Stent Reconstruction Research Articles

Safety and Efficacy of Neuroform for Treatment of Intracranial Aneurysms: A Prospective, Consecutive, French Multicentric Study

Endovascular embolization of wide-neck intracranial aneurysms can be technically challenging, especially when the anatomy is complex. Stent reconstruction of the parent artery is commonly used to treat wide-neck and bifurcated aneurysms. The main objective of this study was to investigate the periprocedural and midterm morbidity and mortality results of this procedure. SENAT is a consecutive, prospective, multicentric study. Patients with unruptured cerebral aneurysms who underwent endovascular treatment with the Neuroform stent system were recruited and recorded. Technical outcomes and complications were also assessed. The midterm anatomic results were re-evaluated at 12-18 months. A total of 113 stents were used to treat the 107 aneurysms in 107 patients. The mean width of the aneurysm sac was 6.2 mm, and the mean diameter of aneurysm neck was 4.5 mm. The complete occlusion rate postprocedure was 66.4%. The rate of progressive occlusion at 12-18 months was 14%, and the rate of recurrence was 9.7%. The rate of subsequent treatment was 4%. The thromboembolic rate in the periprocedural period was 3.7%, and the rate of delayed TE events was 3%. Overall, the mortality rate at 12-18 months was 1%, and the permanent morbidity rate was 1%. Stent-assisted coiling with the Neuroform stent system provides a high level of occlusion with low rates of subsequent treatment despite a predominant population of patients with wide-neck aneurysms. Morbidity and thromboembolic rates were comparable to studies investigating stand-alone coiling.

Beneficial Remodeling of Small Saccular Intracranial Aneurysms after Staged Stent Only Treatment: A Case Series

We evaluated the effect of stent alone treatment for small intracranial aneurysms that were not amenable to coil embolization without prior stent reconstruction. This case series was conducted in the neurosurgical service at a tertiary care hospital in Denver, Colorado. Nine patients were electively treated for intracranial aneurysms. All patients had a single low porosity stent reconstruction device placed across the neck of a small intracranial aneurysm. The main outcome measures were changes in aneurysm size and parent vessel morphology during follow-up. Nine patients underwent stent alone treatment for unruptured intracranial aneurysms. The mean follow-up period was 9.6 months (range 6-17 months). There were no cases of periprocedural morbidity or aneurysm rupture during follow-up. All aneurysms decreased in size, and 3 of 9 aneurysms were gone at follow-up. In addition, at follow-up all parent vessels demonstrated straightening about the aneurysm site. Beneficial remodeling with a decrease in the size of small intracranial aneurysms may be seen after treatment with a single stent alone, particularly if the aneurysm arises at an arterial bend or bifurcation. This phenomenon may be related to a degree of straightening of the parent artery, improving hemodynamic conditions about the aneurysm site.

Endovascular Reconstruction for Treatment of Vertebrobasilar Dolichoectasia: Long-Term Outcomes

VBD can trigger various clinical symptoms, especially ischemic stroke in the posterior circulation, but there is no effective treatment for their prevention. We aimed to validate the feasibility of coil-assisted stent reconstruction in the vascular lumen for the treatment of VBD and to evaluate its long-term effectiveness in preventing ischemic events. Clinical and imaging data of 9 patients with unruptured VBD were reviewed retrospectively. Depending on the length and diameter of the diseased target vessel, multiple LEO and/or Solitaire stents were implanted, assisted by coils. Stent reconstruction in the vascular lumen was successful in all patients. Procedure-related complications occurred in 1 patient who developed brain stem and cerebellar infarction 8 days after endovascular treatment and died in 4 months. Coil embolization of the nondominant side of the vertebral artery was performed 1 month after the operation in 1 patient who developed partial brain stem and cerebellar infarction leading to hemiplegia. The mean follow-up time of the 8 surviving patients was 20.75 ± 6.90 months. Of the 4 patients with dolichoectasia in the anterior circulation, 2 experienced ischemic events in the anterior circulation. Another patient had sudden death at home 26 months after the operation. The conditions of the remaining 5 patients were stable without deterioration, and in 4, DSA/CTA/MRA suggested improved morphology of the vertebral artery compared with that before the operation. Endovascular reconstruction with coil-assisted stent placement or stent placement alone in the vascular lumen for the treatment of VBD is technically feasible and can prevent ischemic events in the territory of stented vessels compared with the natural course, though further studies in larger samples are needed.

Venous Sinus Pulsatility and the Potential Role of Dural Incompetence in Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing; however, a complete understanding of the hydrodynamic dysequilibrium is lacking. To review and characterize catheter manometry findings including pulsatility changes within the venous sinuses in IIH. Cases of venous sinus stent implantation for IIH were retrospectively reviewed. Three cases of venous sinus stent implantation for treatment of IIH are reported. All cases demonstrated severe narrowing (>70%) within the transverse sinus and a high pressure gradient across the lesion (>30 mm Hg). Stent implantation resulted in pulsatility attenuation, correction of pressure gradient, and improvement of flow. We report the finding of high venous sinus pulsatility attenuation after stent implantation for dural sinus narrowing and propose the hypothesis that this finding is a marker of advanced dural sinus incompetence. This characteristic may be useful in identifying patients who would benefit from endovascular stent remodeling.

P-019 Mid-term results of single or multiple overlapping neuroform stents as monotherapy for treating supraclinoid carotid “blister-like” pseudoaneurysms

Introduction“Blister-like” pseudoaneurysms of the supraclinoid internal carotid artery have a malignant natural history and can be difficult to treat, both surgically and via endovascular techniques. These lesions often involve a...

Long‐term Clinical and Angiographic Outcomes in Patients with Spontaneous Cervico‐Cranial Arterial Dissections Treated with Stent Placement

Limited data exist regarding the long-term clinical and angiographic outcomes of patients with spontaneous cervico-cranial arterial dissection treated with stent placement. To report the immediate and long-term clinical and angiographic outcomes of patients who received stent placement for spontaneous cervico-cranial arterial dissection. We reviewed clinical and angiographic data of consecutive patients with spontaneous, cervico-cranial arterial dissection treated with stent placement. Patients with recurrent ischemic symptoms or severe hemodynamic compromise despite maximal medical therapy, or those with compressive symptoms due to expanding pseudoaneurysms were considered for stent placement. Follow-up angiography and intravascular ultrasound (in select patients) was performed to detect in-stent restenosis, intimal flap, thrombus, or persistent pseudoaneurysm. A total of 14 patients were identified, with complete resolution of stenosis achieved in 10 patients immediately post-procedure. Clinical follow-up ranged from 26-900 days, during which there was 1 (7%) TIA, 1 (7%) minor ischemic stroke, and 1 (7%) in hospital death (unrelated to stent placement). Stroke-free survival was 93% at both 1 month and 6 months after the procedure. Follow-up angiography did not reveal any in-stent restenosis. This study demonstrates the feasibility, safety, and intermediate term effectiveness of endovascular stent reconstruction of spontaneous, cervico-cranial arterial dissection.

Stent Reconstruction of an Injured Parotid Duct in a Thoroughbred Colt

To report successful use of stent repair for a chronically injured parotid duct in a thoroughbred colt. Clinical report. A 2-year-old thoroughbred colt. Chronic injury to the parotid duct was identified 4-cm caudal to the facial vessel notch on the ventral border of the right mandible. After careful surgical dissection of the surrounding firm fibrous tissue, the defect was temporarily stented using an 8-Fr human ureteral catheter (223600 ERU(®) SOFT URETERAL(®) , Laboratoires pharmaceutique, Betschdorf, France) to bridge the tissue loss. The rostral end of the catheter exited the oral cavity through a buccotomy stab incision at the level of the second premolar tooth of the maxilla. Primary wound healing occurred and the stent was maintained for 5 weeks with saliva drainage visible when the colt was fed. After stent removal, function was restored with good cosmesis. A tissue defect in the parotid duct can be repaired successfully by temporary use of a stent until wound healing occurs.

Long-Term Clinical and Angiographic Outcomes in Patients with Cervico-Cranial Dissections Treated with Stent Placement: A Meta-Analysis of Case Series

Limited clinical and angiographic data exists for patients with spontaneous or traumatic cervico-cranial dissections treated with stent placement. We reviewed clinical and angiographic data on consecutive patients admitted to our hospital with spontaneous, traumatic, and iatrogenic cervico-cranial dissections treated with stent placement to study immediate and long-term clinical and angiographic outcomes. Additional patients were identified using pertinent studies published between 1980 and 2009, using a search of the PubMed, Cochrane, and Ovid libraries. Post-procedure complications and clinical outcomes were documented. Angiographic abnormalities collected at follow-up included presence of in-stent restenosis or pseudoaneurysm. After applying our strict search criteria, four studies including our series were used in the meta-analysis, representing 46 patients (mean age [standard deviation] 47 ± 14 years; 24 [52%] male) treated with stent placement for dissection. Overall, 72 stents were placed to treat 28 spontaneous, 11 traumatic, and 7 iatrogenic dissection patients with 51 dissections, involving 51 vessels; with a mean pre-stent stenosis of 71 ± 26% and mean post-stent stenosis of 6 ± 15%. The immediate and follow-up post-procedure complication rates per stent placed was 8 (11%) and 8 (11%), respectively. Among the 36 patients who underwent follow-up angiography, in-stent restenosis or pseudoaneurysms were present in 3 (8%) and 2 (6%) patients, respectively. A high rate of sustained resolution of angiographic abnormalities during long-term follow-up was noted, with a low rate of new transient ischemic attack, ischemic stroke, or death, supporting the feasibility, safety, and effectiveness of endovascular stent reconstruction.

Initial Experience with Neuroform EZ in the Treatment of Wide-neck Cerebral Aneurysms

PurposeStent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported.Materials and MethodsSeventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed.ResultsIn all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm.ConclusionThe Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.

P-001 Stent-assisted reconstruction of intracranial dissections: primary and secondary clinical and angiographic endpoints in 164 consecutive cases

PurposeIntracranial dissections (ICDs) of the circle of Willis are recognized as important causes of both ischemic and hemorrhagic cerebrovascular disease. Although endovascular surgery (ES) of ICD has been increasingly reported,...

O-022 Low profile visualized intraluminal support (LVIS) device for the treatment of complex aneurysms: early US experience

IntroductionVery wide necked aneurysms that incorporate a large portion of the parent artery can be challenging to treat with currently available devices. Stents can assist in reconstructing the vessel wall,...

P-014 Venous sinus pulsatility in manometry evaluation of dural sinus narrowing in idiopathic intracranial hypertension

IntroductionIdiopathic intracranial hypertension (IIH) remains a poorly understood and therapeutically challenging disease. Enthusiasm has emerged for endovascular therapy with stent reconstruction of dural sinus narrowing, however a complete understanding of...

Endovascular Stent Reconstruction of the Inferior Vena Cava Complicated by Duodenocaval Fistula

A patient with retroperitoneal metastatic uterine adenocarcinoma resulting in symptomatic occlusion of the inferior vena cava underwent palliative endovascular stent reconstruction and subsequent radiation therapy. She then developed sepsis and massive lower gastrointestinal bleeding. Computed tomography (CT) and cavography demonstrated a fistulous communication between the duodenum and the stented segment of inferior vena cava. Deployment of endovascular stent graft devices successfully occluded the fistulous communication and resulted in clinical improvement.

Endovascular Reconstruction of the Occluded Aortoiliac Segment Using “Double-Barrel” Self-Expanding Stents and Selective Use of the Outback LTD Catheter

To present the early and midterm results of endovascular stent reconstruction of the occluded aortoiliac segment with selective use of the Outback LTD re-entry catheter. Between April 2004 and February 2010, 8 patients (5 women; mean age 58.4 years, range 47-68) with occlusion of the infrarenal aorta extending to the common or external iliac arteries underwent endovascular reconstruction with double-barrel self-expanding stents. Indications for treatment were severe claudication in 6 and ulceration in 2 patients. The technical success rate was 100%, facilitated by the use of the Outback LTD catheter for accurate wire re-entry in 3 cases. There was no in-hospital mortality. One patient had a major complication (femoral artery dissection, brachial artery thrombosis, and retroperitoneal hematoma) unrelated to the re-entry device. Mean operating time was 137 minutes (range 70-253) and length of stay was 1.5 days (range 1-2). During a mean follow-up of 12.5 months (range 6-29), primary patency was 100% with no secondary interventions. Total endovascular reconstruction of the occluded infrarenal aorta that extends into the iliac arteries is durable at midterm follow-up. Adjunctive use of the Outback LTD re-entry catheter can facilitate technical success.

The Effect of Shear Stress on Neointimal Response Following Sirolimus- and Paclitaxel-Eluting Stent Implantation Compared With Bare-Metal Stents in Humans

We aimed to explore the relationship of neointimal thickness (NT) to shear stress (SS) after implantation of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) compared with bare-metal stents (BMS). We then tested the hypothesis that drug elution attenuates the SS effect. Neointimal thickness after BMS implantation has been associated with SS; pertinent data for drug-eluting stents (DES) are limited. Three-dimensional coronary artery and stent reconstruction was performed in 30 patients at 6-month follow-up after SES (n = 10), PES (n = 10), or BMS (n = 10) implantation. Baseline SS at the stent surface was calculated using computational fluid dynamics and NT at follow-up was computed in 3-dimensional space. Neointimal thickness was lower in DES versus BMS (0.03 ± 0.07 mm vs. 0.16 ± 0.08 mm, p < 0.001) and maximum NT was reduced in SES versus PES (0.33 ± 0.13 mm vs. 0.46 ± 0.13 mm, p = 0.025). In the total population, both SS (slope: -0.05 mm/Pa, p < 0.001) and DES (coefficient for DES vs. BMS: -0.17 mm, p = 0.003) were independent predictors of NT. Subgroup analysis demonstrated a significant negative relationship of NT to SS in PES (slope: -0.05 mm/Pa, p = 0.016) and BMS (slope: -0.05 mm/Pa, p = 0.001). Sirolimus elution significantly attenuated the effect of SS on NT (interaction coefficient for SES vs. BMS: 0.04 mm/Pa, p = 0.023), whereas the SS effect remained unchanged in PES (interaction coefficient for PES vs. BMS: 0.01 mm/Pa, p = 0.71). Neointimal thickness is significantly correlated (inversely) to SS in PES as in BMS. Sirolimus elution abrogates the SS effect on the neointimal response following stent implantation, whereas the SS effect is unchanged in PES.

P-017 ‘Double barrel’ stent reconstruction of a symptomatic fusiform basilar artery aneurysm

Objective and importanceGiant fusiform aneurysms of the basilar artery are associated with a high rate of morbidity and mortality. Treatment of these lesions can be difficult especially when there are...

Successful Open Surgery for Recurrent Pseudo-aneurysm after Endovascular Aneurysm Repair in a Patient with Behçet’s Disease

Abdominal aortic aneurysm (AAA) is a life-threatening complication in patients with Behçet’s disease. Recently, endovascular aneurysm repair (EVAR) has been reported with acceptable short-term outcomes. However, we report a case in which open surgery was required for a recurrent pseudo-aneurysm after EVAR. A 54-year-old man with Behçet’s disease was diagnosed with a pseudo-aneurysm at the proximal margin of a previously inserted stent graft for AAA. We performed open surgery for removal of the stent graft and reconstruction of the left accessory renal artery. Long-term outcomes of EVAR in patients with Behçet’s disease are not necessarily acceptable.

Endovascular Therapy in Pediatric Intracranial Carotid Artery Dissection

Intracranial carotid dissection is an underrecognized cause of childhood stroke, and, in the face of limited therapeutic experience, its management is controversial. Reported here is the case of a 12-year-old girl who experienced an intracranial carotid artery dissection with progressive and symptomatic occlusion of the middle cerebral artery. Endovascular treatment with intra-arterial thrombolysis and stent reconstruction was successfully performed to recanalize the occluded arterial segment. Current management of intracranial carotid dissection in children is reviewed, with discussion of the reasons for aggressive endovascular intervention.

Use of Intracranial Stenting to Secure Unstable Liquid Embolic Casts in Wide-Neck Sidewall Intracranial Aneurysms

Onyx HD 500 (eV3, Irvine, CA) is a high-viscosity liquid embolic agent that has recently been approved in the United States as a humanitarian use device for the treatment of wide-neck sidewall intracranial aneurysms. Preliminary evidence suggest that liquid embolic agents can provide improved angiographic results with a lower incidence of recanalization compared to coil embolization. To report unstable Onyx casts and how to deal with them. We report 4 cases of intracranial aneurysms treated with Onyx HD 500 in which, after the aneurysm was successfully obliterated, the Onyx cast was noted to have 1 of 2 types of embolic cast instability. In all 4 cases, an intracranial stent or vascular reconstruction device (VRD) was placed across the Onyx cast at the aneurysm orifice and the cast was stabilized. This series is the first published description of Onyx HD 500 aneurysm cast instability. It is also the first report of using a stent or vascular reconstruction device rescue technique to secure an unstable Onyx cast and represents a new indication for these devices.

Endovascular obliteration of an intracranial pseudoaneurysm: the utility of Onyx

Pseudoaneurysms are rare lesions with a multitude of causes, including infectious, traumatic, and iatrogenic origins. In addition, there are a number of potential treatment options, all of which require consideration to determine the most appropriate management. Historically, surgical intervention has been the method of choice, but because the histopathological features of these lesions make them largely unsuitable for clipping, trapping or excision is often required. More recently endovascular methods have been used, including coil embolization, stent reconstruction, or parent artery occlusion. Although these methods are often successful, situations arise in which they are not technically feasible. The authors describe such a case in a pediatric patient with an iatrogenic pseudoaneurysm. Onyx was used to embolize the lesion and the results were excellent.