O'Kelly-Marotta Research Articles

Arterial spin labeling detects trapped labeled spins in flow-diverted aneurysms and it reflects intra-aneurysmal flow stasis.

This study evaluated arterial spin labeling (ASL) imaging findings in flow-diverted aneurysms (FD-ANs). Twenty-one patients with internal carotid artery aneurysms treated with flow-diverter stent (FDS) were included. Time-of-flight magnetic resonance angiography (TOF-MRA) and ASL were performed before and after follow-up digital subtraction angiography (DSA) on the day, 6 months, and/or 1 year after treatment. Two radiologists rated the clarity of the depiction of FD-ANs for MRA on a 3-point scale and the ASL signal intensity of the aneurysm as negative or positive. A neurosurgeon assessed DSA findings using the O'Kelly-Marotta (OKM) grading scale, categorizing them into filling and stasis grades. The 23 examinations were classified according to the OKM grading scale, and the proportion of ASL-positive cases and the proportion of cases with MRA scores of 1-2 (detectable) were calculated for each grade. The relationship between the OKM grading scale and ASL positivity or MRA detectable was examined using Fisher's exact test. Of seven examinations where the statis grade was 1 or 2, no examinations showed ASL positivity. However, among the 16 examinations in which the stasis grade was 3, 9 examinations showed ASL positivity. A significant association was observed between stasis grade and ASL positivity (p = 0.035). In contrast, no significant relationship was observed between the OKM grading scale and the MRA 3-point scale. High-signal ASL in FD-ANs could reflect stasis within the aneurysm; therefore, noninvasive ASL can indicate reduction in intra-aneurysmal blood flow after treatment and reperfusion during posttreatment observation.

Predicting the O'Kelly-Marotta scale score after flow-diverter stent placement using silent MRA.

Flow-diverter (FD) stents were developed to treat aneurysms that are difficult to treat with conventional coiling or surgery. This study aimed to compare usefulness of Silent MRA and TOF (time of flight) -MRA in patients with aneurysms after FD placement. We retrospectively collected images from 22 patients with 23 internal carotid artery aneurysms treated with FD. Two radiologists conducted MRA and DSA experiments. In the first reading experiment, the radiologists evaluated the aneurysm filling by employing Silent MRA and TOF-MRA and utilizing the modified O'Kelly-Marotta (OKM) scale, a four-class classification system for aneurysms after FD placement. We then calculated the agreement between the modified OKM scale on MRA and the original OKM scale on DSA. In the second reading experiment, the radiologists rated blood flow within the FD using a five-point scale. The weighted kappa value of the OKM scale between DSA and TOF-MRA was 0.436 (moderate agreement), and that between DSA and Silent MRA was 0.943 (almost perfect agreement). The accuracies for the four-class classification were 0.435 and 0.870 for TOF-MRA and Silent MRA, respectively. The mean score of blood flow within FD for TOF-MRA was 2.43 ± 0.90 and that for Silent MRA was 3.04 ± 1.02 (P < 0.001). Silent MRA showed a higher degree of agreement than TOF-MRA in aneurysm filling with DSA. In addition, Silent MRA was significantly superior to TOF-MRA in depicting blood flow within the FD. Therefore, Silent MRA is clinically useful for the follow-up of patients after FD placement.

Preliminary results of intracranial aneurysm treatment with derivo2heal embolization device

IntroductionThe Derivo 2 Heal Embolization Device (D2HED) is a novel flow diverter (FD) providing a fibrin-/heparin-based surface coating aiming at lower thrombogenicity. We evaluate periprocedural aspects and preliminary aneurysm occlusion efficacy for intracranial aneurysm treatment.MethodsThirty-four D2HEDs deployments (34 aneurysms, 32 patients) between 04/2021 and 10/2023 were analyzed. All patients were under dual antiplatelet therapy (dAPT). Periprocedural details, adverse events, and follow-up (FU) imaging were reviewed by consultant-level neuroradiologists. Complication rates and aneurysm occlusion efficacy are compared with performance data of other FDs based on literature research.ResultsEach intervention succeeded in the deployment of one D2HED. Significant and/or increased intraaneurysmal contrast stagnation immediately after D2HED deployment was seen in 73.5% of cases according to O’Kelly-Marotta (OKM) grading scale. Clinically relevant early adverse events occurred in three patients: Among them two cases with fusiform aneurysms in the posterior circulation (ischemic events, early in-stent-thrombosis) and one patient (ischemic event) out of the majority of 31 treated internal carotid artery aneurysms (3,2%). Regarding mid-term FU (> 165 days), one aneurysm did not show progressive occlusion presumably caused by a prominent A1 segment arising from the terminal ICA aneurysm itself. Apart from that, mid-term complete / partial occlusion rates of 80% / 20% could be demonstrated.ConclusionOur case series - although suffering from restricted sample size - suggests a potential effectiveness of D2HED in managing intracranial aneurysms. Further studies with larger samples are warranted to quantify long-term occlusion efficacy and the impact of antithrombogenic surface coating on the necessary (d)APT.

Safety and efficacy of coated flow diverters in the treatment of ruptured intracranial aneurysms: a retrospective multicenter study

BackgroundThis multicenter study evaluated the safety and efficacy of coated flow diverters (cFDs) for the treatment of ruptured intracranial aneurysms.MethodsConsecutive patients treated with different cFDs for ruptured aneurysms under tirofiban...

213 Acute Flow Diversion for Ruptured Cerebral Aneurysms Arising From Vessels of Small Caliber Using FRED Jr: A Clinical Case Series

INTRODUCTION: Ruptured aneurysms arising from small caliber (&lt;2.5 mm) or distal vessels beyond the circle of Willis are considered challenging for all treatment modalities. Recently, the FRED Jr stent, designed for flow diversion in small arteries, was approved in the US for the treatment of non-ruptured aneurysms. METHODS: Clinical and radiological records of patients sustaining SAH treated with FRED Jr between June 2020 and October 2022 were reviewed. Treatment course including anti-platelet therapy, external ventricular drain (EVD) management, and vasospasm, as well as clinical outcomes were analyzed. Angiographic results were assessed according to the O’Kelly-Marotta (OKM) scale. RESULTS: Nine patients with at a median age of 62 (27-75) were included. The median Hunt Hess score was 2 (IQR 1) and modified Fischer score was 4 (IQR 1). Six aAneurysms’ morphologies included were saccular (6 case), 1 blister (1 case) and 2 were and dissecting (2 cases) type, located at the ACOM complex (3), A2/A3 (3), M2/M3 (1), V4 (1), and P2 (1) segments. All stents were deployed successfully with no intraprocedural complications. Post-operatively, no re-bleeding events were encountered. Vasospasm therapy was initiated in 6 cases, and no symptomatic EVD-related hematomas were observed. Post- operative ischemic events were encountered in 2 cases. Median 3-month mRS was 2 (IQR 1) for the7 surviving patients, and 3-months radiographic follow-up revealed OKM scale D in 4/7 cases. CONCLUSIONS: Flow diversion as a potential treatment strategy for acutely ruptured aneurysms arising from small caliber vessels is feasible using FRED Jr. Since As the complication profile reported in this series is comparable to historical microsurgical cohorts and effective protection was conferred by this treatment modality, our small cohort provides a glimpse into acute flow diversion for this subset of difficult-to-treat aneurysms.

310 The Derivo 2 Heal Embolization Device in the Treatment of Ruptured and Unruptured Intracranial Aneurysms: A Retrospective Multicenter Analysis

INTRODUCTION: The Derivo 2 Flow diverter has been previously described for the treatment of intracranial aneurysms. To overcome the risk of in-stent thrombosis and thrombo-embolism as a well-known risk of intracranial flow diverter implantation, the device was modified by adding an antithrombogenic fibrin-heparin coating. The fibrin network aims at surface passivation, reduction of inflammatory reactions and building a scaffold for endothelial cells. The covalently bound heparin reduces the thrombogenicity by locally reducing platelet activation and inhibtion of the coagulation cascade. METHODS: We perform a retrospective multicenter, single-arm trial at seven neurovascular centers. Patients treated with the D2H for unruptured or ruptured intracranial aneurysms are included in the study. The primary endpoint is angiographic aneurysm occlusion at six months as assessed by the O’Kelly-Marotta (OKM) grading scale. Clinical outcome is evaluated after intervention and at six months with major morbidity defined as modified Rankin Scale scores (mRS) of 3-5. RESULTS: Between October 2021 and March 2023 56 patients with ruptured and unruptered intracranial aneurysms were treated with the D2H embolization device and included in our analysis. All patients were subjected to the regular antiplatelet pre- and post-treatment medication as per standard of care in the respective institutions with no deviations being reported. No differences in terms of technical device properties were observed. By the time of the conference, data evaluation will be completed and clinical as well as safety results including angiographic follow-up will be available. CONCLUSIONS: The Derivo 2 heal Flow Diverter is a promising antithrombogenic coated device for the treatment of ruptured and unruptured intracranial aneurysms. Early post-interventional and long-term results will provide further insight into the effect of antithrombogenicity and endothelial healing.

Use of the Tubridge flow diverter in the treatment of intracranial aneurysms: a single center experience

To investigate the safety and effect of Tubridge flow diverter deployment for the treatment of intracranial aneurysms, 85 patients with intracranial aneurysms treated with the Tubridge flow diverter were retrospectively enrolled. The clinical data including the baseline data, aneurysm parameters before and after treatment, and follow-up outcomes were assessed. Among 85 patients, there were 35 (41.2%) males and 50 females (58.8%) aged 17–77 (mean 56.7 ± 11.1) years with 110 aneurysms. Five (5.9%) patients initially presented with subarachnoid hemorrhage from aneurysm rupture. The aneurysm size was 2–30 (mean 8.6) mm, and the aneurysm neck was 2–10.6 (mean 5.7 ± 2.3) mm. Ninety-three Tubridge stents were deployed. Twenty-five (29.4%) patients experienced adjunctive loose coiling. Blood flow was significantly reduced from entering the aneurysm after stent deployment. Periprocedural complications occurred in three (3.5%) patients, including in-stent thrombosis during embolization in one patient (1.2%), conjunctiva edema on the right in one patient (1.2%), and acute multiple cerebral infarctions in one patient (1.2%). Angiographic follow-up was conducted in 67 (78.8%) patients 3–36 (mean 15.3 ± 5.6) months later. In 11 (16.4% or 11/67) patients, blood flow still entered the aneurysm with the O’Kelly-Marotta (OKM) grade B in two (3.0%) patients and grade C in nine (13.4%), whereas complete occlusion (OKM grade D) was achieved in the other 56 (83.6% or 56/67) aneurysms. In-stent stenosis was present in five (7.5%) patients with approximately 25% stenosis in three (4.5%) patients and 50% in two (3.0%). In conclusion, the Tubridge flow diverter can be safely and efficiently applied in the treatment of small and large intracranial aneurysms, with a low periprocedural complication rate, a high occlusion degree, and a low in-stent stenosis rate at follow-up even though large aneurysms may necessitate a longer surgical time and adjunctive coiling.

Abstract TP151: Usefulness of 3D I-Flow Application in Predicting the Outcome of Flow Diverter Stenting for Large or Giant Carotid Aneurysms

Background and Purpose: The flow diverter (FD) has dramatically improved the treatment outcome of large / giant internal carotid artery (IC) aneurysms. However, it is difficult to predict the treatment outcome of FD just after the treatment. 3D iFlow is a novel application of 4D-digital subtraction angiography (4D-DSA) that can evaluate the arrival time of contrast media in 3D images, but its usefulness for neurointervention is unclear. Therefore, the aim of this study was to elucidate the utility of 3D iFlow in predicting the outcome of FD treatment for large / giant IC aneurysms. Methods: A total of 8 cases of large / giant aneurysms at IC cavernous portion treated with FD and were enrolled in this study. 3D iFlow images before and after placement of FD were acquired in all cases. Treatment outcome was evaluated by O’Kelly-Marotta(OKM) Grading Scale with DSA 6 months after treatment. The regions of interests (ROI) were set in IC bifurcation and petrous segment with 3D iFlow application, and the 3D iFlow transit time was measured by comparing the peak contrast intensities in 2 ROIs. We investigated the rate of changes in 3D iFlow transit time before and after the placement of FD. Results: FD was deployed successfully in all cases without coils. The number of OKM grade B, C and D with DSA 6 months after treatment were 2, 3 and 3 cases, respectively. The rate of changes in 3D iFlow transit time was significantly shorter in OKM grade D cases compared with grade B and C (52.5% vs 84.7%, p=0.03). Conclusion: 3D iFlow application may be effective to predict the treatment outcome of FD.

Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series.

Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.

291 Internal Carotid Artery Aneurysms Treated with Fred, Silk, and Pipeline Stents: A Cross-Sectional Study

Abstract Objective Intracranial aneurysms (IAs) are present in ∼ 2 to 5% of the population. Several treatments have been used, including endovascular options such as flow diverter devices (FDDs). The present study retrospectively analyzed the effectiveness of three FDDs in the treatment of 291 aneurysms in the internal carotid artery. The devices analyzed were the flow-redirection endoluminal device (FRED), the SILK Embolization Device and the PIPELINE Embolization Device (PED). Method This is a cross-sectional study which evaluates the outcome of control arteriography. The O'Kelly-Marotta (OKM) Scale was used to assess the degree of filling and flow stasis in the aneurysm 12 months after surgery. Results Conjoining the result of the three devices, most aneurysms (87.9%) were from the classification C-D, that is, they presented complete or almost complete aneurysmal occlusion. However, 6.6% did not obtain aneurysm occlusion, so they were classified as belonging to group A. In group B, a subocclusion was presented in 5.5%. In addition, by analyzing individually the result of each device, there was a bigger proportion of those classified in the group A among those who used SILK and in the group C-D among those who used FRED. Regarding complications, 10 cases were found, corresponding to 4.23% of all 236 patients. Therefore, four of these patients had complications when treated with PED; this proportion is higher than expected concerning the other groups. Conclusion The three devices are safe choices. Particularly, the FRED was found to be the most effective in treating internal carotid artery aneurysms.

FRED Jr stent for acute flow diversion in ruptured cerebral aneurysms arising from small-caliber vessels: a clinical case series.

Treatment of ruptured aneurysms arising from small-caliber (< 2.5 mm) or distal vessels beyond the circle of Willis is considered challenging with all treatment modalities. Recently, the Flow Re-Direction Endoluminal Device Junior (FRED Jr) stent, designed for flow diversion in small arteries, was approved in the United States for the treatment of nonruptured aneurysms. Here, the authors report their experience using this device in the setting of subarachnoid hemorrhage (SAH). Clinical and radiological records of patients sustaining SAH treated with a FRED Jr stent between June 2020 and October 2022 were reviewed. Treatment course, including antiplatelet therapy, external ventricular drain (EVD) management, and vasospasm, and clinical outcomes were analyzed. Angiographic results were assessed according to the O'Kelly-Marotta (OKM) grading scale. Nine patients at a median age of 62 (range 27-75) years were included. The median Hunt and Hess grade was II (IQR I) and the median modified Fisher grade was 4 (IQR 1). Aneurysm morphology types included saccular (6 patients), blister (1 patient), and dissecting (2 patients), and the aneurysms were located at the anterior communicating artery complex (n = 3) at the A2/A3 (n = 3), M2/M3 (n = 1), V4 (n = 1), and P2 (n = 1) arterial segments. All stents were deployed successfully with no intraprocedural complications. Postoperatively, no rebleeding events were encountered. Vasospasm therapy was initiated in 6 patients, and no symptomatic EVD-related hematomas were observed. Postoperative ischemic events were encountered in 2 patients. The median 3-month modified Rankin Scale score was 2 (IQR 1) for the 7 surviving patients, and 3-month radiographic follow-up revealed OKM grade D in 4 of 7 patients. Flow diversion using the FRED Jr stent is feasible as a potential treatment strategy for acutely ruptured aneurysms arising from small-caliber vessels. The complication profile reported in this series is comparable to those of historical microsurgical cohorts, and effective protection was conferred by this treatment modality. Therefore, our small cohort provides a glimpse into a new tool for successfully achieving acute flow diversion for this subset of difficult-to-treat aneurysms.

Safety and efficacy of pipeline embolization device treatments for intradural internal carotid artery aneurysms in a single center in a Japanese population.

The pipeline embolization device (PED) is the most common flow diverter device in the world. To date, there have been no reports of treatment outcomes specific to intradural internal carotid artery (ICA) aneurysms. The safety and efficacy of the PED treatments for intradural ICA aneurysms are reported. 131 patients with 133 aneurysms underwent PED treatments for intradural ICA aneurysms. The mean aneurysm dome size and neck length were 12.7 ± 4.3 mm and 6.1 ± 2.2 mm, respectively. We used adjunctive endosaccular coil embolization for 88 aneurysms (66.2%). A total of 113 aneurysms (85%) were angiographically followed up 6 months following the procedure, and 93 aneurysms (69.9%) were followed up for 1 year. The angiographic outcome at 6 months showed that 94 (83.2%) aneurysms had O'Kelly-Marotta (OKM) grade D, 6 (5.3%) had C, 10 (8.8%) had B, and 3 (2.7%) had A. At 1 year, 82 (88.2%) aneurysms had OKM grade D, 6 (6.5%) had C, 3 (3.2%) had B, and 2 (2.2%) had A. Multivariate analysis showed that aneurysm neck size and adjunctive coiling were statistically significant in aneurysm occlusion status. Major morbidity modified Rankin Scale >2 and mortality rates related to procedures were 3.0% and 0%, respectively. Delayed aneurysm ruptures were not observed. These results reveal that PED treatment of intradural ICA aneurysms is safe and efficacious. The combined use of adjunctive coil embolization not only prevents delayed aneurysm ruptures but also contributes to an increase in the rate of complete occlusion.

Flow diverters in the treatment of unruptured vertebral artery dissecting aneurysm: A single-center experience.

To evaluate the efficacy and safety of flow diverters (FD) in the treatment of vertebral artery dissecting aneurysm (VADA). A total of 16 patients with 17 unruptured VADAs treated with FD from January 2017 to May 2021 were included. Data of clinical outcomes and radiographic examination were collected and assessed by the modified Rankin Scale (mRS) and O'Kelly-Marotta (OKM) grading scale. All patients were treated with a single FD. No perioperative complications occurred. The mean age was 55.1 years old. The mean size of the aneurysm was 10.4 mm. All patients had a favorable occlusion (OKM D + C3) result and the complete occlusion rate in the 6th month was 66.7% (OKM D). The mean clinical follow-up time was 7.8 months, and all patients had a good clinical outcome (mRS = 0). No procedure-related complication occurred at the last follow-up time. FD is an effective and safe tool for treating unruptured VADA. Long-term prospective studies with a large sample are still needed to confirm these findings in the future.

Endovascular treatment of unruptured cavernous carotid aneurysms using flow diverter devices in Vietnam: A single-center prospective study

ObjectiveThis prospective study aims to investigate the safety and effectiveness of flow diverter (FD) in the treatment of unruptured cavernous carotid aneurysms (CCAs) in Vietnam. MethodsA single-center, prospective case series of 32 patients with unruptured CCAs treated by FD at our center from January 2017 to January 2022 was performed. We analyzed the aneurysm characteristics, procedure details, aneurysm occlusion rate, evolution of clinical symptoms, complications, and functional outcomes after treatment. Angiographic study was scheduled at the 6-month and 12-month follow-up. The occlusion rate was evaluated according to the O’Kelly-Marotta (OKM) Scale. Results35 FDs were deployed to treat 32 unruptured CCAs in 32 patients (mean age, 59.25; mean aneurysm size, 12.13 mm). Stent implantation was successful in all patients. Single FD was used in 29 cases (90.6%). Adjunctive coils were placed in five patients (15.6%). Complete aneurysm occlusion was achieved in 61.3% at 6 months and 96.4% at 12 months. Favorable outcome defined as mRS 0–2 was reported in all except one patient. Complete resolution or significant improvement of clinical symptoms was noted in 29 of 30 symptomatic patients (96.7%). Periprocedural complications included vessel perforation with severe SAH leading to death in one case (3.1%), minor vasospasm in four (12.5%), acute in-stent thrombosis in two (6.3%), and puncture-related hematoma in two (6.3%). All of these patients were successfully managed without clinical sequalae after the procedure except for one case. ConclusionFD represents a safe and effective treatment modality that might be considered as a valuable alternative to standard endovascular coiling techniques or carotid sacrifice for unruptured CCAs.

The DERIVO®2 Embolization Device in the treatment of ruptured and unruptured intracranial aneurysms: A multicenter analysis.

Flow diverters are an increasingly used treatment option for intracranial aneurysms. A recent addition to the European market is the DERIVO®2 Embolization Device (DED2), promising improved radiopacity. We aimed to assess the safety and efficacy of the DED2 regarding angiographic and clinical outcomes in ruptured and unruptured cerebral aneurysms. We performed a multicenter trial at six interventional centers. Data were prospectively collected and all patients treated with the DED2 were included. The primary endpoint was angiographic aneurysm occlusion at 6 months as assessed by the O'Kelly Marotta (OKM) grading scale with a favorable outcome definition of OKM C + D. Clinical outcome was evaluated according to the modified Rankin scale (mRS). Between August 2020 and July 2021, 37 patients were treated with the DED2 and were included in our analysis. Five patients presented with ruptured aneurysms. Median age was 60 years, 27 patients were female, and 10 male. Median mRS was 0 (range 0-4). Mean aneurysm size was 8.9 ± 7.1 mm with a mean neck size of 6.5 ± 6.1. The DED2 fully opened at deployment in all cases. Clinical follow-up was available for 30 patients (81%). Twenty-five (83%) had an mRS of 0 or 1. Three patients with ruptured aneurysms died during the follow-up period. No treatment-related major morbidity was observed. Follow-up imaging was available in 27 (90%) patients, with 23 patients (85%) showing satisfactory aneurysm occlusion OKM grade C-D. In this small cohort, the DED2 provided safe and effective treatment of ruptured and unruptured intracranial aneurysms.

Flow diversion effect of the leo braided stent for aneurysms in the posterior and distal anterior circulations: A multicenter cohort study.

Background and purposeThe treatment of aneurysms located in the posterior and distal anterior circulations remains a challenge. Leo stents with a flow diversion (FD) effect may be a potential option, which needs to be clearly studied.MethodsFrom January 2016 to October 2021, 133 patients with 145 aneurysms in the posterior and distal anterior circulations, treated with Leo stents, were retrospectively analyzed in three neurosurgical centers. Data on demographic information, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were retrospectively analyzed.ResultsAfter immediate surgery, 90 aneurysms (60.1%) were in complete occlusion [Raymond-Ray Occlusion Class (RROC) 1 and O'Kelly Marotta (OKM) grade D], 29 aneurysms (20%) in good occlusion (RROC 2 and OKM grade C), 17.9% in incomplete occlusion (RROC 3a or OKM grade B), and no aneurysms in invalid occlusion (RROC 3b and OKM grade A). A total of 112 patients with 117 aneurysms received angiographic follow-up (mean 11.4 months), and the degree of occlusion showed a significant improvement (Z = 3.900, p < 0.001). The complete occlusion rate increased to 84.6% (99/117), while good and incomplete occlusion decreased to 6.8% (8/117) and 8.6% (10/117), respectively. A total of 14 cases (10.5%) presented narrowing of the parent artery, and nine cases (6.8%) had injured side branches. Cerebral hemorrhage occurred in four patients (3.0%), and symptomatic ischemic infarction occurred in six patients (4.5%). The final permanent morbidity (mCS ≥3) and mortality were 2.8% (3/133) and 0.8% (1/133), respectively. For 82 aneurysms treated by stent-assisted with coiling (SAC), large-sized, ruptured aneurysms (χ2 = 7.767, p = 0.005) occurred. For 63 aneurysms treated by LEO stent monotherapy (LSM), multiple aneurysms, fusiform aneurysms (χ2 = 18.958, p < 0.01), and/or small-sized aneurysms (Z = −2.692, p = 0.007) occurred.ConclusionsLeo stents are safe and effective for aneurysms located in the posterior and distal anterior circulations. The overall degree of occlusion improved during a follow-up because of the FD effect of Leo stents. Aneurysms in these areas should be treated with personalized measures.

Endovascular treatment of intracranial vertebral artery unruptured dissecting aneurysms: Comparison of flow diversion and stent-assisted coiling or stenting alone.

PurposeTo investigate the effect and safety of flow diverters in the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery in comparison with stent-assisted coiling or stenting alone.Materials and methodsPatients with unruptured dissecting intracranial aneurysms of the vertebral artery treated with the flow diverter, stent-assisted coiling, or stenting alone were retrospectively enrolled. The clinical data were analyzed and compared.ResultsTwenty-five patients were enrolled in the flow diversion group and 42 patients in the stenting group. Twenty-six flow diverters were deployed in the flow diversion group. Immediate angiography revealed contrast agent retention within the aneurysm cavity in all patients. In the stenting group, 48 stents were deployed, and immediate angiographic outcome showed O'Kelly-Marotta (OKM) grade D in 18 (42.9%) aneurysms, grade C in 16 (38.1%), and grade B in 8 (19.0%). Periprocedural ischemic complications of thrombosis occurred in two (4.8%) patients and were treated with thrombolysis. In the flow diversion group, 19 (76%) patients underwent angiographic follow-up 3–46 (median 24) months after the procedure, with the OKM grade D in 11 (57.9%) patients, C in two (10.5%), and B in six (31.6%). The aneurysm recurrence rate was zero, and all diverters remained patent. Asymptomatic instent stenosis occurred in two (10.5%) patients. In seven of the ten patients with mild or moderate parent artery stenosis before the procedure who experienced angiographic follow-up, the stenosis was improved in five (71.4%) patients. In the stenting group, angiographic follow-up was carried out in 33 (78.6%) patients 6–58 months (median 34) after the procedure, with OKM grade D in 22 (66.7%) patients, grade C in five (15.2%), grade B in three (9.1%), and aneurysm recurrence (grade B, with increased contrast agent into the aneurysm cavity) in three (9.1%). Five (16.7%) patients experienced asymptomatic instent stenosis, and six of the 12 patients (50%) with parent artery stenosis were improved.ConclusionFlow diverters with or without selective adjunctive coiling for the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery may be safe and effective with good occlusion effects not inferior to those of stent-assisted coiling and stenting alone even though the long-term effect still warrants confirmation.

Pipeline embolization of complex, wide-necked middle cerebral artery bifurcation aneurysms: A single-center experience.

To evaluate the performance of Pipeline Embolization Device (PED) in complex, wide-necked middle cerebral artery (MCA) bifurcation aneurysms. We performed a retrospective review of patients treated with PED for complex, wide-necked MCA bifurcation aneurysms between August 2016 and March 2021. In addition to demographic data, we collected aneurysmal neck width, dome-to-neck ratio, complications, and clinical and angiographic follow-up. The embolization degree of aneurysms was evaluated by O'Kelly-Marotta (OKM) grading scale, and the prognosis was assessed with the modified Rankin Scale (mRS). From August 2016 to March 2021, a total of 46 patients with 49 MCA bifurcation aneurysms in our center were enrolled, of whom all received PEDs successfully. The O'Kelly-Marotta (OKM) grading showed that post-procedure 15 patients (32.6%) were grade C, another 8 patients (17.4%) were grade D. Aneurysms with small remnant or complete occlusion were 50%, symptomatic ischemic events occurred in 3 (6.5%), and bleeding events in 1 (2.2%). 41 patients underwent a 6-month angiography follow-up, in which 7 patients (17.1%) remained OKM grade C and 30 patients (73.2%) achieved OKM grade D. Complete occlusion and small remnant aneurysms were up to 90.3%. 40 (97.6%) patients' mRS scores were 0, and 1 (2.4%) patient was 2. No new bleeding and ischemic events occurred during the 6-month. The Pipeline Embolization Device provides a safe and effective treatment alternative for complex, wide-necked MCA aneurysms. A larger number with longer-term follow-up data is needed for further verification.

Multiple Pipeline Embolization Devices for the Treatment of Complex Intracranial Aneurysm: A Multi-Center Study.

BackgroundThe Pipeline for Uncoilable or Failed Aneurysms (PUFS) trial primarily demonstrated the safety and efficacy of the implantation of multiple pipeline embolization devices (multi-PEDs) for large/giant intracranial aneurysms. However, no study has focused on when, why, or how to apply multi-PEDs.ObjectiveThe purpose of this study was to investigate the indications and strategies of using multi-PEDs for complex intracranial aneurysms.MethodsPatients who had been treated with two or more PEDs were included in the post-market multicenter registry study from 2014 to 2019, across 14 centers in China. Indications, strategies, perioperative safety, and clinical outcomes were retrospectively analyzed. The modified Rankin scale (mRS) score was used to evaluate clinical outcomes comprehensively, and the O’Kelly–Marotta (OKM) grading scale was used to evaluate aneurysm healing results.ResultsA total of 55 intracranial aneurysms were treated with multi-PEDs. There were 20 fusiform aneurysms with a large range, 25 large/giant saccular aneurysms, six aneurysms with failed treatment, and four aneurysms with greatly varied diameters of the parent artery. The strategies included telescope techniques in 40 patients and overlap techniques in 15 patients. In total, 120 stents were deployed in 55 patients. The operation styles included 25 patients (55.6%) with two PEDs, 21 patients (38.2%) with two PEDs combined with coiling, four patients (7.3%) with three PEDs, four patients (7.3%) with three PEDs combined with coiling, and one patient (1.8%) with four PEDs. Angiography revealed OKM D in two, OKM C in seven, and OKM A and B in 46 cases after surgery. During the perioperative period, eight patients developed neurological dysfunction, three of whom died. A total of thirty-four patients were followed up with digital subtraction angiography for 2–45 (8.2 ± 8.0) months. Angiography revealed OKM D in 26, OKM C in five, and OKM B in three. At the last follow-up, the mRS score was 0–1 in 52 patients.ConclusionThe treatment of anterior circulation aneurysms with multi-PEDs is safe and effective. The implantation of multi-PEDs could be considered for large-scale fusiform aneurysms, large/giant saccular aneurysms with a jet-sign, salvage of failed PED treatments, and in cases where the diameter of the parent artery varies greatly.

Pipeline flex embolization device for the treatment of large unruptured posterior circulation aneurysms: Single-center experience

PurposeTo investigate the safety and effect of the Pipeline Embolization Device (PED) Flex device in the treatment of large unruptured posterior circulation aneurysms in a single center. Materials and methodsPatients with large unruptured posterior circulation aneurysms which were treated with the PED Flex device were enrolled. The clinical, endovascular and follow-up data were analyzed, and the O’Kelly-Marotta (OKM) grading system was used to assess the aneurysm occlusion status. ResultsFourteen patients with 14 large posterior circulation aneurysms who were treated with the PED Flex device were enrolled. The maximal diameter of aneurysm was 17.0 ± 3.9 mm. Fourteen PED Flex devices were deployed in 14 patients, with a technical success rate of 100%. All stents covered the aneurysm neck with good wall adherence and patent parent artery. Ten (71.4%) aneurysms were treated with a single PED Flex device each, and four (28.6%) patients experienced additional coiling. No neurological complications occurred in the periprocedural period. The mRS was 0 in eleven (78.6%) patients, 1 in two (14.3%), and 2 in one (7.1%) at discharge. All patients were followed up at 6–28 months (median 18), with an mRS score of 0 in all patients. Twelve (85.7%) patients experienced digital subtraction angiography 6–28 (median 18) months after the embolization procedure, and the OKM grade was D in nine (75%), C in two (16.7%), and B in one (8.3%). ConclusionThe Pipeline Flex Embolization Device can be safely applied to treat large unruptured posterior circulation aneurysms with a high complete aneurysm occlusion rate at follow-up.