Stent-assisted Embolization Research Articles

Advancements in Endovascular Treatment of Extracranial Carotid Artery Aneurysms

Traditionally, extracranial carotid artery aneurysms or pseudoaneurysms (ECCAs) have been managed through open surgical repair. Recent literature highlights the increasing success of endovascular techniques in treating ECCAs. Our study explores our center's experience with endovascular management of ECCAs, including the innovative use of Transcarotid Artery Revascularization (TCAR) at a tertiary care center. We performed a retrospective analysis of patients with ECCAs who underwent endovascular intervention at a single institution. We examined our database from the period of 2010 to 2024. Our treatment modalities have expanded to include covered stenting, stent-assisted coil embolization, braided stents, overlapping closed-cell stents, and most recently Transcarotid Artery Revascularization (TCAR). There were 29 extracranial carotid artery aneurysms in 27 patients treated with various endovascular modalities. The average age was 67.6 years, with 17 (63.0%) males and 10 (37.0%) females. 8 (29.6%) patients had prior ipsilateral carotid intervention. 9 (31.0%) aneurysms were symptomatic. The most common etiology was idiopathic, with 16 (55.2%) aneurysms being spontaneous. Treatment modalities included: 2 (6.9%) treated with covered stents, 2 (6.9%) with stent-assisted embolization, 3 (10.3%) with flow-diverting braided stents, 3 (10.3%) with embolization or ligation alone, 17 (58.6%) with overlapping bare metal stents via femoral or radial access, and 2 (6.9%) with overlapping bare metal stents via TCAR. Technical success was achieved in all patients. The mean follow-up duration was 236 days (range: 2 to 3039 days). No perioperative or post-operative complications occurred, including no neurological deficits or embolic events. All patients were discharged on post-operative day 1 or 2. All 29 (100%) stents maintained vessel patency on follow-up imaging, and exclusion of ECCAs was confirmed on post-procedure surveillance imaging. Our study highlights that endovascular therapy is effective in managing ECCAs, with high patency rates and a favorable procedural safety profile.

Safety and effectiveness of LEO stents for dual stent-assisted embolization combined with IA and IV intra-procedural infusion of tirofiban in the treatment of wide-necked intracranial bifurcation aneurysms.

To evaluate the safety and efficacy of employing LEO stents in dual stent-assisted embolization (DSAE) for wide-necked intracranial bifurcation aneurysms, and to assess the effectiveness of combined IA and IV intra-procedural infusion of tirofiban in mitigating perioperative complications. Clinical data and follow-up images from 562 patients with wide-necked intracranial bifurcation aneurysms treated at First Affiliated Hospital of Army Medical University from 2018-2022 were collected. Among them, 65 received DSAE with LEO stents. The study observed treatment success rates, procedure-related complications, perioperative thromboembolic events (TEs) and hemorrhagic events (HEs), immediate postoperative modified Raymond-Roy classification (mRR), and follow-up imaging. Glasgow Outcome Scale (GOS) at discharge and clinical follow-ups were recorded. The study enrolled 65 patients (mean age: 56.77 ± 10.07) with wide-necked intracranial bifurcation aneurysms. Among them, 58 had unruptured aneurysms, 7 ruptured (Hunt-Hess II-III). All aneurysms were successfully embolized without significant stent or bleeding complications. Only one case had intraoprative thrombosis; two postoperative ischemic incidents occurred within three days, no severe bleeding events. Immediate imaging showed modified Raymond-Roy classification: mRRC I (92.3%), mRRC II (4.6%), mRRC III b (3.1%). A total of 43 patients were followed up postoperatively with DSA. Among them, 41 patients exhibited mRRC I, while 2 patients exhibited mRRC II. No aneurysm was recanalized. Discharge GOS: GOS 5-60, GOS 4-1, GOS 3-4. One patient, GOS 1, died from lung cancer; others improved. The utilization of LEO stents for dual stent-assisted embolization of wide-necked intracranial bifurcation aneurysms demonstrated remarkable success and safety, yielding favorable postoperative outcomes and no instances of aneurysm recurrence. The concomitant administration of perioperative antiplatelet medications alongside IA and IV intra-procedural infusion of tirofiban effectively attenuated thromboembolic events (TEs) without concomitant elevations in bleeding risks.

Mid-term outcomes in stent-assisted coil embolization for ruptured cerebral aneurysms in the acute period: A single institution retrospective review

ObjectiveThe purposes of this study were to retrospectively review mid-term outcomes of stent-assisted coil embolization for acutely ruptured cerebral aneurysms, and to identify risk factors. MethodsBetween April 2013 and October 2018, thirty-four consecutive patients had stent-assisted coil embolization for treatment of acutely ruptured cerebral aneurysms that were not amendable by simple coiling. Hospital subarachnoid hemorrhage registry and notes on hospital electronic medical systems were retrospectively reviewed. All patients had a dose of intravenous abciximab 10 mg and heparin 2000 units before stenting and started dual antiplatelet therapy after procedure. ResultsOf the thirty-four consecutive patients, twenty-six (76 %) were treated with braided stents and eight (24 %) were treated with laser-cut stents. There was no rebleeding in thirty-two patients who achieved total aneurysmal occlusion or residual neck only. Rebleeding occurred in two patients who only achieved partial embolization, resulting in mortality. There were three (9 %) thromboembolic complications, in which two were ADL-independent upon hospital discharge and the one with WFNS Grade V succumbed. Twenty (59 %) patients achieved clinical favorable outcomes (mRS 0–2) at follow-up (mean+/-SD: 17+/-15 months). The need of EVD insertion was a statistically significant risk factor for procedure-related cerebral infarction, intracerebral hemorrhage and 30-day mortality. The GOS and mRS were closely related to the need of EVD insertion and sidewall location of aneurysm. ConclusionsThe study established the efficacy and safety profile of stent-assisted embolization for treatment acutely ruptured cerebral aneurysms. The embolization goal should be total aneurysmal occlusion or with minimal residual neck to prevent rebleeding and reduce mortality. The use of such technique should be considered when simple coiling or microsurgical clipping is not feasible or suitable. The need of EVD insertion is an independent risk factor for intracerebral hematoma and 30-day mortality. When needed, EVD insertion shall be considered before antiplatelet agents, and require exceptionally meticulous hemostasis intraoperatively.

Stent-assisted Woven EndoBridge embolization for the treatment of pulsatile tinnitus caused by an ipsilateral high-riding jugular bulb.

Pulsatile tinnitus can be caused by a high-riding jugular bulb (HRJB), characterized by the superior position of the jugular bulb in the petrous temporal bone. The anatomical position and morphology of this entity make it challenging for endovascular treatment. We report our experience with two patients successfully treated with a stent-assisted Woven EndoBridge (WEB; Microvention, Tustin, CA, USA) device. We describe two cases of HRJB in patients presenting with disabling pulsatile tinnitus. Temporary balloon occlusion of the jugular bulb prior to the intervention reduced tinnitus intensity. Both patients were subsequently treated under general anesthesia with the WEB device deployed in the HRJB which was held by a stent deployed in the sigmoid sinus. Both procedures were successful with good positioning of the WEB device and no procedural complications. Both patients had complete resolution of pulsatile tinnitus immediately after the procedure. Follow-up imaging showed successful occlusion of the venous cavity with a widely patent stent. Among patients with pulsatile tinnitus caused by an ipsilateral HRJB, a stent-assisted WEB device seems to be a viable endovascular option with angiographic and clinical success.

Perioperative complications of arteriovenous tirofiban administration versus oral dual antiplatelet therapy for stent-assisted embolization treated aneurysmal subarachnoid hemorrhage: A retrospective, controlled cohort analysis.

Major perioperative complications of stent-assisted embolization treated for aneurysmal subarachnoid hemorrhage patients include the formation of thromboembolic events (TEs) and hemorrhagic events (HEs), for which antiplatelet protocols play a key role. We conducted a single-center retrospective analysis to compare the differences between arteriovenous tirofiban administration with traditional oral dual antiplatelet therapy (DAPT). A total of 417 consecutive patients were enrolled. General clinical characteristics, as well as the perioperative ischemic and hemorrhagic events, were retracted in digital documents. Logistic regression was conducted to identify both risk and protective factors of perioperative TEs and HEs. Perioperative TEs occurred in 21 patients, with an overall perioperative TEs rate of approximately 5.04%; among these patients, the incidence of perioperative TEs in the tirofiban group was less than that in the DAPT group. Additionally, 66 patients developed perioperative HEs, with an incidence of approximately 15.83%; among these patients, the incidence of perioperative HEs was less than that in the DAPT group. No significant differences were seen between the two groups in terms of the mRS score at the time of discharge. This study indicated that an improved perioperative antiplatelet drug tirofiban was an independent protective factor for perioperative TEs in stent-assisted embolization of ruptured intracranial aneurysms, but it did not impart an elevated risk of perioperative HEs and had no significant effects on the near-term prognosis of the patients.

Treatment Strategy of Intracranial Anterior Circulation Aneurysm Presenting with Cerebral Ischemia: A Single-Center Experience.

To investigate the clinical characteristics and treatment strategy of anterior circulation aneurysm presenting with cerebral ischemia. We performed a retrospective review of patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia examined in the Fifth Ward of the Neurosurgery Department of Tianjin Huanhu Hospital between September 2016 and September 2023. Data were reviewed for age, sex, presentation, type and size, location, treatment modalities, postoperative complications, clinical and imaging outcomes, and follow-up outcomes. Among the 13 patients, there were 8 males and 5 females (1.6:1). Their presentations included ischemic stroke (69.23%, 9/13) and transient ischemic attack (TIA) (30.77%, 4/13). The aneurysms were dissecting (46.15%, 6/13), saccular (30.77%, 4/13), and saccular combined with thrombosis (23.08%, 3/13) in shape. There were 6 giant aneurysms, 4 large aneurysms, and 3 microaneurysms. Three (23.08%, 3/13) aneurysms were located at the internal carotid artery (ICA) and 10 (76.92%, 10/13) were located in the middle cerebral artery (MCA). A preoperative magnetic resonance perfusion (MRP) examination was performed in all patients, and 9 (69.23%, 9/13) patients showed hypoperfusion. Treatment modalities included stent-assisted embolization, direct clipping, clipping combined with bypass, resection combined with bypass, isolated combined with bypass, proximal occlusion combined with bypass, and the internal carotid artery constriction combined with bypass. Twelve (92.31%, 12/13) patients had no postoperative complications, and temporary complications occurred in 1 (7.69%, 1/13) patient. Aneurysms disappeared in 11 cases and shrank in 2 cases postoperatively. All patients were followed up for 1 to 72 months. We found no new cerebral infarction, no subarachnoid hemorrhage, and no recurrence or enlargement of aneurysms during the follow-up. Intracranial anterior circulation aneurysm presenting with cerebral ischemia is rare. Saccular aneurysms with wide neck or thrombosis and dissected aneurysms of the anterior circulation may result in cerebral ischemic attack caused by distal vascular embolism. Individualized treatment should be performed, and cerebral revascularization is an effective treatment for patients with intracranial anterior circulation aneurysms presenting with cerebral ischemia.

Safety and efficacy of dual antiplatelet drugs for stent-assisted embolization on risk of stroke and prognosis in patients with ruptured intracranial aneurysms: One center results of CIAP-5 clinical trial.

Although stent-assisted coiling embolization (SAC) has been associated with a higher risk of ischemic and hemorrhagic complications, the use of SAC continues to rise for treating ruptured intracranial aneurysms (RIAs). This study aims to assess the safety and effectiveness of dual antiplatelet therapy (DAPT) in the context of RIAs. We conducted a retrospective analysis at a single center, involving patients with aneurysmal subarachnoid hemorrhage (aSAH) between May 1, 2017 and December 31, 2021. Patients were categorized into two groups: the SAC group and the non-SAC (NSC) group. Patients in the SAC group received DAPT. We compared modified Rankin Scale (mRS) score, along with hemorrhagic and ischemic complications, between the two groups to evaluate the safety and efficacy of DAPT for SAC. The study included a total of 541 patients, of whom 38 (7.0%) experienced hemorrhagic complications and 48 (8.9%) developed ischemic complications. Additionally, 99 (18.3%) and 84 (15.5%) had poor clinical outcomes at discharge and 6 months, respectively. However, no statistically significant differences were observed between the two groups. Our analysis revealed that aneurysm location in the posterior circulation was a significant risk factor for an unfavorable prognosis when antiplatelet drugs were used following SAC (p = 0.025). Administering antiplatelet drugs after SAC for RIAs has demonstrated both safety and effectiveness. However, caution should be exercised when considering this treatment strategy for RIAs located in the posterior circulation due to the potentially elevated risk.

Periprocedural thromboembolic complications of LEO baby stent in endovascular treatment of intracranial aneurysms: Experience in 149 patients.

To report periprocedural thromboembolic complications of LEO Baby stent-assisted coiling of wide-necked intracranial aneurysms and to analyze the possible influencing factors. We retrospectively identified 149 patients with aneurysms who underwent LEO Baby stent-assisted embolization between October 2018 and March 2022. Clinical and radiographic data of patients were reviewed to determine whether a thromboembolic event had occurred. Multivariate logistic analysis was performed to identify significant factors associated with thromboembolic events. Successful stent deployment of the stent was achieved in all patients in the target artery. There were 66 patients (44.3%) with acutely ruptured aneurysms and 83 patients (55.7%) with unruptured aneurysms. Fourteen (9.4%, 95% confidence interval: 4.7%-14.1%) patients were confirmed to have developed a thromboembolic event, including nine patients with acute intraoperative thrombosis and five patients with postoperative thromboembolic events. The rate of thromboembolic events was 6.0% (5/83) in patients with unruptured aneurysms and 13.6% (9/66) in patients with acutely ruptured aneurysms. There was a trend toward an increased rate of thromboembolic events in patients with acute ruptured aneurysms (p = 0.087). Thromboembolic events were significantly associated with the parent-artery diameter (p = 0.010). Our study demonstrates a low rate of thromboembolic complications in unruptured aneurysms treated with LEO Baby stent. Thromboembolic events appear to be more common in ruptured aneurysms. A small diameter of the parent artery is associated with an increased risk of thromboembolic complications, and more relevant studies are still needed.

Stent-Assisted Aneurysm Embolization and Some Literature Review

Stent-Assisted Aneurysm Embolization and Some Literature Review

Feasibility and safety values of activated clotting time-guided systemic heparinization in coil embolization for unruptured intracranial aneurysms.

This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)-guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms. A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time. Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000-1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949-0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005-1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017-1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338). This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.

Six-month Outcomes after PulseRider- and Conventional Single Stent-assisted Embolization for Bifurcation Aneurysms: A Propensity-adjusted Comparison.

Endovascular treatment of wide-necked bifurcation aneurysms (WNBAs) remains challenging despite using a stent. PulseRider is a novel device specifically designed to treat WNBAs, protecting both daughter branches, but the outcomes have not been compared with conventional single stent-assisted embolization. This study aimed to compare the six-month outcomes of PulseRider and single stent-assisted embolization for intracranial unruptured WNBAs using propensity score adjustment. Between February 2012 and October 2021, 46 unruptured WNBAs (34 basilar and 12 middle cerebral arteries) smaller than 10 mm in diameter were treated with PulseRider-assisted embolization (n = 17) or single stent-assisted embolization (n = 29). The immediate and six-month outcomes were compared using inverse probability of treatment weighting analysis. The immediate adequate occlusion rates for the PulseRider- and single stent-assisted embolization were similar (47.1% vs. 62.1%). At six months, adequate occlusion rates for the two groups were also similar (94.1% vs. 86.2%). However, the complete obliteration rate was significantly high after PulseRider-assisted embolization (88.2% vs. 41.4%, adjusted OR 10.54, 95% CI 1.93-57.63). The angiographical improvement rate was also significantly high after PulseRider-assisted embolization (70.6% vs. 37.9%, adjusted OR 6.06, 95% CI 1.54-23.76). The neurologic thromboembolic complication rate was 0% after PulseRider-assisted embolization and 3.4% after single stent-assisted embolization. PulseRider-assisted embolization of WNBAs smaller than 10 mm in diameter was associated with complete obliteration and angiographical improvement at six months. The unique shape of the PulseRider might contribute to the improved midterm aneurysm occlusion.

Endovascular treatment for massive haemoptysis due to pulmonary pseudoaneurysm: report of 23 cases

PurposeTo evaluate the safety and effectiveness of endovascular treatment for massive haemoptysis caused by pulmonary pseudoaneurysm (PAP).MethodsThe clinical data, imaging data, and endovascular treatment protocol of 23 patients with massive haemoptysis caused by continuous PAP were retrospectively analysed. The success, complications, postoperative recurrence rate, and influence of the treatment on pulmonary artery pressure were also evaluated.ResultsNineteen patients with a bronchial artery-pulmonary artery (BA-PA) and/or nonbronchial systemic artery-pulmonary artery (NBSA-PA) fistula underwent bronchial artery embolization (BAE) and/or nonbronchial systemic artery embolization (NBSAE) + pulmonary artery embolization (PAE). The pulmonary artery (PA) pressures before and after embolization were 52.11 ± 2.12 (35–69 cmH2O) and 33.58 ± 1.63 (22–44 cmH2O), respectively (P = 0.001). Four patients did not have a BA-PA and/or NBSA-PA fistula. Embolization was performed in two patients with a distal PAP of the pulmonalis lobar arteria. Bare stent-assisted microcoils embolization was performed in the other two patients with a PAP of the main pulmonary lobar arteries. The PA pressures of the four patients before and after treatment were 24.50 ± 1.32 (22–28 cmH2O) and 24.75 ± 1.70 (22–29 cmH2O), respectively (P = 0.850). The technique had a 100% success rate with no serious complications and a postoperative recurrence rate of 30%.ConclusionEndovascular treatment is safe and effective for massive haemoptysis caused by PAP. BAE and/or NBSAE can effectively reduce pulmonary hypertension in patients with a BA-PA and/or NBSA-PA fistula.

Woven EndoBridge Device Migration and Microsnare Retrieval Strategy: Single Institutional Case Reports with Technical Video Demonstration.

The Woven EndoBridge (WEB) (MicroVention/Terumo) device is a treatment option for wideneck bifurcation aneurysms. An uncommon adverse effect is WEB device migration. While certain bailout strategies for WEB recovery have been described, there is still a paucity of information on optimal strategies to maximize both short and long-term post-operative outcomes. We add 2 cases at our institution to the existing literature of WEBectomy in the setting of complicated intracranial aneurysm treatment. We discuss the long-term imaging outcomes with additional fluoroscopy video demonstrating our technique. Our findings reflect a clear benefit for the use of the Amplatz GooseneckTM microsnare (Medtronic) device as a means of WEB recovery, coupled with potential stent-assisted WEB embolization to remove the aneurysm from the parent circulation, while minimizing recurrence and thromboembolic complications.

A nomogram to predict the risk of bleeding after discharge from stent-assisted ruptured aneurysm embolization in a Chinese population.

The occurrence of bleeding events after stent-assisted embolization of a ruptured artery requiring continuous double antiplatelet therapy may seriously affect the prognosis of this group of patients. A nomogram can provide a personalized, more accurate risk estimate based on predictors. We, therefore, developed a nomogram to predict the probability of bleeding events in patients with stent-assisted ruptured aneurysm embolization. We performed a single-center retrospective analysis of data collected from patients undergoing stent-assisted ruptured aneurysm embolization between January 2018 and December 2021. Forward stepwise logistic regression was performed to identify independent predictors of adverse events of bleeding after stent-assisted embolization and to establish nomograms. Discrimination and calibration of this model were performed using the area under the ROC curve (AUC-ROC) and the calibration plot. The model is internally validated by using resampling (1000 replicates). A total of 131 patients were identified, and a total of 118 patients met the study criteria. The predictors included in the nomogram were body mass index (BMI), AAi, and MA-ADP. The model showed good resolving power with a ROC area of 0.893 (95% CI: 0.834 ~ 0.952) for this model with good calibration. The nomogram can be used to individualize, visualize, and accurately predict the risk probability of bleeding events after stent-assisted embolization of ruptured aneurysms.

Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms

PurposesBraided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. MethodsPatients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. ResultsThe deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. ConclusionsBraided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

Enterprise 2 Stent-Assisted Embolization of Paraclinoid Aneurysms: A Single Center Preliminary Study.

Enterprise stent has been widely used for assisted embolization in wide-necked aneurysms while delayed ischemia or thromboembolic complications for its incomplete stent apposition. The purpose of this study was to summarize and analyze the clinical experience of using Enterprise 2 (EP2) stent-assisted embolization in the treatment of paraclinoid aneurysms. From January 2019 to December 2020, the clinical and imaging data of 98 patients with paraclinoid aneurysms treated with EP2 stent-assisted embolization were enrolled retrospectively. Preliminary experience and follow-up outcomes of EP2 stent-assisted embolization of paraclinoid aneurysms were assessed by using the Raymond grade and modified Rankin Scale. Of the 98 aneurysms, all stents were released satisfactorily. The immediate postprocedural angiography revealed a complete occlusion of the aneurysms with 77.55% of the (76/98) patients, and the last follow-up angiograms showed complete occlusion with 83.67% of the (82/98) patients. The average aneurysm size was (4.11 ± 1.25) mm, the aneurysm diameter was (4.41 ± 1.37) mm, the vessel radius was (3.87 ± 0.32) mm, the diameter at the distal of stent was (3.23 ± 0.21) mm, and the proximal was (4.18 ± 0.23) mm. Among the 98 aneurysms, 13 cases had incomplete stent apposition, 3 cases had intraoperative knotting, and the stents were improved post adjusted; 2 cases had vasospasm and 1 case had stenosis during operation, the symptoms were improved after symptomatic treatment. The result demonstrated that stent length and inner bending radius of parent artery were the pivotal factors affecting incomplete stent apposition (P < 0.01). The EP2 stent for the treatment of paraclinoid aneurysms is safe and effective, however, the length of the stent and the inner bending radius of parent artery are important factors affecting incomplete stent apposition.

Hemodynamic Comparison of Treatment Strategies for Intracranial Vertebral Artery Fusiform Aneurysms.

ObjectiveThis study comparatively analyzed the hemodynamic changes resulting from various simulated stent-assisted embolization treatments to explore an optimal treatment strategy for intracranial vertebral artery fusiform aneurysms. An actual vertebral fusiform aneurysm case treated by large coil post-stenting (PLCS) was used as a control.Materials and MethodsA single case of an intracranial vertebral artery fusiform aneurysm underwent a preoperative and eight postoperative finite element treatment simulations: PLCS [single and dual Low-profile Visualized Intraluminal Support (LVIS)], Jailing technique (single and dual LVIS both simulated twice, Pipeline Embolization Device (PED) with or without large coils (LCs). Qualitative and quantitative assessments were performed to analyze the most common hemodynamic risk factors for recurrence.ResultsJailing technique and PED-only had a high residual flow volume (RFV) and wall shear stress (WSS) on the large curvature of the blood flow impingement region. Quantitative analysis determined that PLSC and PED had a lower RFV compared to preoperative than did the jailing technique [PED+LC 2.46% < PLCS 1.2 (dual LVIS) 4.75% < PLCS 1.1 (single LVIS) 6.34% < PED 6.58% < Jailing 2.2 12.45% < Jailing 1.2 12.71% < Jailing 1.1 14.28% < Jailing 2.1 16.44%]. The sac-averaged flow velocity treated by PLCS, PED and PED+LC compared to preoperatively was significantly lower than the jailing technique [PED+LC = PLCS 1.2 (dual LVIS) 17.5% < PLCS 1.1 (single LVIS) = PED 27.5% < Jailing 1.2 = Jailing 2.2 32.5% < Jailing 1.1 37.5% < Jailing 2.1 40%]. The sac-averaged WSS for the PLCS 1.2 (dual LVIS) model was lower than the PED+LC, while the high WSS area of the Jailing 1 model was larger than for Jailing 2 [PLCS 1.2 38.94% (dual LVIS) < PED+LC 41% < PLCS 1.1 43.36% (single LVIS) < PED 45.23% < Jailing 2.1 47.49% < Jailing 2.2 47.79% < Jailing 1.1 48.97% < Jailing 1.2 49.85%].ConclusionsFor fusiform aneurysms, post large coil stenting can provide a uniform coil configuration potentially reducing the hemodynamic risk factors of recurrence. Flow diverters also may reduce the recurrence risk, with long-term follow-up required, especially to monitor branch blood flow to prevent postoperative ischemia.

Risk factor management matters more than pharmaceutical cyclooxygenase-2 inhibition in the prevention of de novo intracranial aneurysms.

Pathophysiological studies of saccular intracranial aneurysm (sIA) disease have shown that inflammation plays a crucial role in sIA development. Pharmaceutical inhibition of COX-2-PGE2-NF-κB signaling (COX-2, cyclooxygenase-2; PGE2, prostaglandin E2; NF-κB, nuclear factor κB) has been shown in animal models to inhibit sIA formation and progression suggesting that use of medication inhibiting COX-2 could reduce intracranial aneurysm formation also in patients. The impact of COX-2 inhibition on de novo sIA formation was studied in two cohorts: in a previously described angiographically followed cohort of 1419 sIA patients and in a cohort of 117 sIA patients treated with stenting or stent-assisted embolization. Patients were identified from our population-based Kuopio Intracranial Aneurysm Database. Data on the use of anti-inflammatory medications and hospital diagnoses were obtained from national registries. Risk factors were identified by univariate and multivariate analyses. De novo sIA patients were younger and more often smokers. Use of COX-2 selective inhibitors or nonsteroidal anti-inflammatory drugs did not significantly reduce de novo sIA formation, but the percentage of patients with de novo sIA formation was smaller in patients with prescribed regular acetylsalicylic acid medication (1.1% vs. 3.6%). In the multivariate analysis, however, neither acetylsalicylic acid use nor other type of pharmaceutical inhibition of COX-2 reduced the formation of de novo sIAs. The risk was mostly affected by age, smoking history and irregular usage of antihypertensive medication regardless of used COX-2 inhibition level. For the prevention of de novo sIA formation, risk factor management with focus on cessation of smoking and treating hypertension adequately seems more important than pharmaceutical COX-2 inhibition.

Low profile visualized intraluminal support stent-assisted Hydrocoil embolization for acutely ruptured wide-necked intracranial aneurysms: A propensity score-matched cohort study

PurposeTo compare the safety and efficacy of low profile visualized intraluminal support (LVIS) stent-assisted hydrogel coil embolization and LVIS stent-assisted bare platinum coil embolization for acutely ruptured wide-necked intracranial. Methods89 patients who underwent LVIS stent-assisted hydrogel coil embolization (hydrogel coil group) and 145 patients who underwent LVIS stent-assisted bare platinum coil embolization (platinum coil group) were retrospectively reviewed after 1:2 propensity score matching (PSM). Procedure-related complications, clinical and angiographic follow-up outcomes were compared between the two groups. ResultsAll baseline characteristics were equivalent between hydrogel coil group and platinum coil group after PSM. There were no statistical differences in immediate postoperative embolization results, clinical and angiographic follow-up outcomes between the two groups (P = 0.514, P = 0.323 and P = 0.949, respectively). Intraprocedural aneurysm rupture, intraprocedural thrombosis and postprocedural thrombosis occurred in 2 patients (2.2%, 2/89), 1 patient (1.1%, 1/89) and 1 patient (1.1%, 1/89) of the hydrogel coil group compared with 1 patient (0.7%, 1/145), 1 patient (0.7%, 1/145) and 2 patients (1.4%, 2/145) of the platinum coil group, respectively (P = 0.559, P = 1.000 and P = 1.000). Nevertheless, the rate of postprocedural aneurysm early rebleeding in the hydrogel coil group was significantly lower than that in the platinum coil group (0.0% vs 4.8%, P = 0.046). ConclusionLVIS stent-assisted hydrogel coil embolization may reduce the risk of aneurysm early rebleeding compared with LVIS stent-assisted bare platinum coil embolization for the treatment of acutely ruptured wide-necked intracranial aneurysms, which implies that hydrogel coil may improve the safety of stent placement for ruptured intracranial aneurysms.

Predisposing factors for the deformation of parent artery of anterior circulation saccular aneurysm after stent-assisted embolization: A retrospective cohort study.

It has been previously reported in several studies that deformation of parent artery (DPA) occurs after stent-assisted coil embolization (SACE) for intracranial aneurysms (IAs). To investigate the predisposing factors of stent-induced DPA, as well as its effect on the follow-up of aneurysm embolization. Clinical and imaging data were collected from 198 patients (201 aneurysms). Angles of the stent-covered parental artery were measured before treatment and during follow-up. Cases in which the angle had changed more than 5 degrees, were defined as DPA. The related factors of DPA were analyzed. The relation between DPA and follow-up results was also studied. Univariate analysis revealed that sex (p = 0.014), age (p = 0.017), aneurysm location (p < 0.001), stent type (p < 0.001), aneurysm size (p = 0.019), and pretreatment angle (p = 0.002) correlated with DPA. On the other hand, multivariate analysis revealed that aneurysms located in the anterior communicating artery (ACOA) (OR = 4.559, p = 0.013) and middle cerebral artery (MCA) (OR = 9.474, p < 0.001) were independent predisposing factors for DPA after stent implantation, whereas a braided stent (OR = 0.221, p = 0.030), flow diverter (FD) device (OR = 0.100, p = 0.028) were negative factors to develop DPA. The complete occlusion rate in the DPA group was higher (p = 0.035) than in the non-DPA group. Aneurysms located in ACOA and MCA are more prone to DPA after SACE than aneurysms at other locations in the anterior circulation, braided stents and FD devices do not predispose to induce vascular deformation. DPA may be beneficial for the long-term cure of IAs after SACE.