Endovascular Treatment Of Wide-necked Aneurysms Research Articles

The Role of Dual Antiplatelet in Stent-Assisted Coiling in Wide-Neck Aneurysm

Highlight: Dual antiplatelet is the gold standard for endovascular treatment of wide-neck aneurysms. The role of dual antiplatelet is to prevent stent thrombosis after treatment. The thrombosis rate reported during stent-assisted coiling is quite high. ABSTRACT Stent-assisted coiling (SAC) in wide-neck aneurysm treatment is associated with antiplatelet use. Dual antiplatelet therapy (DAPT) has been the gold standard for protecting against thrombosis events and is widely accepted for endovascular embolization treatment with a stent-assisted or flow diverter. Some patients experience vascular events due to the reduced efficacy of antiplatelet agents despite taking DAPT. The reported thrombosis rates during stent-assisted coiling embolization range from 2% to 20%. Thromboembolic complications, such as in-stent thrombosis, can manifest in 4.6% of cases. The correlation between platelet reactivity during treatment and bleeding events remains unclear. However, the association between High Residual Platelet Reactivity (HRPR) or hyporesponsiveness and ischemic events is well established. Based on various laboratory definitions, hyperresponsiveness in patients with clopidogrel occurs in about 14–30% of patients due to major and minor bleeding. Therefore, the optimization of antiplatelet therapy has developed significantly in the neurointerventional community.

Micro-snare retrieval as bail-out technique for a distally migrated WEB-device: A case report.

Intra-procedural intrasaccular device migration is an uncommon complication of endovascular treatment of wide-neck aneurysms. We report the case of a 52-years old Caucasian male who presented with a 3 × 3 mm posterior facing top of the basilar aneurysm in which treatment with WEB-SL (Woven EndoBridge-single layer) device was tempted. Inadvertent WEB migration in the right posterior cerebral artery occurred after detachment. Two retrieval attempts were performed using a combined technique with two different stent-retrievers and a 5-Fr distal access catheter. Upon WEBectomy attempt, the device rolled over the stents, and the passages were unsuccessful. The device was successfully removed using a microSnare, catching and retrieving it inside the 5-Fr distal access catheter. Micro-Snare is an effective bail-out technique to recover migrated intrasaccular WEB devices in cerebral arteries.

Endovascular treatment of wide-necked aneurysms of the visceral and renal arteries using the double microcatheter technique via a single access route

We aimed to evaluate the utility of and complications associated with the double microcatheter technique for the treatment of wide-necked visceral and renal artery aneurysms (VRAAs). Nine patients (mean age, 58 years; age range, 42-69 years; 4 men, 5 women) with wide-necked VRAAs who underwent treatment with the double microcatheter technique from January 2016 to July 2018 were included in the study. For all patients, anatomical features were confirmed using cone-beam computed tomography (CT) with rotational angiography. The aneurysmal location, size, volume, neck-to-dome ratio, number of coils used, and coil packing density were investigated. Technical success, complications (coil migration and organ ischemia), changes in the complete blood count or serum creatine level, and recurrence were also evaluated. Three renal artery aneurysms and 6 splenic artery aneurysms were treated by the double microcatheter technique. The mean size of the aneurysms was 26.09±4.76 mm, mean volume was 6.19±3.69 cm3, and mean neck-to-dome ratio was 1.53±0.24. The number of coils used ranged from 7 to 16. The mean packing density was 11.32%±3.72%. Technical success was achieved in all 9 patients. Renal ischemia occurred in two patients with renal artery aneurysm, one of whom showed minimal scar formation on follow-up CT after infarction. No coil migrations or disease recurrences were observed. The double microcatheter technique for the treatment of wide-necked VRAAs appears to be relatively safe and useful. However, complex renal artery aneurysm should be carefully managed in order to prevent infarction.

EndoVascular Treatment Of Wide-Neck Aneurysms, an EvaLuation of Safety and EffectiVeness of Stryker Surpass Evolve™ Flow Diverter System

EndoVascular Treatment Of Wide-Neck Aneurysms, an EvaLuation of Safety and EffectiVeness of Stryker Surpass Evolve™ Flow Diverter System

Initial and Long-Term Outcomes of Complex Bifurcation Aneurysms Treated by Y-Stent-Assisted Coiling with Low-Profile Braided Stents.

Coiling complex intracranial bifurcation aneurysms often necessitates the implantation of double stents in various configurations, such as Y-stent placement. Low-profile braided stents have been introduced recently to facilitate the endovascular treatment of wide-neck aneurysms. We aimed to investigate the feasibility, safety, efficacy, and durability of Y-stent-assisted coiling with double low-profile braided stents for the treatment of complex bifurcation aneurysms. A retrospective review was performed to identify patients who were treated using Y-stent-assisted coiling with low-profile braided stents. Technical success was assessed, as were initial and follow-up clinical and angiographic outcomes. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed using the modified Rankin Scale. Forty patients with 40 intracranial aneurysms were included in the study. Y-stent placement was successfully performed in all cases. Immediate postprocedural digital subtraction angiography images revealed total aneurysm occlusion in 72.5% of cases. The mean angiographic follow-up time was 24.8 months. The last follow-up angiograms showed complete occlusion in 85% of patients. During follow-up, only 1 patient showed an increase in the filling status of the aneurysm and that patient did not require retreatment. There was no mortality in this study. The overall procedure-related complication rate, including asymptomatic complications, was 17.5%. A permanent morbidity developed in 1 patient (2.5%). The long-term angiographic and clinical outcomes of this retrospective study demonstrate that Y-stent-assisted coiling using low-profile braided stents is an effective, relatively safe, and durable endovascular treatment for wide-neck and complex bifurcation aneurysms.

The Neuroform Atlas stent to assist coil embolization of intracranial aneurysms: a multicentre experience

ObjectiveTo assess the clinical safety and efficacy of the Atlas microstent in stent-assisted coil embolization of wide-necked intracranial aneurysms.MethodsSingle-center observational study in 36 patients (24 female, 12 male, mean age...

Does stent type impact coil embolization outcomes in extended follow-up of small-sized aneurysms (< 10mm)?

Self-expandable stents have enabled endovascular treatment of wide-necked aneurysms (ordinarily viewed as technically prohibitive), with favorable outcomes. However, the impact of stent type on occlusive stability has not been adequately investigated. In small-sized unruptured saccular aneurysms, we generated estimates of stent-assisted coil embolization outcomes during follow-up monitoring. Stent type and other risk factors linked to recanalization were analyzed. A cohort of 286 patients harboring 312 small-sized unruptured aneurysms (< 10mm) was subjected to mid-term and extended follow-up monitoring after stent-assisted coiling. Three types of stents (Enterprise, 192; Neuroform, 27; LVIS, 93) were deployed in this population; all medical records and radiologic data of which were reviewed. Mid-term recanalization rates and related risk factors were assessed using binary logistic regression analysis. A total of 49 aneurysms (15.7%) displayed recanalization at 6months postembolization, with 34 and 15 instances of minor and major recanalization, respectively. Multivariate analysis indicated that wide-necked aneurysms (> 4mm) (HR = 2.362; p = 0.017), incomplete occlusion at time of coiling (HR = 2.949; p = 0.002), and stent type (p = 0.048) were significant factors in mid-term recanalization, whereas hypertension (p = 0.095) and packing density ≤ 30% (p = 0.213) fell short of statistical significance. Compared with Enterprise (HR = 2.828) or Neuroform (HR = 4.206) stents, outcomes proved more favorable with use of LVIS. Above findings demonstrate that in addition to occlusive status at time of coil embolization and neck size, stent type may affect follow-up outcomes of stent-assisted coil embolization in small-sized aneurysms. LVIS (vs Enterprise or Neuroform stents) performed best during follow-up monitoring in terms of limiting recanalization.

Endovascular treatment of a complex broad neck bifurcation aneurysm at peripheral center by pconus stent: A new neck bridging device

Endovascular treatment of wide-necked aneurysms is a challenge in itself, especially, if branches are incorporated in the neck or base of the aneurysm. The problem is greater if the availability of technical resources and expertise is limited. Difficult endovascular treatment options in such cases include the use of double balloon remodeling and bilateral intracranial stents with associated higher complication rates. However, with availability of a new neck bridging device, treatment of such aneurysms is becoming relatively easy. We present a case of the ruptured basilar top aneurysm with incorporated bilateral posterior cerebral artery origins treated with pCONus stent-assisted coiling. We intend to draw the attention of neurointerventionists to newly available neck bridging device which has lower thrombogenicity than stents, require a shorter learning curve, are compatible with routine delivery catheters, can be deployed quickly and can be performed even on a single plane digital subtraction angiography equipment with minimal expertise.

Single-center experience with a dual microcatheter technique for the endovascular treatment of wide-necked aneurysms.

The endovascular treatment of wide-necked aneurysms can be technically challenging due to distal coil migration or impingement of the parent vessel. In this paper, the authors illustrate an alternative method for the treatment of wide-necked intracranial aneurysms using a dual microcatheter technique. The authors' first 100 consecutive patients who underwent coil embolization of a wide-necked aneurysm using a dual microcatheter technique are reported. With this technique, 2 microcatheters are used to introduce coils into the aneurysm. The coils are deployed either sequentially or concurrently to form a stable construct and prevent coil herniation or migration. Angiographic and clinical outcomes are reported. The technical success rate of the dual microcatheter technique is 91% with a morbidity and mortality of 1% and 2%, respectively. Clinical outcomes are excellent with 93% of patients demonstrating a modified Rankin Scale score of 0-2 at long-term follow-up regardless of their score at presentation. Retreatment rates are 18%. The dual microcatheter technique may be a safe and efficacious first line of treatment for widenecked aneurysms.

The LVIS Jr. microstent to assist coil embolization of wide-neck intracranial aneurysms: clinical study to assess safety and efficacy

This study was aimed to assess clinical safety and efficacy of the LVIS Jr. microstent in stent-assisted coil embolization of wide-neck intracranial aneurysms. IRB approved single-center interventional clinical study in 22 patients (10 females, 12 males, mean age 55, age range 33-74 years) for the endovascular treatment of wide-neck aneurysms. After obtaining informed consent, patients were included according to the following criteria: aneurysm fundus-to-neck ratio < 2 or neck diameter > 4 mm, and a parent vessel diameter of ≤3.5 mm. Primary end point for clinical safety was absence of death, absence of major or minor stroke, and absence of transient ischemic attack. Primary end point for treatment efficacy was complete angiographic occlusion according to the Raymond-Roy Occlusion Classification (RROC) immediately after the procedure and at follow-up after 3 and 6 months on magnetic resonance imaging (MRI). In 20/22 (91 %) of patients, the primary end point of safety was reached; in the two remaining patients, transient ischemic attack, but no permanent deficit was observed; in 16/22 (73 %), efficient occlusion (RROC1) was reached, and in 6/22 (27 %), a residual neck remained (RROC2). Single [seven with antegrade, two in crossover configuration, and four with "first-balloon-then-stent" (FBTS) technique] or double-stent (eight patients with Y configuration and one patient with X configuration) deployment was technically successful in all cases. Deployment of the LVIS Jr. microstent in various single- or double-stent configurations is safe and effective to assist the treatment of intracranial wide-neck aneurysms.

Stent-Assisted Coil Embolization of Wide-Necked Intracranial Aneurysms Using a Semi-Deployment Technique: Angiographic and Clinical Outcomes in 31 Consecutive Patients

We describe a modified stent-assisted coiling technique, named the semi-deployment technique, in the endovascular treatment of wide-neck aneurysms. Thirty-one consecutive patients with 31 wide-necked or fusiform intracranial aneurysms were treated with the semi-deployment technique. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcome and follow-up angiography were evaluated. In every case, the semi-deployment technique was successfully deployed. Immediate angiography demonstrated complete occlusion in 24 cases (77.4%), neck remnant in four cases (12.9%), and incomplete occlusion in three cases (9.7%). Procedural-related morbidity occurred in one patient (3.2%) but no procedural-related mortality. A favorable clinical outcome (Modified Ran-kin Scale score 0-2) was observed in 90.3% of the patients (average follow-up time, 23.1 months). No rehemorrhage of treated aneurysms occurred. Angiography follow-up was obtained in 22 cases (71.0 %). Three aneurysms (13.6 % of the follow-up angiograms) demonstrated recanalization. No delayed coil or stent migration was found. One patient had in-stent stenosis as a delayed complication. We found that the semi-deployment technique was helpful in the treatment of wide-neck aneurysms.

Treatment of a wide-necked aneurysm of the anterior cerebral artery using two Enterprise stents in “Y”-configuration stenting technique and coil embolization: a technical note

The endovascular treatment of wide-necked aneurysms remains challenging. The "Y"-stenting technique has been used for stent-assisted coil embolization of wide-necked bifurcation aneurysms. So far, this technique has been described for aneurysms of the basilar apex or the middle cerebral artery bifurcation and only for open stent systems using the Neuroform stent. We report a 52-year-old woman with recurrence of a wide-necked aneurysm of the anterior cerebral artery that was successfully retreated by stent-assisted coiling using the "Y"-stenting technique with the Enterprise stent system.

Evaluation of a Neck-Bridge Device to Assist Endovascular Treatment of Wide-Neck Aneurysms of the Anterior Circulation

Intracranial aneurysms with a wide-neck or an unfavorable dome-to-neck ratio may be difficult to treat properly and safely. Our aim was to evaluate the TriSpan neck-bridge device to assist coiling of wide-neck bifurcation aneurysms in the anterior circulation. In 14 patients, we performed 16 TriSpan-assisted coil embolizations with wide-neck bifurcation aneurysms of the anterior circulation. Eleven procedures were indicated for acutely ruptured aneurysms. Five were performed electively for the following: recurrent aneurysm after coil only (n = 1) or after TriSpan-assisted embolization (n = 2), aneurysm remnant after clipping (n = 1), and aneurysm incidentally found (n = 1). Procedural and clinical complications were recorded. Follow-up angiography was performed, and clinical outcomes were assessed by using the modified Rankin Scale score. TriSpan-assisted embolization was successful in 15/16 (93.8%) procedures, with complete occlusion in 2/16 (12.5%), near-complete occlusion in 10/16 (62.5%), and incomplete occlusion in 3/16 (18.75%). There were 6 (37.5%) intraprocedural complications: thrombus formation (n = 3), protrusion of a TriSpan loop in the parent artery (n = 1), TriSpan displacement in the aneurysm (n = 1), and tangling of a coil loop in the device (n = 1). Three patients died in the hospital (21.4%). Follow-up angiography or MR angiography was available in 8 (57.1%) patients and showed complete (n = 2), near-complete (n = 2), and incomplete occlusion (n = 4). Long-term clinical outcome was no (n = 4) or minor symptoms (n = 1) and moderate (n = 2), moderately severe (n = 2), or severe handicap (n = 2). The use of the TriSpan device is feasible in the anterior circulation and can assist treatment of difficult wide-neck bifurcation aneurysms.

Utility of catheter-assisted Guglielmi detachable coiling in the treatment of wide-necked aneurysms

Catheter-assisted Guglielmi detachable coiling (CAGDC) is a technical option that was developed to allow the endovascular treatment of wide-necked aneurysms. We report upon our experiences of the CAGDC in treating aneurysms with an assessment of its efficacy and safety. The effect of CAGDC of wide-necked aneurysms was retrospectively evaluated in 10 patients (5 females, 5 males, mean age 56, range 40-76 yrs) who underwent the procedure. All the aneurysms were successfully embolized with CAGDC. Eight patients presented with SAH from an acutely ruptured aneurysm. Six patients were available for an angiographic follow up (mean: 10.3 months, range: 6-12 months). At the angiographic follow-up, all the aneurysms were stable and occluded (3 aneurysms with complete and 3 with near complete packing of the sac and neck). Complications directly related to the procedure were encountered in two patients (one coil migration, one thrombo-embolism). Three patients died as a result of complication of subarachnoid hemorrhage. CAGDC is a viable option for the treatment of wide neck aneurysms prior to balloon (or stent) assisted coil embolization.

A Novel Microcatheter-Delivered, Highly-Flexible and Fully-Retrievable Stent, Specifically Designed for Intracranial Use

A new microcatheter-delivered, highly-flexible, fully-retrievable intracranial stent has been developed in order to facilitate the endovascular treatment of wide-necked aneurysms, though it might also prove useful for other intracranial pathology. The nitinol stent has radiopaque proximal and distal markers, is available in a wide range of sizes and is as flexible as a micro-guidewire. It is electrolytically detached, allowing retrieval even after full deployment. The stent is compatible with all currently available embolic agents and does not degrade MR images.

Utility of Balloon-Assisted Guglielmi Detachable Coiling in the Treatment of Cerebral Aneurysms

Balloon-assisted Guglielmi detachable coiling (BAGDC) is a new technical option developed to allow endovascular treatment of wide-necked aneurysms. Aim of the following work is to report a single center experience of BADGC of aneurysms with assessment of its efficacy and safety. BAGDC of wide-necked aneurysms (SNR close to 1) was retrospectively evaluated in 37 patients (28 females, nine males, mean age: 56.6 yrs, range: 27-81 yrs) who underwent the procedure between january 1999 and january 2002 for a total of 45 procedures on 41 aneurysms.Twenty- nine patients presented with SAH from an acutely ruptured aneurysm. In two patients BAGDC failed whereas 35 patients successfully underwent BADGC (39 aneurysms). Twenty-nine patients (31 aneurysms) were available for angiographic follow- up (mean: 10 mo, range: 3-24 mo). At the last angiographic follow-up 29/33 aneurysms (87%) resulted stable and occluded (22 aneurysms with dense and seven with loose packing of the sac and the neck), two aneurysms showed regrowth, one aneurysm showed a neck remnant and another one a sac and neck remnant. Complications directly related to the procedure occurred in five patients (three perforations, one thromboembolism, one femoral AV) with a mortality and morbility rate of 2.7 and 5.4 respectively. BAGDC is a promising adjunct to treatment of wide-necked aneurysms broadening the spectrum of indications for endovascular treament of challenging aneurysms.

Endovascular Management of Wide-Necked Aneurysms

Learning Objectives: After reading this article, the participant should be able to: Recall the causes of difficulties that arise in endovascular treatment of wide-necked aneurysms. Describe the indications, techniques, and potential complications of the endovascular treatment of wide-necked aneurysms. Identify the currently available and potential future options to be used in the endovascular treatment of wide-necked aneurysms.

Ion Implantation and Protein Coating of Detachable Coils for Endovascular Treatment of Cerebral Aneurysms: Concepts and Preliminary Results in Swine Models

Complete anatomic obliteration remains difficult to achieve with endovascular treatment of wide-necked aneurysms using Guglielmi detachable platinum coils (GDCs). Ion implantation is a physicochemical surface modification process resulting from the impingement of a high-energy ion beam. Ion implantation and protein coating were used to alter the surface properties (thrombogenicity, endothelial cellular migration, and adhesion) of GDCs. These modified coils were compared with standard GDCs in the treatment of experimental swine aneurysms. In an initial study, straight platinum coils were used to compare the acute thrombogenicity of standard and modified coils. Modified coils were coated with albumin, fibronectin, or collagen and underwent Ne+ ion implantation at a dose of 1 x 10(15) ions/cm2 and an energy of 150 keV. Coils were placed in common iliac arteries of 17 swine for 1 hour, to evaluate their acute interactions with circulating blood. In a second study, GDCs were used to treat 34 aneurysms in an additional 17 swine. GDCs were coated with fibronectin, albumin, collagen, laminin, fibrinogen, or vitronectin and then implanted with ions as described above. Bilateral experimental swine aneurysms were embolized with standard GDCs on one side and with ion-implanted, protein-coated GDCs on the other side. The necks of aneurysms were evaluated macroscopically at autopsy, by using post-treatment Day 14 specimens. The dimensions of the orifice and the white fibrous membrane that covered the orifice were measured as the fibrous membrane to orifice proportion. Histopathological evaluation of the neck region was performed by light microscopy and scanning electron microscopy. Fibronectin-coated, ion-implanted coils showed the greatest acute thrombogenicity (average thrombus weight for standard coils, 1.9 +/- 1.5 mg; weight for fibronectin-coated coils, 8.6 +/- 6.2 mg; P < 0.0001). By using scanning electron microscopy, an intensive blood cellular response was observed on ion-implanted coil surfaces, whereas this was rare with standard coils. At Day 14, greater fibrous coverage of the necks of aneurysms was observed in the ion-implanted coil group (mean fibrous membrane to orifice proportion of 69.8 +/- 6.2% for the ion-implanted coil group, compared with 46.8 +/- 15.9% for the standard coil group; P = 0.0143). The results of this preliminary experimental study indicate that ion implantation combined with protein coating of GDCs improved cellular adhesion and proliferation. Future application of this technology may provide early wound healing at the necks of embolized, wide-necked, cerebral aneurysms.