Giant Wide-neck Aneurysms Research Articles

Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck Aneurysms – SCENT: 3-year outcomes

BackgroundTo report the 3-year safety and effectiveness of the Surpass Streamline flow diverter in the SCENT trial (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide-Neck...

Treatment of large and giant posterior communicating artery aneurysms with the Surpass streamline flow diverter: results from the SCENT trial

BackgroundThe Surpass flow diverter was developed to treat intracranial aneurysms not amenable to standard treatment. Indications for use allow placement in the internal carotid artery to the terminus, including the...

Use of Surpass Streamline Flow Diverter for the Endovascular Treatment of Craniocervical Aneurysms: A Single-Institution Experience

Flow diversion has revolutionized endovascular treatment for cerebral aneurysms. The Surpass Streamline flow diverter (SSFD) has shown promise for expanding flow diversion device options for aneurysm treatment. SSFD differs from earlier stents by maintaining high porosity with increased pore density to ensure appropriate flow disruption. Given the delivery system's increased dimension options and potential greater flow-diverting properties, SSFD is poised to extend the anatomic and pathologic reaches of flow diversion therapy. Data pertaining to SSFD-treated aneurysms were gathered retrospectively between 2019 and 2020, including aneurysm location, size, symptoms, complications, and occlusions rates at follow-up. Size was categorized as small (<10 mm), large (10-25 mm), and giant (>25 mm) according to SCENT (Surpass Intracranial Aneurysm Embolization System Pivotal Trial to Treat Large or Giant Wide Neck Aneurysms) criteria. Aneurysm occlusion on follow-up imaging was characterized by Simple Measurement of Aneurysm Residual after Treatment (SMART) grading with adequate occlusion defined as grades 3 and 4. Imaging was performed at time of treatment and 6-month and 1-year follow-up. There were 42 aneurysms treated with SSFD throughout the cerebrovascular system: 3 cervical, 4posterior, and 35 intracranial anterior circulation. Complete occlusion rates at 6 months and 1 year were 48% and 57% with adequate occlusion achieved in 89.6% and 85.7%, respectively. Rates of complete occlusion were higher for small (69%) compared with large (38%) aneurysms. Our data suggest comparable complete occlusion rates compared with SCENT (66.1% vs. 57% in our center) and adequate occlusion rates. Similar occlusion rates to prior studies despite broadened inclusion criteria and diversity of treated aneurysms demonstrate favorable generalizability of flow-diverting technology to a wide array of aneurysmal pathology.

Pipeline for Distal Cerebral Circulation Aneurysms.

Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms. To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes. Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning. A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0±6 mm. The mean follow-up was 12 mo (SD=12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up. Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

Pipeline for uncoilable or failed aneurysms: 3-year follow-up results.

OBJECTIVE The long-term effectiveness of endovascular treatment of large and giant wide-neck aneurysms using traditional endovascular techniques has been disappointing, with high recanalization and re-treatment rates. Flow diversion with the Pipeline Embolization Device (PED) has been recently used as a stand-alone therapy for complex aneurysms, showing significant improvement in effectiveness while demonstrating a similar safety profile to stent-supported coil treatment. However, relatively little is known about its long-term safety and effectiveness. Here the authors report on the 3-year safety and effectiveness of flow diversion with the PED in a prospective cohort of patients with large and giant internal carotid artery aneurysms enrolled in the Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial. METHODS The PUFS trial is a prospective study of 107 patients with 109 aneurysms treated with the PED. Primary effectiveness and safety end points were demonstrated based on independently monitored 180-day clinical and angiographic data. Patients were enrolled in a long-term follow-up protocol including 1-, 3-, and 5-year clinical and imaging follow-up. In this paper, the authors report the midstudy (3-year) effectiveness and safety data. RESULTS At 3 years posttreatment, 74 subjects with 76 aneurysms underwent catheter angiography as required per protocol. Overall, complete angiographic aneurysm occlusion was observed in 71 of these 76 aneurysms (93.4% cure rate). Five aneurysms were re-treated, using either coils or additional PEDs, for failure to occlude, and 3 of these 5 were cured by the 3-year follow-up. Angiographic cure with one or two treatments of Pipeline embolization alone was therefore achieved in 92.1%. No recanalization of a previously completely occluded aneurysm was noted on the 3-year angiograms. There were 3 (2.6%) delayed device- or aneurysm-related serious adverse events, none of which led to permanent neurological sequelae. No major or minor late-onset hemorrhagic or ischemic cerebrovascular events or neurological deaths were observed in the 6-month through 3-year posttreatment period. Among 103 surviving patients, 85 underwent functional outcome assessment in which modified Rankin Scale scores of 0-1 were demonstrated in 80 subjects. CONCLUSIONS Pipeline embolization is safe and effective in the treatment of complex large and giant aneurysms of the intracranial internal carotid artery. Unlike more traditional endovascular treatments, flow diversion results in progressive vascular remodeling that leads to complete aneurysm obliteration over longer-term follow-up without delayed aneurysm recanalization and/or growth. Clinical trial registration no.: NCT00777088 (clinicaltrials.gov).

Combined Effects of Flow Diverting Strategies and Parent Artery Curvature on Aneurysmal Hemodynamics: A CFD Study.

PurposeFlow diverters (FD) are increasingly being considered for treating large or giant wide-neck aneurysms. Clinical outcome is highly variable and depends on the type of aneurysm, the flow diverting device and treatment strategies. The objective of this study was to analyze the effect of different flow diverting strategies together with parent artery curvature variations on altering intra-aneurysmal hemodynamics.MethodsFour ideal intracranial aneurysm models with different parent artery curvature were constructed. Computational fluid dynamics (CFD) simulations of the hemodynamics before and after applying five types of flow diverting strategies (single FD, single FD with 5% and 10% packing density of coils, two FDs with 25% and 50% overlapping rate) were performed. Changes in pressure, wall shear stress (WSS), relative residence time (RRT), inflow velocity and inflow volume rate were calculated and compared.ResultsEach flow diverting strategy resulted in enhancement of RRT and reduction of normalized mean WSS, inflow volume rate and inflow velocity in various levels. Among them, 50% overlapped FD induced most effective hemodynamic changes in RRT and inflow volume rate. The mean pressure only slightly decreased after treatment. Regardless of the kind of implantation of FD, the mean pressure, inflow volume rate and inflow velocity increased and the RRT decreased as the curvature of the parent artery increased.ConclusionsOf all flow diverting strategies, overlapping FDs induced most favorable hemodynamic changes. Hemodynamics alterations post treatment were substantially influenced by parent artery curvature. Our results indicate the need of an individualized flow diverting strategy that is tailored for a specific aneurysm.

Pipeline for Uncoilable or Failed Aneurysms: Results from a Multicenter Clinical Trial

To evaluate the safety and effectiveness of the Pipeline Embolization Device (PED; ev3/Covidien, Irvine, Calif) in the treatment of complex intracranial aneurysms. The Pipeline for Uncoilable or Failed Aneurysms is a multicenter, prospective, interventional, single-arm trial of PED for the treatment of uncoilable or failed aneurysms of the internal carotid artery. Institutional review board approval of the HIPAA-compliant study protocol was obtained from each center. After providing informed consent, 108 patients with recently unruptured large and giant wide-necked aneurysms were enrolled in the study. The primary effectiveness endpoint was angiographic evaluation that demonstrated complete aneurysm occlusion and absence of major stenosis at 180 days. The primary safety endpoint was occurrence of major ipsilateral stroke or neurologic death at 180 days. PED placement was technically successful in 107 of 108 patients (99.1%). Mean aneurysm size was 18.2 mm; 22 aneurysms (20.4%) were giant (>25 mm). Of the 106 aneurysms, 78 met the study's primary effectiveness endpoint (73.6%; 95% posterior probability interval: 64.4%-81.0%). Six of the 107 patients in the safety cohort experienced a major ipsilateral stroke or neurologic death (5.6%; 95% posterior probability interval: 2.6%-11.7%). PED offers a reasonably safe and effective treatment of large or giant intracranial internal carotid artery aneurysms, demonstrated by high rates of complete aneurysm occlusion and low rates of adverse neurologic events; even in aneurysms failing previous alternative treatments.

Stent-assisted Coiling of Complex Intracranial Aneurysms

Objective: To discuss the indications, technical details, and safety of endovascular treatment of complex intracranial aneurysms using coiling in combination with stent-assisted remodeling of the parent artery. Methods: Forty-one consecutive patients with complex intracranial aneurysms were treated with stent-assisted coiling. Three patients had double aneurysms that were located within 5mm. Nine patients had giant wide-necked aneurysms. Two patients had neck remnants at 2 years after the initial coiling. One patient had recurrent aneurysm at 3 years after the initial coiling. Twenty-six patients had acutely ruptured aneurysms. Neuroform, LEO and SolitaireAB stents, and Matrix, Orbit coils were used. Results: All endovascular procedures were performed uneventfully. There were no complications. Postoperative angiography showed complete dense packing (95% to 100%) in all aneurysms, except 2 giant aneurysms, which had subtotal embolization. In patients with acutely ruptured aneurysms, there was no intrastent thrombosis or stenosis of the stent lumen. Twenty-one patients underwent angiography at 3 to 6 months postoperatively. All of them showed a good outcome, except that one giant aneurysm showed a slight residual filling inside the sac. Discussion: Stent-assisted remodeling of the parent artery in combination with various types of coils can increase the cure rate of intracranial complex aneurysms. In patients with acutely ruptured aneurysms, antiplatelet drugs should be weighed against the risks of possible open surgeries. Although we have not encountered complications in our emergent cases without using antiplatelet drugs, we should still be cautious when deploying stent without anticoagulation treatment.

Intracranial Stenting in the Treatment of Wide-Necked Aneurysms

We positioned the following self-expanding stents certified for intracranial application: 16 Neuroform (Boston Scientific), three INX (Medtronic), one Leo (Balt). 6F calibre femoral introducers and guiding catheters were used for stent placement changing to 5F calibre introducers and guiding catheters (Envoy, Cordis) for the Neuroform 2 and 3 stents. All procedures were carried out under general anaesthesia and heparinization. Our pharmacological protocol consisted of adjunctive treatment with anti-aggregants during the interventional procedure and for the following six months, without premedication. From November 2000 to August 2006 we treated 28 patients (27 F/1M) with giant wide-necked aneurysms and one dissecting basilar artery aneurysm requiring the placement of 29 stents. We successfully positioned 20 stents: 11 stents combined with coils (8 immediate; 3 late) with complete exclusion of the aneurysm from the circulation in seven cases and subtotal exclusion in four; nine stents not followed by embolization with complete exclusion of the aneurysm from the circulation in six cases and subtotal exclusion in three. Stenting was not possible in nine cases due to extreme vessel tortuosity and the poor flexibility of release systems for the first stents. No late stent occlusion or subarachnoid haemorrhage were encountered after treatment.