Endovascular Treatment Of Cerebral Aneurysms Research Articles

O-007 Initial Institutional Experience Using a Target P2Y12 Reaction Units Range to Tailor the Clopidogrel Dose Administered to Patients with Cerebral Aneurysms Treated with the Pipeline Embolization Device and Stents

Background and purposeVariability in response to the P2Y12 receptor antagonists administered to patients with cerebral aneurysms treated with the Pipeline Embolization device (PED) or stents may play an important role...

Balloons and stents in the endovascular treatment of cerebral aneurysms: vascular anatomy remodeled.

Wide-neck intracranial aneurysms were originally thought to be either untreatable or very challenging to treat by endovascular means because of the risk of coil protrusion into the parent vessel. The introduction of the balloon remodeling technique (BRT) and later stents specifically designed for intracranial use has progressively allowed these lesions to be endovascularly treated. BRT and stent-assisted coiling technique (SACT) were first designed to treat sidewall aneurysms but, with gained experience and further technical refinement, bifurcation complex-shaped wide-neck aneurysms have been treated by coiling enhanced by BRT and SACT. In this article, we will review and describe the inherent benefits and drawbacks of BRT as well as SACT.

Radiation dose analysis of large and giant internal carotid artery aneurysm treatment with the pipeline embolization device versus traditional coiling techniques

BackgroundFlow diversion is an effective and increasingly accepted method for endovascular treatment of cerebral aneurysms. Additionally, the public has heightened concerns regarding radiation exposure from medical procedures. This study analyzes...

Headaches Following Endovascular Treatment of Cerebral Aneurysms: Coil Embolization vs. Flow Diversion (P5.125)

Headaches Following Endovascular Treatment of Cerebral Aneurysms: Coil Embolization vs. Flow Diversion (P5.125)

Advances in Endovascular Approaches to Cerebral Aneurysms

Recent advancements in all phases of endovascular aneurysm treatment, including medical therapy, diagnostics, devices, and implants, abound. Advancements in endovascular technologies and techniques have enabled treatment of a wide variety of intracranial aneurysms. In this article, technical advances in endovascular treatment of cerebral aneurysms are discussed, with an effort to incorporate a clinically relevant perspective. Advancements in diagnostic tools, medical therapy, and implants are reviewed and discussed.

Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms

Background and purposeVariability in response to clopidogrel therapy is increasingly being recognized as an important factor in thromboembolic and hemorrhagic complications encountered after neurointerventional procedures. This study aims to determine...

Correlation Between Activated Clotting Time and Activated Partial Thromboplastin Time During Endovascular Treatment of Cerebral Aneurysms

Purpose: Endovascular treatment (EVT) of intracranial aneurysms (IAs) requires continuous anticoagulation to avoid thromboembolic complications.To monitor the anticoagulation, different tests may be used, including the activated clotting time (ACT) and the activated partial thromboplastin time (APTT). The aim of this study was to compare ACT and APTT for the monitoring of anticoagulation during EVT of IAs. Methods: Patients referred for EVT of an IA were included. After induction, baseline ACT and APTT were recorded, followed by a bolus infusion of unfractionated heparin (50 UI kg). The same tests were controlled 5 minutes later with the purpose of doubling the baseline ACT value. Correlation and agreement between both tests were evaluated for the percentage of change after the bolus. Multiple linear regressions were also calculated to show confounding factors. Complications and outcomes were also recorded. Results Results: Forty-five patients were checked for enrollment, and 24 were included for analysis. Mean (SD) percent variation for APTT was 432.1 (75.7) and 60.6 (23.0) for ACT, with P

Stretch-Resistant Coils for Intracranial Aneurysms: One Step Forward or Two Steps Back?

Endovascular treatment of cerebral aneurysms was boosted by the introduction of the Guglielmi detachable coil system (Boston Scientific, Natick, Massachusetts) in 1991. The concept of “detachability” made the selective placement of long coils into the lumen of an aneurysm much safer: Inserted

Endovascular treatment of cerebral aneurysms using the hydrocoil embolic system.

HydroCoils are platinum helical coils coated with a layer of hydrophilic acrylic polymer (hydrogel), which on contact with blood causes disentanglement of polymer chains and expansion. We retrospectively reviewed a series of 29 patients harboring 29 cerebral aneurysms treated with the Hydrocoil Embolic System in the period 2004-2005, discussing the results of endovascular procedures in terms of safety and efficacy. The immediate post-procedure angiographic control demonstrated complete aneurysm occlusion in 21 cases (72.4%), near-complete occlusion in seven cases (24.1%), whereas in one case (3.4%) there was a procedure failure with major perfusion of the sac. Five patients (17.2%) experienced thromboembolic complications, including an asymptomatic lacunar stroke of the head of the caudate nucleus, a thalamic infarct following hypotension secondary to pulmonary edema, temporal ischemia secondary to vasospasm and a small right occipital ischemic lesion. Only one patient (3.4%) suffered a major ischemic accident. No other procedure-related complication occurred. Three-month follow-up control with MR angiography and 12-month follow-up angiography demonstrated no recurrence of aneurysms. Overall, after a mean follow-up of 12 months, the clinical outcome was good recovery in 26 patients (89.6%), moderate disability in three patients (10.3%) and no vegetative status or death. Our HydroCoil series supports the safety and midterm durability of hydrogel-coated aneurysm coils in the treatment of cerebral aneurysms.

A Novel Neck-Sealing Balloon Technique for Distal Access Through a Giant Aneurysm

In endovascular treatment for cerebral aneurysms using balloons, stents, or flow diverters, a microguidewire or microcatheter needs to be navigated distally across the neck of the aneurysm. However, this is sometimes difficult when there is a wide-neck or large aneurysm with a tortuous or atherosclerotic parent vessel. In this case report, we describe a new technique for navigating a microcatheter into a distal vessel. An 81-year-old woman presented with trigeminal neuralgia and diplopia due to abducens nerve palsy because of a giant cavernous carotid artery aneurysm. We planned stent-assisted coil embolization of the aneurysm and tried to advance a microcatheter into a distal vessel across the neck of the aneurysm. Although we attempted several previously reported techniques, these were unsuccessful. We then navigated a balloon into the aneurysm, slowly inflated it within the aneurysm, pulled it back gently, and sealed the neck orifice of the aneurysm with the balloon. We easily navigated a microcatheter into the distal vessel. The stent-assisted coil embolization was completed with no complications. This novel neck-sealing technique with a balloon for distal access may be useful in cases in which other methods are unsuccessful. In addition, this technique offers the advantages of not producing a loop in the microcatheter within an aneurysm and not requiring retraction of the microcatheter to reduce the loop.

A new-generation, low-permeability flow diverting device for treatment of saccular aneurysms

We report a preclinical comparative study of a 96-strand braided flow diverter. The 96-strand braided device was compared with the currently commercially available flow diverter with 48 strands. The devices were implanted across the neck of 12 elastase-induced aneurysms in New Zealand White rabbits and followed for 1 and 3months (n = 6 respectively). Aneurysm occlusion rates, parent artery stenosis and patency of jailed branch occlusions were assessed by angiography, histology and scanning electron microscopy studies. It was feasible to navigate and implant the 96-strand device over the aneurysm orifice in all cases. At follow-up two aneurysms in the 48-strand vs. one in the 96-strand group were not occluded. This aneurysm from the 96-strand group however had a tracheal branch arising from the sac and showed a reverse remodelling of the vascular pouch at 3months. In the occluded aneurysms, the parent artery was always completely reconstructed and the aneurysm orifice was sealed with neointimal tissue. No in-stent stenosis or jailed branch artery occlusion was observed. The 96-strand flow diverter proved to be safe, biocompatible and haemodynamically effective, induced stable occlusion of aneurysms and led to reverse remodelling of the parent artery. • Flow diversion has been introduced to improve endovascular treatment of cerebral aneurysms • A new low-permeability flow diverter is feasible for parent artery reconstruction. • The Silk 96 flow diverter appears effective at inducing aneurysm healing. • The covered branches remained patent at follow-up.

O-018 Variability in Response to a 75mg Daily Clopidogrel Dose in a Cohort of 90 Patients Undergoing Endovascular Treatment of Unruptured Cerebral Aneurysms

Background and PurposeRecent studies have suggested that variability in response to clopidogrel therapy may explain some of the thromboembolic and hemorrhagic complications encountered after endovascular treatment of cerebral aneurysms with...

E-008 Packing Volume Densities by Coated vs Non-coated Coils in Endovascular treatment of Cerebral Aneurysms

IntroductionHydrogel coils have been introduced to efficiently increase the aneurysmal packing volumes which may, in turn, decreases the recurrence rate of the endovasularly treated cerebral aneurysms. There is no definite...

Rescue Treatment of Thromboembolic Complications During Endovascular Treatment of Cerebral Aneurysms

Acute intraprocedural thrombus formation complicating endovascular cerebral aneurysm treatment is often treated with intra-arterial or intravenous administration of thrombolytic agents or glycoprotein IIb/IIIa (GpIIb/IIIa) inhibitors. We sought to evaluate the morbidity and mortality associated with such treatments using a large multihospital database. Using the Premier Perspective Database, we examined outcomes for patients receiving endovascular coiling for ruptured and unruptured aneurysms requiring rescue therapy, defined as treatment with GpIIb/IIIa inhibitors and fibrinolytic therapy. We compared discharge status, length of stay, and complication rates across 3 groups: (1) patients receiving GpIIb/IIIa inhibitors only, (2) patients receiving fibrinolytic therapy only, and (3) patients receiving both GpIIb/IIIa inhibitors and fibrinolytics. Student t test was used to compare continuous variables, and Fisher exact test was used to compare categorical variables. Seven-percent (254/3627) of patients treated for unruptured aneurysms received rescue therapy. When compared with patients receiving GpIIb/IIIa inhibitors alone, patients receiving only fibrinolytics had significantly higher rates of discharge to institutions other than home (37.5% [9/24] versus 7.4% [15/201]; P<0.0001). Eight-percent of patients (338/4204) treated for ruptured aneurysms received rescue therapy. When compared with patients receiving GpIIb/IIIa inhibitors alone, patients receiving only fibrinolytics had significantly higher rates of mortality (26.0% [18/69] versus 14.5% [35/241]; P=0.02) and discharge to institutions other than home (59.4% [41/69] versus 36.5% [88/241]; P<0.0001). Pharmacological rescue therapy occurred in 7% to 8% of endovascular coiling patients with unruptured and ruptured intracranial aneurysms. Rescue therapy with thrombolytic agents resulted in significantly more morbidity and mortality than rescue therapy with GpIIb/IIIa inhibitors.

Assisted techniques for the endovascular treatment of complex or atypical cerebral aneurysms

In the last ten years, the endovascular approach to the management of cerebral aneurysms has gone from being an alternative to surgery to being the first-choice technique in the vast majority of cases. The continuous development of new assisted techniques and of new materials for embolization has multiplied its therapeutic possibilities, so that safe and efficacious endovascular treatment is now possible for aneurysms that would have required surgery only a few years ago. These continuous technological advances require the professionals who treat patients with cerebral aneurysms to achieve a high degree of specialization and to keep up to date through continuous training. In this article, we review some of the most widely used assisted techniques in the endovascular treatment of cerebral aneurysms, discussing their main indications, their advantages over conventional embolization techniques, and their possible limitations.

Complications of endovascular treatment of cerebral aneurysms

The number of neuroendovascular treatments of both ruptured and unruptured aneurysms has increased substantially in the last two decades. Complications of endovascular treatments of cerebral aneurysms are rare but can potentially lead to acute worsening of the neurological status, to new neurological deficits or death. Some of the possible complications, such as vascular access site complications or systemic side effects associated with contrast medium (e.g. contrast medium allergy, contrast induced nephropathy) can also be encountered in diagnostic angiography. The most common complications of endovascular treatment of cerebral aneurysms are related to acute thromboembolic events and perforation of the aneurysm. Overall, the reported rate of thromboembolic complications ranges between 4.7% and 12.5% while the rate of intraprocedural rupture of cerebral aneurysms is about 0.7% in patients with unruptured aneurysms and about 4.1% in patients with previously ruptured aneurysms.Thromboembolic and hemorrhagic complications may occur during different phases of endovascular procedures and are related to different technical, clinical and anatomic reasons. A thorough knowledge of the different aspects of these complications can reduce the risk of their occurrence and minimize their clinical sequelae. A deep understanding of complications and of their management is thus part of the best standard of care.

Retained and Fractured Microcatheter: A Cause of Transient Ischaemic Attacks: Endovascular Management Using Carotid Stents

A retained microcatheter is a rare complication of endovascular treatment of cerebral aneurysms. We describe such a case that was complicated by delayed microcatheter fracture within the internal carotid artery and subsequent thrombo-embolism resulting in transient ischaemic attacks. We also describe endovascular management of this complication through the use of several carotid stents.

Initial experience with an extremely soft bare platinum coil, ED coil-10 Extra Soft, for endovascular treatment of cerebral aneurysms

Background and purposeThe ED coil-10 Extra Soft (EDC-10 ES) is an extremely soft coil with excellent operability for embolization of cerebral aneurysms and is frequently used as a ‘finishing coil’....

Midterm and long-term follow-up of cerebral aneurysms treated with flow diverter devices: a single-center experience

The introduction of flow diverter devices is revolutionizing the endovascular approach to cerebral aneurysms. Midterm and long-term results of angiographic, cross-sectional imaging and clinical follow-up are still lacking. The authors report their experience with endovascular treatment of intracranial aneurysms using both the Pipeline embolization device and Silk stents. From October 2008 to July 2011 a consecutive series of 104 intracranial aneurysms in 101 patients (79 female, 22 male; average age 53 years) were treated. Three of the 104 aneurysms were ruptured and 101 were unruptured. Silk stents were implanted in 47 of the aneurysms and Pipeline stents in the remaining 57. In 14 cases a combination of flow diverter devices and coils were used to treat larger aneurysms (maximum diameter > 15 mm). Patients underwent angiographic follow-up examination at 6 months after treatment, with or without CT or MRI, and at 1 year using CT or MRI, with or without conventional angiography. In all cases placement of flow diverter stents was technically successful. The mortality and morbidity rates were both 3%. Adverse events without lasting clinical sequelae occurred in 20% of cases. Angiography performed at 6 months after treatment showed complete aneurysm occlusion in 78 of 91 cases (86% of evaluated aneurysms) and subocclusion in 11 (12%); only in 2 cases were the aneurysms unchanged. Fifty-three aneurysms were evaluated at 1 year after treatment. None of these aneurysms showed recanalization, and 1 aneurysm, which was incompletely occluded at the 6-month follow-up examination, was finally occluded. Aneurysmal sac shrinkage was observed in 61% of assessable aneurysms. Parent artery reconstruction using flow diverter devices is a feasible, safe, and successful technique for the treatment of endovascular treatment of cerebral aneurysms.

O-026 Coil costs and aneurysm size: 2 years of data

The material costs associated with endovascular treatment of cerebral aneurysms include access catheters, equipment utilization, personnel costs, and embolization materials. The costs of coiling aneurysms in general has been discussed,...