Endovascular Treatment Of Aneurysms Research Articles

Predictors of occlusion, long-term outcomes, and safety in a cohort of 674 aneurysms treated with the Pipeline embolization device.

By providing a more physiological approach to the treatment of intracranial aneurysms, the Pipeline embolization device (PED) has revolutionized the endovascular treatment of aneurysms. Although there are many flow diverters on the market, the authors report their experience with the PED, the first flow diverter to be approved by the Food and Drug Administration. They aimed to assess the efficacy and safety of PED flow diversion for the treatment of a wide range of aneurysms, as well as to look at factors affecting occlusion. This is a retrospective study of a prospectively maintained database of patients treated with the PED between January 2011 and December 2019. Charts were reviewed for patient, aneurysm, and procedure characteristics. The primary outcomes of interest were complication rates, occlusion outcomes (O'Kelly-Marotta grading scale), and functional outcomes (modified Rankin Scale [mRS]). Secondary outcomes included predictors of incomplete occlusion at 6 and 24 months of follow-up. The study cohort included 581 patients with 674 aneurysms. Most aneurysms (90.5%) were in the anterior circulation and had a saccular morphology (85.6%). Additionally, 638 aneurysms (94.7%) were unruptured, whereas 36 (5.3%) were acutely ruptured. The largest mean aneurysm diameter was 8.3 ± 6.1 mm. Complications occurred at a rate of 5.5% (n = 32). The complete occlusion rate was 89.3% at 24 months' follow-up, and 94.8% of patients had a favorable neurological outcome (mRS score 0-2) at the last follow-up. On multivariate analysis, predictors of incomplete aneurysm occlusion at 6 months were hypertension (OR 1.7, p = 0.03), previous aneurysm treatment (OR 2.4, p = 0.001), and increasing aneurysm neck diameter (OR 1.2, p = 0.02), whereas a saccular morphology was protective (OR 0.5, p = 0.05). Predictors of incomplete occlusion at 24 months were increasing aneurysm neck diameter (OR 1.2, p = 0.01) and previous aneurysm treatment (OR 2.3, p = 0.01). The study findings are corroborated by those of previous studies and trials. The complete occlusion rate was 89.3% at 24 months' follow-up, with 94.8% of patients having favorable functional outcomes (mRS score 0-2). Aneurysm treatment before PED deployment and an increasing aneurysm neck diameter increase the risk of incomplete occlusion at 6 and 24 months.

Numerical investigation of pulsed flow in aortic aneurism with and without stent by lattice Boltzmann method

Endovascular treatment of aortic aneurysms with an endoprosthesis is proposed for the prevention of the aneurysms' rupture risk and clogging of blood vessels. This paper aims to study the impact of stents with different porosities, placed in fusiform aortic aneurysms, on the hemodynamic parameters: velocity and shear rate of the flow inside the aneurysms, using pulsed boundary conditions derived from real measurements. The numerical investigations are performed with the Lattice Boltzmann method. The blood is treated as a Newtonian fluid and then as a non- Newtonian fluid with the Carreau-Yasuda and Cross models. The reduction obtained by a single stent is modest and unfavorable to thrombotic occlusion. Overlapping of several stents is proposed to promote occlusion. The results found show good agreement with medical theory.

Feasibility, Safety, and efficacy of endovascular treatment for M1 hilltop Aneurysms: A retrospective study

ObjectiveThis retrospective study aimed to evaluate the feasibility, safety, and efficacy of endovascular treatment (EVT) for M1 hilltop aneurysms, a specific M1 segment subtype located at the highest point of the middle cerebral artery (MCA). MethodsThe study included 54 patients with M1 hilltop aneurysms who underwent EVT between December 2017 and [end date]. Treatment decisions were based on angiographic findings and patient characteristics. Clinical and radiological data were reviewed, and outcomes were assessed using the Raymond-Roy classification (RRC) and modified Rankin Scale (mRS). Follow-up radiological examinations were conducted at specific intervals. ResultsEVT was successful in all 54 cases. Immediate postprocedural angiograms showed favorable occlusion (RRC I or II) in 59.3% and aneurysm remnants (RRC III) in 40.7%. Procedure-related complications occurred in 7.4% of patients, including thromboembolism and ICA dissection, with no permanent neurological impairment. During a mean 18.2-month follow-up, no neurological deterioration or aneurysmal rupture occurred. Most patients showed stable/improved occlusion on follow-up imaging, with a 14% recurrence rate. Retreatment was required in 2% of cases. ConclusionsEVT appears feasible, safe, and effective for treating M1 hilltop aneurysms. It resulted in favorable occlusion and low recurrence/retreatment rates. Neck diameter and stent usage influenced immediate outcomes and recurrence. Larger studies with longer follow-ups are needed to validate these findings further.

Comparison of the hemocompatibility of neurovascular flow diverters with anti-thrombogenic coatings

Despite the continual progress in technology, thromboembolic complications still occur following endovascular treatment of cerebral aneurysms and remain the primary contributor to morbidity and mortality. Thus, coating the surfaces of blood-contacting flow diverters may reduce thrombus-related complications in clinical use. In this study, the hemocompatibility of different commercially available flow diverters Pipeline Flex Embolization Device with Shield Technology (Medtronic), the p64 MW HPC (Phenox), and the DERIVO 2heal (Acandis) was investigated using an in vitro blood circulation model. The DERIVO 2 flow diverter was included in this study as an uncoated device. The markers of coagulation (thrombin-antithrombin complex (TAT)), thrombocytes (β-thromboglobulin (β-TG)), inflammation (PMN elastase), and complement system (SC5b-9, C3a, and C5a) activation were detected by enzyme-linked immunosorbent assay (ELISA). In addition to blood cell counts and hemolysis, thrombogenicity was determined using scanning electron microscopy. Flow diverters with anti-thrombogenic coatings resulted in significantly lower activation of coagulation (TAT) and platelets (β-TG) and lower adhesion of platelets compared with the uncoated DERIVO 2 flow diverter. There were no significant differences between the coated flow diverters in terms of TAT and β-TG levels, as well as platelet adhesion. However, significantly lower activation of the complement system (SC5b-9 and C5a) was observed for the DERIVO 2heal flow diverter in comparison with the Pipeline Flex Shield and the p64 MW HPC flow diverters emphasizing the improved hemocompatibility of the fibrin/heparin-coated DERIVO 2heal flow diverter.

Intraoperative Complications in Cerebral Endovascular Aneurysmal Surgery: A Retrospective Single-Center Study (2019-2023)

BACKGROUND: Endovascular cerebral aneurysm surgery, also known as endovascular neurosurgery, represents a minimally invasive approach aimed at diagnosing and treating intracerebral aneurysms through the use of catheters, wires, and various specialized instruments. This innovative approach has emerged as a promising alternative to traditional open surgical methods for addressing cerebral aneurysms. However, it is essential to acknowledge that while endovascular procedures offer numerous advantages, such as reduced morbidity and mortality rates, they are not devoid of associated risks, some of which can have life-threatening consequences. This paper seeks to delve into the realm of intraoperative complications in patients undergoing endovascular treatment for aneurysms, shedding light on the challenges and complexities within this field. METHODS: For this retrospective investigation, we conducted a comprehensive analysis of medical records spanning a five-year period, from 2019 to 2023. These records were obtained from the Neurosurgical Clinic of Belgrade, located within the University Clinical Center of Serbia. The study cohort comprised 44 patients who encountered intraoperative complications during endovascular aneurysm treatment. Patient information, including age, gender, aneurysm size, location, specific segment, and details regarding the nature of the intraoperative complications, was meticulously collected. Subsequently, the gathered data underwent rigorous statistical analysis. RESULTS: Out of a total of 429 patients who underwent endovascular treatment for aneurysms, 44 experienced intraoperative complications. The average age of these individuals was 55.4 years, ranging from 13 to 83 years, with the majority being women (37 out of 44, or 84.1%). Thirteen patients (29.5%) presented with significant preoperative co-morbidities and had previously experienced subarachnoid hemorrhaging before undergoing treatment. The most prevalent location for aneurysms was the internal carotid artery (ICA), accounting for 40.9% of cases, with the C6 segment being the most frequently affected at 27.3%. Other notable locations included the anterior communicating artery (ACoA) at 34.1% and the middle cerebral artery (MCA) at 13.6%. Regarding intraoperative complications, technical issues were the most frequent, affecting 84.1% of patients, while biological mishaps impacted 7 out of 44 patients (15.9%). Coil failure occurred in 16 out of 44 patients (36.4%), and stent failure was observed in 14 out of 44 patients (31.8%). Catheter-related problems were noted in 5 patients (11.4%), as were thromboembolic events, also in 5 patients (11.4%). Contrast extravasation was observed in 3 patients (6.8%), and hematoma formation occurred in 1 patient (2.3%). Additionally, 12 out of 44 aneurysms were found to be ruptured (27.3%). In this retrospective study spanning five years, our investigation focused on intraoperative complications in 44 out of 429 patients who underwent endovascular aneurysmal surgery. Our findings underscored that the primary source of these complications was related to technical issues, aligning with observations from previously referenced studies. Notably, coil and stent failures emerged as prominent concerns, along with catheter-related problems and thromboembolic events. CONCLUSION: In conclusion, the endovascular approach to treating aneurysms, while offering a minimally invasive option, is not exempt from inherent risks and complications. Despite these challenges, endovascular neurosurgery continues to hold significant value as a crucial alternative for the treatment of intracerebral aneurysms.

Comparative cost analysis of endovascular and open approaches for elective treatment of middle cerebral artery aneurysms

Background Intracranial aneurysms of the middle cerebral artery can be treated using several open surgical and endovascular approaches. Given the growing evidence of clinical equipoise between these various treatment strategies, there is a need to assess the costs associated with each. Methods Cost of aneurysm treatment was divided into two categories for comparison. “Initial cost” comprised the total in-hospital expenses for initial aneurysm treatment and “total cost” comprised initial aneurysm treatment and all expenses relating to readmission due to treatment-related complications, prescribed catheter angiograms for monitoring of treatment stability, and any retreatments needed for a given aneurysm. The open surgical group was subdivided into a pterional approach group and a lateral supraorbital (LSO) approach group for. Results Median initial cost was $37,152 (IQR $31,318–$44,947) for aneurysms treated with the pterional approach, $29,452 (IQR $27,779–$32,826) for aneurysms treated with the LSO approach, and $19,587 (IQR $14,125–$30,521) for aneurysms treated with endovascular approaches. The median total cost was $39,737 (IQR $33,891–$62,259) for aneurysms treated with the pterional approach, $31,785 (IQR $29,513–$41,099) for aneurysms treated with the LSO approach, and $24,578 (IQR $18,977–$34,547) for aneurysms treated with endovascular approaches. Analysis of variance test demonstrated variance across groups for both initial and total cost ( p = 0.004, p = 0.008, respectively). In our subsequent analysis, initial cost and total cost were higher in the pterional group than the endovascular group ( p = 0.003 and p = 0.006, respectively). Conclusions Endovascular treatment of elective aneurysms has a significantly lower cost than open surgical treatment with the pterional approach, but not with the LSO approach. For aneurysms not amenable to endovascular treatment, a minimally invasive LSO approach carries a lower cost burden than a pterional approach.

Our experience with the using of pCONUS2 implant for endovascular occlusion of cerebral bifurcation aneurysms

Objective ‒ to analyze the outcomes of endovascular treatment of aneurysms occluded by microcoils using pCONUS2 implants.Materials and methods. A retrospective analysis of treatment outcomes from January 2021 to March 2023 was conducted at the SO «Scientific-practical center of endovascular neuroradiology NAMS of Ukraine». Among 532 patients with cerebral aneurysms, 22 were treated with bifurcation implants pCONUS2 (Hydrophilic Polymer Coating (HPC)). The study group comprised 22 patients (11 females, 11 males, average age 53.01 years) with 26 aneurysms (3 patients had multiple aneurysms, one of which was excluded from use pCONUS2), including 9 (40.9 %) ruptured aneurysms. All of them were operated on during the acute period. Induction and controlled implantation of pCONUS2 were successfully performed in all patients. No technical problems have been registered that could make it difficult to navigate, start and detach the device. Results. Initial occlusion assessment using the modified Raymond-Roy classification (mRRC) showed total occlusion (mRRC 1) in 12 cases (54.5 %), near-complete occlusion (mRRC 2) in 6 cases (27.3 %), and residual filling (mRRC 3a and 3b) in 4 cases (18.2 %). Twenty-one patients were discharged or transferred for further treatment to the department of neurology with satisfactory treatment results (0–2 points on the modified Rankin Scale). One patient with a basilar artery aneurysm died from subarachnoid hemorrhage and severe vasospasm (6 points on the modified Rankin Scale). Angiographic follow-up was available for 9 patients, with stable occlusion in 7 cases and improvement from mRRC 3a to mRRC 1 in 2 cases.Conclusions. pCONUS bifurcation implants serve as an additional tool for treating wide-neck cerebral aneurysms, demonstrating high technical success rates and low complication and mortality rates.

Periprocedural antiplatelet medication assessed by VerifyNow for neuroendovascular treatment: Comparison of prasugrel with clopidogrel

Objective The maintenance dose of prasugrel (PRAS) for neuroendovascular treatment requires much research. We report the antiplatelet effect of PRAS measured by VerifyNow P2Y12 reaction units (PRUs) in patients during the perioperative period of neuroendovascular treatment. Methods Between January 2017 and January 2023, 230 patients who underwent endovascular treatment for unruptured intracranial aneurysms or carotid artery stenosis at our institution were retrospectively identified. Patients received dual antiplatelet therapy with 100 mg aspirin (ASA) and 75 mg clopidogrel (CLP)/day (CLP group, n = 186) or 100 mg ASA and 3.75 mg PRAS/day (PRAS group, n = 44) 2 weeks before the procedures. The PRU value was compared between the CLP and PRAS groups. In the study, we defined 95≦PRU < 208 as the optimal range. Perioperative complications within seven days of surgery were also analyzed. Results The mean value of PRU was significantly low in the PRAS group (179.13 ± 66.03 in CLP vs. 154.75 ± 54.01 in PRAS, p = 0.024). The proportion of the patients who exhibited 95≦PRU < 208 was significantly higher in the PRAS group (55.4% vs. 72.7%, p = 0.036). Ischemic and hemorrhagic complication rates were not significantly different between the CLP and PRAS groups (7.6% vs. 0%, p = 0.076; 4.7% vs. 0%, p = 0.361). The ischemic complication rate was higher in patients with a PRU > 208 than in those with PRU < 208 (12.5% vs. 3.8%, p = 0.044). The hemorrhagic complication rate was not significantly different between the PRU < 95 and 95≦PRU groups (8.4% vs. 3.2%, p = 0.224). Conclusions Maintenance dose PRAS further decreased the PRU value and reached the optimal range in more cases than CLP during the perioperative period of neuroendovascular treatment. Ischemic complications significantly increased in the 208 < PRU group.

Safety and efficacy of endovascular versus microsurgical treatment of unruptured wide-necked middle cerebral artery aneurysms: a propensity score-matched analysis of the NeuroVascular Quality Initiative Quality Outcomes Database Cerebral Aneurysm Registry.

Unruptured, wide-necked middle cerebral artery (WN-MCA) aneurysms have traditionally been considered ideal candidates for microsurgery (MS), although endovascular treatment (EVT) has dramatically increased in popularity with the advent of novel devices such as intrasaccular flow disruptors. The purpose of this study was to evaluate the safety and efficacy of MS versus EVT for unruptured WN-MCA aneurysms. The NeuroVascular Quality Initiative Quality Outcomes Database (NVQI-QOD) Cerebral Aneurysm Registry, a multiinstitutional, prospectively collected procedural database, was queried for cases of unruptured WN-MCA aneurysms treated with MS or EVT between 2015 and 2022. A wide neck was defined as an aneurysm neck ≥ 4 mm or a dome/neck ratio ≤ 2. Demographics and aneurysm characteristics were queried. Propensity score matching (PSM) was utilized to match aneurysm size, number of aneurysms treated, patient age, and aneurysm status. Safety outcomes were evaluated including intraoperative and postoperative complication rates. Aneurysm occlusion status and clinical outcomes using the modified Rankin Scale (mRS) score at discharge and the last follow-up were also assessed. Of 671 unruptured MCA aneurysms, 319 were wide necked. Thirty cases were excluded, as the aneurysm had been previously treated. Two hundred eighty-nine operations (203 EVT, 86 MS) in 282 patients satisfied inclusion criteria. After PSM, there were 86 operations in each group for analysis. The mean aneurysm width was 5.0 (EVT) versus 4.9 mm (MS; p = 0.285). Safety data showed similar intraoperative (7.0% EVT vs 3.5% MS, p = 0.496) and postoperative (4.7% vs 7%, p = 0.746) complication rates. The MS patients were more likely to have complete aneurysm occlusion at discharge (90.4% vs 58.8%, p < 0.001). In a limited subset of patients (52.9%) for whom outcome data were available, the EVT patients were more likely to have an mRS score 0 at discharge (50/59 [84.7%] vs 29/54 [53.7%], p < 0.0003] and at the last follow-up (36/55 [65.5%] vs 13/36 [36.1%], p = 0.006). This study describes a large, modern cohort of propensity score-matched patients who underwent treatment of unruptured WN-MCA aneurysms. Safety data on intraoperative and postoperative complication rates were similar in both treatment groups. MS was more likely to result in complete aneurysm occlusion at discharge. In a subset of patients with available outcome data, EVT was associated with better functional outcomes at discharge and the last follow-up. Given the lack of complete follow-up data and rates of retreatment, these results should be interpreted cautiously.

Endovascular treatment of mycotic aneurysms: An update meta-analysis

IntroductionIntracranial mycotic or infectious aneurysms result from the infection of arterial walls, most caused by bacterial or fungal organisms. These infections can weaken the arterial wall, leading to the formation of an aneurysm, a localized dilation, or a bulge. The management can be conservative mainly based on antibiotics or invasive methods such as clipping or endovascular treatment. PurposeWe performed a systematic review and meta-analysis of the current literature on endovascular treatment of mycotic aneurysms, analyzing the safety and efficacy associated with this procedure. MethodsWe systematically searched on PUBMED, Cochrane Library, Embase, and Web of Science databases. Our search strategy was carefully crafted to conduct a thorough investigation of the topic, utilizing a comprehensive combination of relevant keywords. This meta-analysis included all studies that reported endovascular treatment of mycotic aneurysms. To minimize the risk of bias, studies with fewer than four patients, studies where the main outcome was not found, and studies with no clear differentiation between microsurgical and endovascular treatment were excluded. ResultsIn a comprehensive analysis of 134 patients, it was observed that all except one patient received antibiotics as part of their treatment. Among the patients, 56% (a total of 51 out of 90 patients) underwent cardiac surgery. Additionally, three patients required a craniotomy following endovascular treatment. 12 patients experienced morbidity related to the procedures performed, indicating complications arising from the interventions. Furthermore, four aneurysms experienced rebleeding while treatment. A pooled analysis of the endovascular treatment of the mycotic aneurysm revealed a good level of technical success, achieving a 100% success rate in 12 out of 14 studies (97–100%; CI 95%; I2 = 0%), as illustrated in Fig. 2. Similarly, the aneurysm occlusion rate demonstrated a notable efficacy, with a success rate of 97% observed in 12 out of 14 studies (97–100%; CI 95%; I2 = 0%), as depicted in Fig. 3. ConclusionThe results strongly support the efficacy of endovascular treatment in achieving technical success, complete aneurysm occlusion, and favorable neurological outcomes. Additionally, the notably low incidence of complications and procedure-related mortality reaffirms the safety and benefits associated with this intervention.

CIRSE Standards of Practice for the Endovascular Treatment of Visceral and Renal Artery Aneurysms and Pseudoaneurysms

BackgroundEndovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms is an effective, minimally invasive treatment that has been successfully used since the early 1990s, with refined and expanded techniques and tools currently offering excellent outcomes. Due to increased detection of such lesions in recent years, many of which are asymptomatic, revision of the indications for intervention and the correct endovascular treatment approaches has become essential.PurposeThis document will presume that the indication for treatment is clear and approved by the multidisciplinary team and will define the standards required for the performance of each intervention, as well as their relative advantages and limitations. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but recommend a reasonable approach to, and best practices for, the performance of the endovascular treatment of visceral and renal artery aneurysms and pseudoaneurysms.MethodsThe writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in endovascular treatments. The writing group reviewed the existing literature on visceral and renal artery aneurysms and pseudoaneurysms, performing an evidence search using PubMed to identify publications in English and relating to human subjects from 1990 to 2022. The final recommendations were formulated through consensus.ResultsEndovascular treatment has an established role in the successful management of visceral and renal artery aneurysms and pseudoaneurysms, and this Standards of Practice document provides up-to-date recommendations for its safe performance.

Endovascular treatment of multiple intracranial aneurysms.

Multiple intracranial aneurysms are difficult to treat. In order to investigate the effect and safety of endovascular treatment for multiple intracranial aneurysms, 54 consecutive patients with 116 multiple intracranial aneurysms treated with endovascular embolization were retrospectively enrolled. Angiography was performed immediately after embolization and at each follow-up. All clinical data were analyzed. Of the 116 aneurysms, 56 (48.3%) were embolized with coiling alone, 19 (16.4%) with stent-assisted coiling, 31 (26.7%) with stenting alone, and 10 (8.6%) with flow diverters plus coiling. After embolization, 31 (27.6%) aneurysms with stenting alone had no apparent change in size, and in the remaining 84 aneurysms, complete occlusion was achieved in 50 aneurysms (59.5%), near-complete occlusion in 26 (31.0%), and incomplete occlusion in 8 (9.5%). Thrombus formation at the aneurysm neck occurred in 3 patients (5.6%), coil protrusion in 2 (3.7%), and intraprocedural rupture in 1 (1.9%), resulting in a total complication rate of 11.1%. Follow-up angiography was performed in 44 (81.5%) patients 6 to 90 months (mean 49) later. Among 50 completely occluded aneurysms, 38 (76%) aneurysms remained completely occluded, and 4 (8%) aneurysms recurred. Among 26 aneurysms with initial near-complete occlusion, 12 (46.2%) aneurysms with neck remnant had progressive thrombosis to complete occlusion, 2 (7.7%) had no change compared with immediate occlusion, and 5 (19.2%) regrew. In conclusion, endovascular embolization with intracranial stenting and coiling is safe and effective and may play an increasingly important role in the management of multiple intracranial aneurysms.

Pave and Pop: A novel addition to the endovascular treatment of hemodialysis access aneurysms.

Hemodialysis access sites can be complicated by both true and false aneurysms with significant potential morbidity. Aneurysms have traditionally been treated by a variety of surgical methods. Less commonly, endovascular treatment with stent graft placement has been used as an alternative to open surgery. Four patients with symptomatic aneurysmal disease in the hemodialysis access site were treated. All patients had stent grafts (SGs) placed across the diseased segment. Once the diseased segment was excluded, blood was drained from the aneurysm with an 18 g needle. All patients were seen in clinic at 1- and 3-months post procedure. All patients were able to receive adequate hemodialysis post procedure. Two patients were cannulated via the SG after 1 month. No aneurysm refilling was seen. No SG infections or fractures were seen. A novel addition to the endovascular treatment of aneurysmal disease in hemodialysis patients is described, that both excludes the aneurysm and drains it, providing improvement in the aesthetic appearance of the access site.

Physician-Modified Single-Fenestrated EndoSuture Aneurysm Repair (FESAR) for Urgent Juxtarenal AAA Repair.

To describe the endovascular treatment of a symptomatic juxtarenal abdominal aortic aneurysm (JAAA) using a combination of endoanchors (Heli-FX EndoAnchor, Medtronic, Minneapolis, Minnesota) and a physician-modified single-fenestrated endograft. An 85 year-old patient unfit for open aortic repair presented for a symptomatic JAAA, characterized by an infrarenal neck with 0.6 cm in length and 23 mm in diameter. A 28 mm-diameter Endurant aortic cuff (Medtronic, Minneapolis, Minnesota) was modified with a single fenestration for the left renal artery (LRA) and diameter-reducing tie, then re-sheathed and deployed. The LRA was cannulated with a 7F sheath and the constraining wire was withdrawn. Being the shortest neck length on the right side of the cuff, the endograft was anchored to the aortic wall on this side with 2 endoanchors. The LRA was stented and flared, then a distal physician-modified (without free-flow) bifurcated Endurant graft (Medtronic, Minneapolis, Minnesota) was overlapped with the proximal cuff and stabilized with 6 endoanchors. Correct positioning with complete aneurysm exclusion was confirmed with a 30 day and 9 month computed tomography angiograms. In extremely selected cases, association of endoanchors and single-fenestrated physician-modified graft may be useful to treat complex urgent aortic aneurysm using readily available devices. This technical note demonstrates the feasibility of a single-fenestrated physician-modified Endurant endograft deployed in combination with endosuture fixation (FESAR), to urgently treat a juxtarenal aortic aneurysm unfit for open repair and not suitable for standard endovascular repair nor off-the-shelf endografts.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects.

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

Six-month Outcomes after PulseRider- and Conventional Single Stent-assisted Embolization for Bifurcation Aneurysms: A Propensity-adjusted Comparison.

Endovascular treatment of wide-necked bifurcation aneurysms (WNBAs) remains challenging despite using a stent. PulseRider is a novel device specifically designed to treat WNBAs, protecting both daughter branches, but the outcomes have not been compared with conventional single stent-assisted embolization. This study aimed to compare the six-month outcomes of PulseRider and single stent-assisted embolization for intracranial unruptured WNBAs using propensity score adjustment. Between February 2012 and October 2021, 46 unruptured WNBAs (34 basilar and 12 middle cerebral arteries) smaller than 10 mm in diameter were treated with PulseRider-assisted embolization (n = 17) or single stent-assisted embolization (n = 29). The immediate and six-month outcomes were compared using inverse probability of treatment weighting analysis. The immediate adequate occlusion rates for the PulseRider- and single stent-assisted embolization were similar (47.1% vs. 62.1%). At six months, adequate occlusion rates for the two groups were also similar (94.1% vs. 86.2%). However, the complete obliteration rate was significantly high after PulseRider-assisted embolization (88.2% vs. 41.4%, adjusted OR 10.54, 95% CI 1.93-57.63). The angiographical improvement rate was also significantly high after PulseRider-assisted embolization (70.6% vs. 37.9%, adjusted OR 6.06, 95% CI 1.54-23.76). The neurologic thromboembolic complication rate was 0% after PulseRider-assisted embolization and 3.4% after single stent-assisted embolization. PulseRider-assisted embolization of WNBAs smaller than 10 mm in diameter was associated with complete obliteration and angiographical improvement at six months. The unique shape of the PulseRider might contribute to the improved midterm aneurysm occlusion.

A comprehensive simulation framework for predicting the eCLIPs implant crimping into a catheter and its deployment mechanisms

Tubular flow diverters (FDs) represent an important subset of the endovascular treatment of cerebral aneurysms (CAs), acting to reduce aneurysm inflow, eventually resulting in aneurysm thrombosis and occlusion. eCLIPs (product of Evasc Neurovascular Enterprises, Vancouver, Canada), an innovative non-tubular implant causes flow diversion by bridging the neck of bifurcation CAs. However, in a small subset of challenging bifurcation aneurysms with fusiform pathology, the currently available eCLIPs models do not provide sufficient neck bridging resulting in a gap created between the device structure and the aneurysm/artery wall. To overcome this challenge, a new design of the eCLIPs (VR-eCLIPs) was developed by varying the rib length to cover such an inflow gap. To optimize the new product development process, and avoiding expensive and time-consuming iterative manufacture of prototype devices, we have developed a new finite element model to simulate the crimping and expansion processes of the VR-eCLIPs implant, and assess the possibility of plastic deformation. Results indicated that neither eCLIPs nor VR-eCLIPs experience plastic deformation during the crimping process. Upon full expansion, the ribs of VR-eCLIPs interact with the aneurysm and artery wall to cover the inflow gap that exists in certain challenging anatomies. This process serves as a basis to expedite design development prior to prototype manufacturing.

Abstract 172: Outcomes and Complications of Stent‐Assisted Aneurysm Repair in Acute Subarachnoid Hemorrhage

Introduction The use of detachable coils for endovascular embolization of cerebral aneurysms has become a safe and effective alternative to direct surgical clipping in patients with ruptured aneurysmal subarachnoid hemorrhage. However, endovascular treatment of wide‐necked, large (&gt;10 mm), and complex ruptured aneurysms continues to remain challenging despite multiple technical advancements in recent years. In order to improve treatment outcomes in these difficult cases, the use of stent‐assisted embolization has been attempted in endovascular treatment of intracranial aneurysms. In order to avoid thromboembolic complications in these cases, patients require treatment with antiplatelet therapy. Previous studies have shown that antiplatelet therapy poses an increased risk of hemorrhagic complications; this risk might be further heightened in the setting of acute subarachnoid hemorrhage (SAH), as these patients can develop an abnormal coagulation status. The purpose of this study was to retrospectively analyze the results and complications associated with stent‐assisted embolization of intracranial aneurysms in the acute treatment of subarachnoid hemorrhage at Dell Seton Medical Center. Methods Data from patients with acutely‐ruptured intracranial aneurysm treated with stent‐assisted embolization at Dell Seton Medical Center in the period between 2021 and 2022 were retrospectively assessed, with the focus of addressing aneurysm occlusion, clinical outcomes and complications. Results Fifteen patients with ruptured intracranial aneurysms were included in the analysis. Post‐procedural re‐rupture and hemorrhagic complications were observed in three patients, leading to death in two patients. Thromboembolic complications were observed in one patient, with the clinical outcome of death due to basilar stent thrombosis. Immediate complete occlusion and occlusion with residual neck was achieved in 66.7% of cases. Conclusion In the case of ruptured intracranial aneurysms with large and complex morphology and a wide neck, the use of stent‐assisted repair may be necessary compared to simpler and smaller aneurysms that can be treated with coils alone. The use of stent‐assisted repair in acutely‐ruptured aneurysms in this series of cases demonstrated rapid and good aneurysmal occlusion. The post‐procedural complication rate proved to be higher than in non‐ruptured stent‐assisted coiling. However, the overall resulting morbidity and mortality rates in this cohort of patients is lower than could have been expected; furthermore, the complication rates found in this study are in line with those reported in similar studies. In most cases in the emergency setting, it is not possible to appropriately prepare a patient with antiplatelet therapy pre‐procedurally. As a result, the proper antiplatelet medication regimen and its appropriate timing continue to remain a significant topic of investigation. In addition, there continues to be further investigation into the optimal timing of intervention to minimize risk of peri‐procedural and post‐procedural complications. Further retrospective analysis of patient data over multiple years and across multiple centers is needed to better assess outcomes and complications of stent‐assisted aneurysm repair in acute subarachnoid hemorrhage.

Abstract 007: Device‐related Technical Complications with Flow Diversion of Intracranial Aneurysms: A Systematic Review and Meta‐analysis

Introduction Flow diverters (FD) have become a revolutionary approach in the endovascular treatment of intracranial aneurysms (IAs), supplanting traditional methods (1). Despite their demonstrated efficacy and safety, unforeseeable device‐related technical complications, such as fish‐mouthing, device braid narrowing, deformation, ovalization, and collapsing have been reported during implantation and follow‐up (2,3,4). However, the definitions and reporting of these complications remain inconsistent. We conducted a systematic review and meta‐analysis to assess overall device‐related technical complication rates associated with flow diversion and provide an overview of the current reported definitions. Methods We searched six databases up to April 4th, 2023, and included studies that reported device‐related technical complications related to FD treatment for IAs. We considered five main outcome measures as device‐related technical complications: (1) fish‐mouthing, (2) device braid collapsing, (3) device braid narrowing, (4) device braid deformation, and (5) device braid ovalization. The data from these studies were pooled using a random‐effects model. Results We included 48 studies involving 3,572 patients and 3,939 aneurysms. Among them, 14 studies (39%) provided definitions for fish‐mouthing. However, none of the included studies offered specific definitions for device braid collapsing, narrowing, or deformation, despite reporting rates for these complications in five, six, and three studies, respectively. The pooled rates for device‐related technical complications were as follows: 3% (95% CI 2 – 4%; I2 = 27%) for fish‐mouthing, 1% (95% CI 0 – 3%; I2 = 0%) for collapsing, 7% (95% CI 2 – 20%; I2 = 85%) for narrowing, and 1% (95% CI 1 – 4%; I2 = 0%) for deformation. Device braid ovalization data were not available. Conclusion The findings of this study suggest that FD treatment for IAs generally exhibits low rates of fish‐mouthing, device braid narrowing, collapsing, and deformation. However, the lack of standardized definitions hinders the ability to objectively compare device outcomes, emphasizing the need for uniform device‐related complication definitions in future prospective studies on FD.

Hyaluronidase Injection to Reduce Periorbital Edema after Surgery for Unruptured Intracranial Aneurysms

Background: In the era of endovascular treatment for intracranial aneurysms, microsurgical treatment might necessitate the minimization of postoperative discomforts such as headache, nausea, vomiting, and edema. The current study aimed to evaluate the effectiveness of hyaluronidase on the reduction of periorbital edema after clipping surgery for unruptured intracranial aneurysms. Methods: From July 2016 to March 2018, the patients who underwent elective surgery for unruptured intracranial aneurysms were included. A mixture of 4500 IU hyaluronidase was injected subcutaneously on the sectional plane of the scalp incision. The photographs of patients’ faces were obtained on postoperative day 1, 3, and 7. The degree of periorbital edema was judged on the grading system based on the vertical palpebral aperture. The thickness of the scalp, temporalis muscle, and soft tissue was measured on a preoperative computed tomography (CT) scan, and other variables (e.g., intraoperative input and output, serum albumin level) were Results: A total of 60 patients were included in this study, and a hyaluronidase mixture was injected in 30 patients. The periorbital edema tended to resolve in 7 days after surgery, but notable differences between the two groups was observed at day three after surgery in this study. On the ordinal logistic regression analysis on the grade of periorbital edema, hyaluronidase injection is significantly associated with the reduction of periorbital edema throughout the postoperative period. (p value &lt; 0.05)Conclusion: Hyaluronidase injection might be helpful in reducing periorbital edema after surgery for unruptured intracranial aneurysms.