Endovascular Treatment Of Complex Aneurysms Research Articles

Acute Complex Endovascular Aortic Repair - Off-the-shelf vs. Surgeon-modified Stent Grafts

Treatment of complex abdominal and thoracoabdominal aortic aneurysms is challenging. Open surgical repair is a high-risk operation, especially in emergency cases. Endovascular aneurysm repair with a patient-specific custom-made stent graft in patients with symptomatic or ruptured complex aortic aneurysms is not possible, due to the manufacturing time required. In such cases, alternative endovascular techniques can be used. The "off-the-shelf" and "surgeon-modified" stent grafts are valid options for the endovascular treatment of complex aneurysms in urgent and emergent patients. The former are standardised commercially manufactured fenestrated or branched stent grafts, which are available off-the-shelf with an anatomical feasibility in 50 - 80% of the patients. The "surgeon-modified" stent grafts refer to a technique, in which a commercially available stent graft is modified by the surgeon under sterile conditions directly before the implantation, in order to add the required fenestrations, scallops and/or branches. The modification takes approximately 60 - 120 min and haemodynamic stability of the patient is mandatory. Because of the off-label use of the commercial stent graft, detailed patient consent about the modification complications and risks should be performed whenever possible. A comparison of results on mortality and morbidity between "off-the-shelf" and "surgeon-modified" stent grafts has been published, although a direct comparison would be unfair for several reasons (different design, lack of extensive outcomes reports, long learning curve and different modification techniques). The "surgeon-modified" and "off-the-shelf" fenestrated/branched stent grafts are used in the treatment of high-risk patients with symptomatic or contained ruptured complex aneurysms. The outcomes of the two techniques are good, although the long-term durability of the former should be further investigated.

Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio

BackgroundEndovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge.The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization.MethodsWe report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019.ResultsEighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36–81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%.ConclusionThe Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

Percutaneous AXillary Artery (PAXA) Access at the First Segment During Fenestrated and Branched Endovascular Aortic Procedures

The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR). The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study (clinicaltrials.gov: NCT03223311). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery. Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69-78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received abare or covered stenting to the AXA and in one patient mechanical failure of the delivery system wasrecorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p=.002), oral anticoagulants therapy (p=.005) and procedure length (p=.028). Atshort term follow up (6 months), no late complications were observed, and all access vessels were patent. PAXA on the first segment using a large sheath (10-16F) is technically feasible, relatively safe withno need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.

Endovascular Treatment of Complex Aneurysms with the Use of Covera Stent Grafts.

To characterize the short-term results of a newly available self-expanding covered stent (Covera; CR Bard Peripheral Vascular Inc., Murray Hill, New Jersey) for the reconstruction of target vessels in complex aneurysms. From August 2017 to November 2018, this self-expanding covered stent was used in 17 patients (mean 72.6 ± 7.6 years of age) during endovascular aneurysm repair (EVAR) with hypogastric preservation (11.8%), branched EVAR (29.4%), fenestrated (F)-EVAR (17.6%), chimney+ F-EVAR (11.8%), or chimney EVAR (29.4%). In more than 48 stented arteries (2.8 ± 1.1/patient), 25 were preserved using this self-expanding covered stent. All target vessels were successfully preserved. There was no 30-day mortality and 1 in-hospital death. Intraoperative aneurysm exclusion was successful in 14 patients (82.4%) with a perioperative technical success rate of 82.4%. The actuarial survival rate was 93.8% at 6 months and 85.9% at 12 months. Aneurysm sac regression of >5 mm was observed in 4 cases (23.5%), and the sac remained stable in the remaining patients (13 cases [76.5%]). At 12 months, the primary clinical success rate was 76.5%, and assisted primary clinical success rate was 82.4%. No type 3 endoleak was related to a disruption of the reconstruction with the self-expanding covered stent. This new self-expanding covered stent provides good short-term patency in chimneys, branches, or fenestrations. Larger series with long-term follow-up are required to determine if the stent can sustain the mechanical stress to which it will be submitted in these repairs.

Silk flow-diverter stent for the treatment of complex intracranial aneurysms: A one-year follow-up multicenter study.

Background Flow-diverter stents have been successfully used in the treatment of complex aneurysms with limited therapeutic alternatives. We report our experience using the Silk flow diverter (SFD; Balt Extrusion, Montmorency, France) for the treatment of complex aneurysms in four Argentine centers. Methods We conducted a retrospective review of 246 consecutive patients who were treated with the SFD at four Argentine centers between January 2009 and January 2017. The patient and aneurysm characteristics, as well as the details of the procedure, were analyzed. The angiographic and clinical findings were recorded during and immediately after the procedure and at 12-month follow-up. Results Angiography follow-up at 12 months was possible in 235 patients (95.5%) with 282 aneurysms. A total of 265 aneurysms (93.9%) presented with complete occlusion of the aneurysmal sac (class 1) and 17 aneurysms (6.1%) presented with partial occlusion (class 2). The 12-month clinical follow-up showed 11 patients with major events (seven, scale 2; five, scale 3; and two, scale 4). The morbidity and mortality rates were 4.2% (11/289) and 2.1% (5/289), respectively. Conclusions The treatment of aneurysms with the SFD was associated with a low rate of complications and a high percentage of aneurysmal occlusion. These findings suggest that SFD is an effective and safe alternative in the endovascular treatment of complex aneurysms.

Technique for treating complex aneurysms with Hercules stent graft modified by the surgeon

Endovascular treatment of thoracoabdominal aneurysms with fenestrated stent grafts expands its applicability because of good technical results. However, stent graft customization requires an average of 6 to 12 weeks, which makes this technique ineligible for symptomatic or ruptured aneurysms. Authors advocate perioperative fenestration by the surgeon, allowing this technique to be used for emergency cases with good results and favorable prognosis. This article describes a technique for intraoperative changes of the Hercules stent graft (MicroPort Scientific Corporation, Shanghai, China) to include the ostia of visceral arteries by making fenestrations and scallops, with a temporary diameter-reducing wire as a further modification to facilitate positioning and catheterization of fenestrations with guidewires.

Long-term Radiographic Results of Stent-Assisted Embolization of Cerebral Aneurysms

Aneurysmal subarachnoid hemorrhage is a disabling disease. Endovascular coiling provides minimally invasive, effective, and safe treatment of both ruptured and unruptured intracranial aneurysms. Intracranial stents have improved the endovascular treatment of complex aneurysms, but the long-term durability of this treatment modality needs clarification. To elucidate the long-term success of intracranial stent use in the treatment of aneurysms. Four hundred ten patients were treated with stent-assisted endovascular management of 464 aneurysms. Treatment of 363 small aneurysms, 88 large aneurysms, and 13 giant aneurysms was analyzed with respect to both long-term anatomic results with digital subtraction angiography and magnetic resonance angiography over the follow-up period. The 6-month angiographic results of 387 aneurysm treatments revealed complete aneurysm occlusion in 282 (72.9%), residual aneurysm neck in 50 (12.9%), and residual aneurysm filling in 55 (14.2%). Long-term radiographic follow-up, performed in 262 patients (mean, 3.63 years), showed significant recurrence of only 3 aneurysms after 6-month follow-up imaging. Forty-eight aneurysms (11.9%) were considered radiographic failures during the follow-up period. The aneurysm recurrence rate after stent-assisted embolization in this series was similar to published data using only coil embolization for the period between treatment and the initial follow-up imaging. For aneurysms that do not initially recur, the presented data suggest improved durability in the subsequent long-term follow-up period. DSA, digital subtraction angiographyMRA, magnetic resonance angiography.

Endovascular Treatment of Complex Aneurysms at the Vertebrobasilar Junction With Flow-Diverting Stents

Large or giant complex vertebrobasilar junction aneurysms have a dismal natural history and are often challenging to treat with standard endovascular or neurosurgical techniques. To report initial experience with endovascular treatment of these aneurysms using flow-diverting stents (FDS). Ten patients with FDS treatment of complex vertebrobasilar junction aneurysms were collected from 4 large cerebrovascular centers. Clinical/angiographic presentation and outcome were retrospectively analyzed. Of 10 aneurysms, 7 presented with brainstem compression, 2 with ischemia, and 1 with subarachnoid hemorrhage, and 3 were recurrent after stent-assisted treatments. Eight were giant. Morphology was fusiform in 5, fusiform dissecting in 1, and multilobulated saccular in 4. Six were partially thrombosed. In addition to FDS (mean number of devices, 3.9; range, 1-9), contralateral vertebral artery sacrifice and adjunctive coiling were performed in 9 and 5 of the 10 patients, respectively. At follow-up, 5 of 10 were completely occluded, 4 showed minimal residual filling, and 1 was retreated with an additional FDS. Postinterventionally, worsening mass effect and ischemic complications were seen in 2 and 4 of 10, respectively. Clinical outcome was good in 6 (modified Rankin Scale score, 0-2). Four fatalities were related to sequelae of subarachnoid hemorrhage, late FDS thrombosis, progressive mass effect, and delayed intracranial hemorrhage. FDS may be used to treat complex vertebrobasilar junction aneurysms with overall good angiographic outcome. A combined reconstructive/deconstructive approach appears useful to avoid endoleaks. FDS strategies, like other endovascular and neurosurgical approaches to these lesions, are associated with significant risk and therefore should be reserved for those cases in which alternative approaches either are deemed unsafe or are likely to be ineffective. FDS, flow-diverting stentPED, Pipeline Embolization DeviceSAH, subarachnoid hemorrhageVA, vertebral arteryVBJ, vertebrobasilar junction.

Stent assisted coil embolization of wide-necked bilobed anterior inferior cerebellar artery aneurysm with incorporated artery arising from the dome: a technical note

BackgroundA technique for stent-assisted coil embolization of a bilobed wide-necked saccular aneurysm of the anterior inferior cerebellar artery (AICA) with the AICA arising from the dome of the aneurysm is...

Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms

Objective The Leo self-expandable stent is a new retractable stent that is delivered via a conventional catheter. The aim of this study was to evaluate the use of this stent for endovascular treatment of complex aneurysms. Methods Twenty-eight complex cerebral aneurysms (27 saccular and 1 fusiform) in 28 patients were treated electively. They were located at the internal carotid artery (17), basilar trunk (3), anterior cerebral artery (1), anterior communicating artery (3), vertebral artery (2) and middle cerebral artery (2). One aneurysm exhibited recanalization after primary endovascular treatment without stent. Clinical outcome was assessed with the modified Glasgow Outcome Scale. Results Deployment of Leo stent was successful in 26 lesions, and difficulties in stent positioning due to tortuous cerebral circulation in 2 cases, which were treated with Neuroform stent. Additional coil embolization was performed in 26 lesions. No permanent neurological deficits were encountered consequent to endovascular procedure. Complete or partial occlusion immediately after stent deployment was achieved in all aneurysms. There was no immediate coil embolization was chosen in 3 cases because of subsequent reduced filling of the aneurysms with contrast agent on angiograms. There were 3 asymptomatic parent artery occlusion related to the deployment of the Leo stent, one stent migration. Follow-up revealed patent stents in the remaining cases. No angiographic recurrences arose. Conclusion The Leo stent is very useful for endovascular treatment of complex cerebral aneurysms because it is easy to navigate and place precisely. A drawback is that in-stent thrombosis caused by stent placement and stiffer delivery catheters to place larger stents.

Branched devices for thoracoabdominal aneurysm repair: Early experience

This study reports the initial clinical results and experience with the planning of branched stent grafts in high-risk patients with thoracoabdominal aortic aneurysms (TAAAs). High-risk patients with TAAAs were considered for this study. Based on evaluation with computed tomography angiography (CTA), 21 custom-made branched stent grafts were designed for the selected patients. Two patients had associated bilateral aneurysms of the common iliac arteries, so an iliac branched device was also used. Between August 2006 and April 2008, 23 patients (10 women, 13 men) were selected to undergo endovascular TAAA repair. Mean age was 72 years old. Two patients were excluded after 1-mm-slice CTA analysis. Eleven patients have underdone TAAA repair so far. The mean follow-up period at present is 8 months (range, 18 days-21 months). Overall technical success was accomplished in all 11 patients. Two renal artery branches occluded. Operative times varied from 3 to 8 hours. Mean contrast volume was 193 mL (range, 48-420 mL). Eight patients required a stay of </=4 days at the intensive care unit. Three patients died. Two deaths were procedurally related: one patient died of myocardial infarction, and the other had ischemic cerebellar stroke and died 3 months later of pulmonary sepsis. The third patient was readmitted 3 days after hospital discharge and died of alcoholic pancreatitis. One man had permanent paraplegia. Two women had transitory paraparesis. Striking hematologic and systemic inflammatory abnormalities were observed. Increasing reports on stent graft technology indicate that this procedure might become a reality in the future for endovascular treatment of complex aneurysms in all aortic segments. Branched stent grafts seem to be feasible and can be offered as an effective alternative to most patients with TAAAs, especially for those who are currently excluded from open surgical procedures.