circulation to recruit and supply territory of the vessel affected by the malformation.

Pipeline versus non-pipeline flow diverter treatment for M1 aneurysms: A systematic review and meta-analysis.

The flow diversion treatment of aneurysms located distal to the Circle of Willis has recently increased in frequency. We conducted a systematic review and meta-analysis of the clinical and radiological outcomes of flow diverter (FD) embolization in treating M1 aneurysms. PubMed, Web of Science, Ovid Medline, Ovid Embase, and Scopus were searched up to May 2024 using the Nested Knowledge platform. We included studies assessing the long-term clinical and radiological outcomes for M1 aneurysms. Results of FDs classified as Pipeline Embolization Devices (PED) versus other types of FDs. Angiographic occlusion rates, ischemic and hemorrhagic complications, and favorable clinic outcomes were included. All data were analyzed using R software version 4.2.2. Thirteen studies with 112 total patients (58 patients for PED and 54 patients for other FD devices) were included in our meta-analysis. The overall adequate (complete + near-complete) occlusion rates were 85.1%. The complete occlusion rate was higher with PED than with other FD devices (72.9% PED and 41.6% for non-PED FDs, respectively, p-value <.01). The ischemic complications were 9.9% and 9.0% for the PED and non-PED groups, respectively (p-value = .89). The overall modified Rankin Scale 0-2 was 100% for the non-PED and 97.1% for the PED group (p-value = .51). In-stent stenosis rate was 7.5% for PED devices compared to 2.6% in the non-PED group (p-value = .35). This relatively small meta-analysis showed high rates of adequate and complete occlusion in FD treatment of M1 segment aneurysms, with favorable safety profiles. PEDs were associated with higher rates of complete aneurysm occlusion compared to other types of FDs.

Endovascular Coiling of Ruptured Tiny Saccular Intracranial Aneurysms: A Systematic Review and Meta-Analysis

BackgroundThe safety and efficacy of endovascular coiling of ruptured tiny saccular intracranial aneurysms (IAs) (≤ 3mm) remains unknown. MethodsA comprehensive search of PubMed, Embase, Web of Science, and Scorpus databases up to November 15, 2023 was performed. Pooled prevalence was calculated for occlusion rates, recanalization, retreatment, long-term favorable outcome, and procedure-related complications and mortality. Pooled odds ratios were calculated to compare these outcomes between coiling and stent-assisted coiling (SAC). Results42 studies with 2,174 ruptured tiny saccular IAs treated with coiling were included. The follow-up complete aneurysm occlusion rate was 83.9% (95% CI: 77.2–88.9%). The rates of recanalization and retreatment were 7.7% (95% CI: 5.7–10.2%) and 5.8% (95% CI: 4.5–7.5%). The range of median Hunt and Hess grades was 1.4–2.9 and the favorable outcome rate was 85.6% (95% CI: 81.1–89.2%). The rates of thromboembolism, intraprocedural rupture, and mortality were 4.6% (95% CI: 3.6–5.8%), 5.4% (95% CI: 4.1–7.0%), and 5.6% (95% CI: 4.4–7.2%), respectively. Comparison of coiling and SAC revealed no significant difference, except for a higher likelihood of follow-up complete aneurysm occlusion in SAC (odds ratio [OR] 0.37, 95% CI: 0.17–0.80) and recanalization in the coiling (OR, 3.21 [95% CI, 1.37–7.51]). ConclusionsOur meta-analysis demonstrates that coiling for ruptured tiny saccular IA is a feasible, effective, and safe approach that is associated with favorable clinical outcomes in both the short and long term for patients with mild to moderate Hunt and Hess grades.

Flow-Diverting Devices in the Treatment of Vertebral Artery Aneurysms: Insights into Efficacy and Safety from a Systematic Review and Meta-analysis.

The objective of this study is to conduct a systematic review and meta-analysis aimed at evaluating the efficacy and safety of flow-diverting devices (FDs) treatment for intracranial vertebral artery (VA) aneurysms. We searched PubMed, Web of Science, OVID, and Embase for English-language studies up to February 2024 and included clinical studies on FD treatment of intracranial VA aneurysms. Sensitivity analysis evaluated outcome stability. Of 2273 articles, 29 studies involving 541 aneurysms treated with FDs were included. Based on the Methodological Index for Non-Randomized Studies (MINORS), six were high-quality and 23 moderate quality. FD treatment showed a 95% rate of favorable clinical outcomes (95% CI, 89-99%), 81% (95% CI, 74-88%) complete aneurysmal occlusion, 4% (95% CI, 2-7%) ischemic complication incidence, 1% (95% CI, 0-3%) hemorrhagic complication incidence, 95% (95% CI, 87-100%) posterior inferior cerebellar artery (PICA) preservation, and 6% (95% CI, 3-10%) in-stent stenosis or occlusion across clinical and angiographic follow-up periods of 13.62months (95% CI, 10.72-16.52) and 11.85months (95% CI, 9.36-14.33), respectively. Subgroup analyses, based on a 12-month angiographic follow-up threshold, indicated no statistically significant differences in rates of complete aneurysm occlusion, PICA preservation, or in-stent stenosis or occlusion incidence (p > 0.05) between subgroups. Moreover, significant differences were observed in clinical and angiographic outcomes between ruptured and unruptured aneurysms, particularly in hemorrhagic complications (p < 0.05), without significant disparity in ischemic complications (p > 0.05). The results' stability was confirmed via sensitivity analysis. FDs treatment for VA aneurysms is efficacious and safe, offering high rates of positive clinical and angiographic outcomes with minimal complications, underscoring FDs' viability as a treatment option for VA aneurysms. The study was registered with PROSPERO (registration number: CRD42024499894).

Treatment of basilar artery aneurysms with two braided stents: Two centers experience of low-profile visualized intraluminal support stents versus Pipeline flow diverters.

Both low-profile visualized intraluminal support (LVIS)stents and Pipeline flow diverters (FDs) are therapeutic strategies for basilar artery (BA) aneurysms, but they have not been directly compared. A total of 132 consecutive patients with 139 BA aneurysms treated with either LVIS stent or Pipeline FDs were analyzed. Propensity score matching (PSM) was used to control for age, sex, hypertension, aneurysm size, shape, location, and duration of follow-up. The treatment results of these two braided stents were compared. LVIS stent was placed in 88 (63.3%) and Pipeline FDs in 51 (36.7%) procedures. Patients with Pipeline FDs tended to be younger and have less hypertension, whereas aneurysms had larger aneurysm size. After PSM, similar complete or near-complete occlusion rates (76.7% vs 73.3%, p = .766) and favorable functional outcomes (86.7% vs 90.0%, p = 1) were achieved in patients treated with LVIS stents and Pipeline FDs, respectively. Further comparisons were conducted at three different locations (basilar apex/basilar trunk/vertebrobasilar artery junction [VBJ]) separately, and the results showed a higher complete or near-complete aneurysm occlusion rate after Pipeline FD treatment than LVIS treatment (86.7% vs 59.2%, p = .012) only at VBJ, where a particularly high proportion of non-saccular shape (70.9%) and a male preponderance were noted. Both braided stents were effective in the treatment of BA aneurysms, with good occlusion rates and favorable functional outcomes. Pipeline FD achieved a particularly higher aneurysm occlusion rate than LVIS stent at VBJ, where lesions often require reconstruction of the diseased vessel.

Evaluation of the EMBOPIPE flow diverter device: in vivo and in vitro experiments

BackgroundAlthough flow diverter device (FDD) has brought revolutionized advances in endovascular treatment of intracranial aneurysms, it also presents considerable drawbacks as well, as the innovation for novel device has never stopped. This preclinical research aims to evaluate the safety and efficacy of a newly developed FDD, the EMBOPIPE, through in vivo and in vitro experiments.MethodsAneurysms were induced in 20 New Zealand white rabbits which were randomized to three follow-up groups according to the time elapsed after EMBOPIPE implantation (28, 90, and 180 days). Additional EMBOPIPEs were implanted in the abdominal aorta to cover the renal artery in nine rabbits. Angiography was performed immediately after device placement in all groups. Aneurysm occlusion, patency of renal arteries, and pathological outcomes were assessed. For the in vitro experiments, we measured the thrombogenic potential of EMBOPIPEs (n = 5) compared with bare stents (n = 5) using the Chandler loop model. Evaluation indicators were the platelet counts, macroscopic observations and scanning electron microscopy.ResultsEMBOPIPEs were successfully deployed in 19 of 20 rabbit aneurysms (95.0%). The rates of complete or near-complete aneurysm occlusion were 73.3%, 83.3%, and 100% in the 28-, 90-, and 180-day groups, respectively. All renal arteries covered by EMBOPIPEs remained patent, and the mean difference in renal artery diameter before and after the device placement in the three groups was 0.07 mm, 0.10 mm, and 0.10 mm, respectively (p = 0.77). Renal pathology was normal in all cases. The pathological findings of the aneurysms were as follows: thickened and adequate neointimal coverage at the aneurysm neck, minimal inflammatory response, near-complete smooth muscle cell layer, and endothelialization along the device. In vitro experiments showed that the platelet counts were significantly higher in EMBOPIPE blood samples than in bare stent samples and that platelet adhesion to the device was lower in the EMBOPIPE stent struts compared with bare stent struts through macroscopic observations and scanning electron microscopy.ConclusionsThe EMBOPIPE can achieve high rates of aneurysm occlusion while maintaining excellent branch artery patency. It exhibited wonderful pathological results. This novel device with phosphorylcholine surface modification could reduce platelet thrombus attached to the stent struts.

Woven EndoBridge versus stent-assisted coil embolization for the treatment of ruptured wide-necked aneurysms: A multicentric experience.

The potentially higher risk of hemorrhagic complications is of concern in stent-assisted coiling (SAC) of ruptured wide-necked intracranial aneurysms (IAs). The Woven EndoBridge (WEB) is considered an appealing alternative since antiplatelet therapy is not required. Herein, we aimed to compare the safety and effectiveness of WEB vs. SAC for the treatment of ruptured wide-necked IAs. This was an international cross-sectional study of consecutive patients treated for ruptured wide-neck IAs with WEB or SAC at four high-volume neurovascular centers between 2019 and 2022. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow-up and functional status at last follow-up. Safety outcomes included periprocedural hemorrhagic/ischemia-related complications. One hundred five patients treated with WEB and 112 patients treated with SAC were included. The median procedure duration of endovascular treatment was shorter for WEB than for SAC (69 vs. 76 min; p = 0.04). There were no significant differences in complete aneurysm occlusion rates (SAC: 64.5% vs. WEB: 60.9%; adjusted OR [aOR] = 0.70; 95%CI 0.34-1.43; p = 0.328). SAC had a significantly higher risk of complications (23.2% vs. 9.5%, p = 0.009), ischemic events (17% vs. 6.7%, p = 0.024), and EVD hemorrhage (16% vs. 0%, p = 0.008). The probability of procedure-related complications across procedure time was significantly lower with WEB compared with SAC (aOR = 0.40; 95%CI 0.20-1.13; p = 0.03). WEB and SAC demonstrated similar obliteration rates at follow-up when used for embolization of ruptured wide-necked IAs. However, SAC showed higher rates of procedure-related complications primarily driven by ischemic events and higher rates of EVD hemorrhage. The overall treatment duration was shorter for WEB than for SAC.

Correlation of Flow Diverter Malapposition at the Aneurysm Neck with Incomplete Aneurysm Occlusion in Patients with Small Intracranial Aneurysms: A Single-Center Experience.

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. 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. 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. 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.

Safety and efficacy of the pipeline embolization device for treatment of small vs. large aneurysms: a systematic review and meta-analysis.

Flow diversion with the pipeline embolization device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (≥ 1year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (< 10mm) versus large (10-25mm) aneurysms at long-term following treatment with PED. A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We conducted a comprehensive search of English language databases including Ovid MEDLINE and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Our analysis included 19 studies with 1277 patients and 1493 aneurysms. Of those, 1378 aneurysms met our inclusion criteria. The mean age was 53.9years, and most aneurysms were small (89.75%; N = 1340) in women (79.1%; N = 1010). The long-term occlusion rate was 73% (95%, CI 65 to 80%) in small compared to 84% (95%, CI 76 to 90%) in large aneurysms (p < 0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3 to 9%) in small compared to 7% (95%, CI 4 to 13%) in large aneurysms (p = 0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p = 0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. The long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.

Early clinical experience with the new generation Pipeline Vantage flow diverter in the treatment of unruptured saccular aneurysms using short-term dual antiplatelet therapy.

The Pipeline Vantage flow diverter with Shield technology (PV) used in this study is a 4th-generation flow diverter (FD) designed to reduce thrombogenicity, promote endothelialization of the implant and increase efficiency in achieving aneurysm closure. In this study, we report the aneurysm occlusion rate, complication rate and clinical outcome with short-term dual antiplatelet therapy (DAPT) in the treatment of unruptured intracranial saccular aneurysms using the PV. We retrospectively identified patients treated between September 2021 and January 2023 with the PV and subsequently underwent short-term DAPT for 3 months. Patient and aneurysm characteristics, peri- and post-procedural complications, clinical outcomes and the grade of aneurysm occlusion were documented. Thirty patients with 32 aneurysms were treated. Successful FD implantation was achieved in all cases (100%). No periprocedural complications were documented. The overall symptomatic complication rate was 10% and the neurologic, treatment-related symptomatic complication rate was 6.6%. Only one symptomatic complication (3.3%) was device-related. Permanent clinical deterioration occurred in 2/30 patients (6.6%), leading to deterioration of the mRS within the first 3 months after treatment. No mortality was documented. The rate of complete aneurysm occlusion after 3 months and after a mean imaging follow-up of 9.9 months was 65.6% and 75%, respectively. Implantation of the PV for the treatment of saccular intracranial aneurysms achieves a good aneurysm occlusion rate with a low rate of complications. In addition, the use of short-term DAPT after PV implantation appears to be safe.

Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience. An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion. Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications. Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.

Early Termination versus Standard Regimen Duration of Dual Antiplatelet Therapy in Intracranial Aneurysm Patients Treated With Pipeline Embolization Device Flex With Shield Technology: Preliminary Experience of 3 U.S. Centers

Pipeline Flex Embolization Device with Shield Technology (PED-Shield) is a third-generation flow diverter with reduced thromboembolic potential. However, safety profile and dual antiplatelet therapy (DAPT) recommendations with PED-Shield is not well -established. We aim to assess the safety and complication profile with early termination of DAPT with use of PED-Shield. Databases of 3 high-volume cerebrovascular centers were retrospectively reviewed. We identified patients with unruptured and ruptured intracranial aneurysms treated with PED-Shield. Patient demographics, aneurysm characteristics, complications, and angiographic outcomes were extracted. All patients who had early termination of DAPT, defined as <180 days, as well as standard duration were included. A total of 37 patients, totaling 37 aneurysms, had early termination of DAPT and 24 patients with 24 aneurysms received standard duration (>180 days) of DAPT. There was no difference in pre-procedural DAPT regimens between the groups (P= 0.503). Following DAPT termination, o1ne major thromboembolic complication was observed in the early termination group while no major or minor thromboembolic or hemorrhagic complication was noted in the standard duration group. Time of angiographic follow-up was not statistically different (P= 0.063) between the early termination (343 days, interquartile range [IQR] 114-371 days) and the standard duration (175 days, IQR 111-224.5 days) groups. There were no statistically significant differences in complete aneurysm occlusion (P= 0.857), residual neck (P= 0.582), and aneurysm remnant (P= 0.352) rates between the groups on angiography. Early termination of DAPT proves safe after PED-Shield treatment of intracranial aneurysms with comparable complete occlusion rates.

Impact of branch arteries on efficacy of endoluminal flow diverters: Insights from posterior communicating artery aneurysms.

Flow diverter treatment may inevitably require jailing of the branch vessels. While the patency of covered branch arteries and associated safety risks have been a topic of substantial interest, the question of whether the characteristics of branch vessels affect flow diversion's efficacy remains unanswered. In this study, we aimed to assess the impact of branch arteries on the efficacy of endoluminal flow diverters, specifically focusing on posterior communicating artery (Pcomm) aneurysms. Following PRISMA guidelines, we systematically searched the MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane databases with predefined keywords. Studies providing data for flow diversion outcomes in Pcomm aneurysms were included. Outcomes of interest included complete and adequate aneurysm obliteration, ischemic and hemorrhagic complications, and Pcomm occlusion in the follow-up period. A random or fixed effects model was used to calculate the odds ratios (ORs) and pooled event rates with their corresponding confidence intervals (CI). The overall complete and adequate aneurysm occlusion rates were 72.25% (95% CI: 64.46-78.88%) and 88.37% (95% CI: 84.33-92.6), respectively. Fetal-type Pcomm aneurysms had significantly lower complete aneurysm occlusion rates than the nonfetal-type Pcomm aneurysms (OR: 0.12, 95% CI: 0.05-0.29). Overall ischemic and hemorrhagic complication rates were 2.62% (95% CI = 0.71-5.32) and 0.71% (95% CI: 0-2.24), respectively. There were no significant associations between Pcomm morphology and complications (OR: 3.61, 95% CI = 0.42-31.06 for ischemic complications and OR: 2.31, 95% CI = 0.36-14.6 for hemorrhage). Overall Pcomm occlusion rate was 32.04% (95% CI = 19.96-47.13), and the Pcomm patency was significantly lower in nonfetal-type Pcomm aneurysms (OR: 0.10, 95% CI = 0.02-0.44). Our meta-analysis suggests that flow diversion is a safe treatment option for Pcomm aneurysms, regardless of fetal-type Pcomm morphology. However, on the other hand, our findings indicate that Pcomm anatomy or the presence of jailed large branches can affect the efficacy of flow diverter treatment.

Flow Diverter Performance in Aneurysms Arising From the Posterior Communicating Artery: A Systematic Review and Meta-Analysis.

Flow diverters (FDs) have demonstrated a safe and effective profile. However, the use of FDs for posterior communicating artery (PComA) aneurysms remains controversial. To evaluate the safety and effectiveness of FDs for PComA aneurysms using a systematic review and meta-analysis of the literature. We performed a systematic search from inception until June 2022 for flow diversion in PComA aneurysms. Primary effectiveness was the rate of complete aneurysm occlusion defined by Raymond-Roy class 1. Primary safety outcomes were treatment-related ischemic/hemorrhagic (composite) events causing morbidity and mortality. Secondary safety was PComA patency at follow-up. Random-effects meta-analyses were used to calculate proportions, and statistical heterogeneity was assessed. A total of 13 studies with 397 patients harboring 403 aneurysms were included. Mean age was 48 years, and the mean aneurysm size was 5.3 mm. Most aneurysms were unruptured (65%). Complete occlusion at final follow-up was 73% (CI 66%-79%), and adjunctive coils were used in 10% of aneurysms. Retreatment rate was 2% (CI 0%-9%). The primary safety composite outcome was 4% (CI 3%-7%), and mortality was 1%. PComA patency at final follow-up was 76% (CI 57%-89%). Subgroup analysis, patients with fetal PComAs had a lower complete occlusion rate (42% fetal PComA vs 77%, psubgroupdifference = <.01). The performance of FDs in PComA aneurysms is comparable with outcomes found in other subtypes of supraclinoid aneurysms. Effectiveness was acceptable and safety favorable. However, effectiveness was suboptimal in patients with fetal-type PComAs; alternative treatments should be considered in these cases.