Treatment Of Wide-necked Aneurysms Research Articles

A large UK single-centre experience in the long-term safety and efficacy of Woven Endobridge in the treatment of wide-neck intracranial aneurysms and risk factors associated with re-bleeding and re-treatment.

Endovascular treatment of wide neck aneurysms remains complicated with a determined and continuous technological effort towards treatment options that can offer safer and efficacious outcomes. The Woven Endobridge device was introduced in 2010 and has become a mainstay endovascular treatment for wide neck and large intracranial aneurysms. A recent review of the Woven Endobridge Clinical Assessment of Intrasaccular Aneurysm Therapy (WEBCAST) and WEBCAST2 trials and the five-year follow-up of patients was published. Our aim is to demonstrate real-life experience of aneurysms and patients treated with Woven Endobridge from a large high-volume specialist centre. A retrospective review was performed of patients treated with Woven Endobridge from March 2013 to March 2018. Primary efficacy outcomes were defined as per Raymond-Roy Occlusion Criteria (RROC) resulting in long-term complete occlusion (RROC1) and adequate occlusion (RROC1 and RROC2). Primary Safety outcomes were defined as procedure-related morbidity, rate of re-bleeding and rate of re-treatment. Seventy-nine aneurysms were treated during the five-year period. Adequate aneurysm occlusion (RROC1 and RROC2) achieved was 81%. Retreatment was required in 18% of patients (14/79). Greater retreatment rate was demonstrated in partially thrombosed aneurysms, aneurysms with larger neck and dome diameter and dome heights. Woven Endobridge treatment of wide-neck intracranial aneurysms offers a safe and efficacious outcome. This large UK single-centre experience demonstrates congruity with recent five-year outcomes of WEBCAST and WEBCAST2 trials.

Hemodynamic analysis of coil filled patient-specific middle cerebral artery aneurysm using porous medium approach

Cerebral aneurysms are bulges of an artery, which could be life-threatening when ruptured. Depending on their size, shape, and location, they need to be managed either through clipping or an endovascular coiling intervention. When coiled, reduced hemodynamic activity enables the coil to get thrombosed and achieve flow stasis. However, some coils delivered into the aneurysm tend to prolapse into the parent vessel and cause stroke due to obstruction and embolization. The recurrence of an aneurysm after endovascular coiling is of concern in the treatment of wide necked aneurysms. The initial packing density or improper coiling of the aneurysm and its relation to recurrence remains uncertain. This study investigates the influence of reduction in coil fill volume and packing density on the aneurysm recurrence using hemodynamic parameters by analyzing its flow features. Finite element method based commercial computational fluid dynamics solver is employed for performing patient-specific simulations for the coil filled aneurysm. The present approach uses porous medium based formulation. The numerical simulations show that any reduction below the optimal coil fill volume and packing density inside the aneurysm increases the velocity magnitude, wall shear stress, time-averaged wall shear stress, and spatial gradient of wall shear stress and reduces the relative residence time. The hemodynamic parameters and flow features suggest that a reduction in the coil packing density inside the aneurysm increases the chances of aneurysm recurrence. Hence, an assessment on how to achieve optimal coil fill volume and packing density is critical in reducing the risk of aneurysm recurrence.

Woven Endobridge embolization: Indications and innovation.

The treatment of intracranial aneurysms has seen incredible advancements over the last few decades. Long-term occlusion of wide-neck bifurcation aneurysms remains technically challenging. The Woven Endobridge (WEB) embolization device is innovative in its construction and uses. The design of the device has evolved over the last decade. Pre-clinical and clinical trials are ongoing and continue to inform the development of intrasaccular flow-diverting devices. The WEB device is currently approved by the U.S. Food and Drug Administration (FDA) for treating wide-neck aneurysms. The safety and efficacy of the WEB device have yielded promising clinical results that may have additional indications. This review aims to discuss the development of the WEB device and the current state of the WEB device in the treatment of wide-neck aneurysms. We also summarize ongoing clinical studies and potential innovative uses.

Intracranial wide neck aneurysms: clinical and angiographic outcomes of endovascular management

BackgroundThe treatment of intracranial wide neck aneurysms (WNAs) is usually difficult, hence several endovascular techniques were developed. This study aims to assess the clinical and angiographic imaging outcome of endovascular management of intracranial wide neck aneurysm. Forty patients were referred to the neuro-endovascular unit, at our hospital, each with a wide neck aneurysm. They were assessed regarding clinical presentation, aneurysm size, the character of the aneurysm, and the age and sex of the patient. Post-procedural, clinical, and angiographic outcomes of the patients who underwent endovascular intervention were reviewed.ResultsIn this study, the mean aneurysmal neck was 5.4 ± 1.6 mm (mm). Endovascular intervention was carried out in all 40 patients in the form of simple coiling in 3 patients, double-catheter technique in 5 patients, balloon-assisted coiling (BAC) in 16 patients, stent-assisted coiling (SAC) in 13 patients, and flow diverter (FD) in 3 patients. Regarding clinical outcome, 4 patients had unfavorable outcome (the modified Rankin Scale, mRS > 2) at presentation and 3 patients at discharge. There was no unfavorable clinical outcome at 6- and 12-month follow-ups. Overall angiographic outcome at 1-year follow-up, 37/40 aneurysms (92.5%) had complete occlusion while two aneurysms had neck recurrence and one aneurysm had neck recanalization.ConclusionThe current endovascular techniques in the treatment of WNAs are considered effective, feasible, and safe.

Endovascular Management of Hemorrhagic Stroke.

Significant advances in endovascular neurosurgery tools, devices, and techniques are changing the approach to the management of acute hemorrhagic stroke. The endovascular treatment of intracranial aneurysms emerged in the early 1990s with Guglielmi detachable coils, and since then, it gained rapid popularity that surpassed open surgery. Stent-assisted coiling and balloon remodeling techniques have made the treatment of wide-necked aneurysms more durable. With the introduction of flow diverters and flow disrupters, many aneurysms with complex geometrics can now be reliably managed. Arteriovenous malformations and fistulae can also benefit from endovascular therapy by embolization using n-butyl cyanoacrylate (NBCA), Onyx, polyvinyl alcohol (PVA), and coils. In this article, we describe the role of endovascular treatment for the most common causes of intracerebral and subarachnoid hemorrhages, particularly ruptured aneurysms and vascular malformations.

The Evolution of Endovascular Therapy for Intracranial Aneurysms: Historical Perspective and Next Frontiers.

The history of cerebral aneurysm treatment has a rich and storied past with multiple notable luminaries contributing insights. The modern era has transitioned from primarily clip ligation to increasing use of endovascular therapy. Even more recently, the use of intrasaccular flow diverters has been introduced for the treatment of wide necked aneurysms. The field is continuing to transform, and bioactive coils and stents have resurfaced as promising adjuvants to promote aneurysm healing. Advanced imaging modalities are being developed that could further advance the endovascular arsenal and allow for porous memory polymer devices to enter the field. This focused review highlights notable historic contributions and advances to the point of futuristic technology that is actively being developed.

Comaneci device-assisted embolization of wide-necked carotid aneurysms with an unfavorable ratio

BackgroundEndovascular treatment is the technique of choice for most intracranial aneurysms. However, the treatment of morphologically complex wide-necked aneurysms with an unfavorable anatomy is still a therapeutic challenge.The purpose of the study is to describe the initial experience with the Comaneci embolization assist device for the treatment of wide-necked aneurysms with an unfavorable ratio for direct embolization.MethodsWe report a retrospective single-center analysis taken from a prospective database of consecutive aneurysms of the anterior circulation treated using the Comaneci device in the period from March 2017 to March 2019.ResultsEighteen aneurysms were collected from 16 patients (9 women and 7 men) treated using the Comaneci device. The mean age was 48.4 years (range 36–81). Twelve patients had SAH, three were incidental aneurysms and one had compressive symptoms. A complete asymptomatic occlusion rate of 88.8% was obtained. The major complication rate was 5.55%.ConclusionThe Comaneci embolization assist device is a safe, effective option for endovascular treatment of complex aneurysms with an unfavorable ratio.

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

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

Low rates of recanalization for wide-necked aneurysms treated with stenting after balloon-assisted coiling: combination of techniques delivers stable and improved results during follow-up

In the treatment of wide-necked aneurysms, stenting may be required after balloon-assisted coiling (BAC) for reconstructing the lumen/flow of the parent artery in cases of coil herniation. The potential benefits and complications of both techniques remain unclear when used together. Our aim was to assess the safety and long-term angiographic outcomes of stenting after BAC. Retrospective review of 87 unruptured wide necked aneurysms (in 80 patients) treated with BAC and requiring stent placement at the final stage of the procedure due to coil prolapse. Aneurysm characteristics, technical issues, clinical records, and MR results were assessed. Post-treatment and follow-up angiograms were evaluated by two independent reviewers and categorized as "stable," "further thrombosis," or "recanalization." The mean maximum diameter was 9.1±4.7mm and aspect ratio 1.20 ± 0.47. Complete and near-complete initial occlusion were observed in 53 (60.9%) and 28 (32.2%) of all treated aneurysms, respectively. Angiographic follow-up (80 aneurysms; mean, 34.68±25.26months) revealed stability and further thrombosis in 92.4% (74/80). Recanalization was observed in six cases (7.5%, 6/83), four of which were retreated. No significantly different outcomes were found in terms of aneurysm size (p = 0.641). Transient and reversible procedure-related complications occurred in eight (9.2%), minor permanent deficits in 2.3%, and major deficits, including death, in four cases (4.6%). Our results suggest that treatment of wide-necked aneuryms with stent placement after BAC yields low recanalization rates and enhanced angiographic outcomes in long-term follow-up.

Treatment of Wide-Necked Bifurcation Aneurysms

BackgroundRecently, numerous devices dedicated to the treatment of wide-necked aneurysms have become available. We present our initial experience with the pCANvas device and present the technical success rate, clinical outcome and immediate angiographic occlusion rates.ObjectiveWe sought to determine the efficacy of flow with the pCANvas for the treatment of unruptured intracranial aneurysms.MethodsWe performed a retrospective review of our prospectively collected data to identify patients treated with the pCANvas device between February 2015 and February 2017. The patient demographics, aneurysm characteristics, immediate and delayed clinical and radiographic follow-up data were recorded.ResultsWe identified 17 patients (13 female) treated only with the pCANvas device. The average age of the patients was 60.5 ± 13.3 years (range 25–75 years). The average dome width was 7.6 ± 3.2 mm (range 3–15.8 mm), dome height 7.1 ± 3.2 mm (range 3–12.9 mm) and neck width 5.4 ± 3.2 (range 3–16.3 mm). The average aspect ratio was 1.5 ± 0.8 (range 0.6–3.7). At the end of the procedure 15 aneurysms continued complete filling of the aneurysm (Raymond Roy Classification[RRC] 3) with 2 aneurysms showing only filling of the neck of the aneurysm (RRC 2). Early follow-up angiography was available for 16 patients and at this stage 11 aneurysms showed persistent and complete filling of the aneurysm (RRC 3), 5 aneurysms showed complete occlusion of the aneurysm (RRC 1) and 7 aneurysms underwent repeat treatment with coiling.ConclusionThe early results on the use of the pCANvas are promising; however, longer term follow-up and larger studies are required.

The pCONus Device in Treatment of Wide-necked Aneurysms : Technical and Midterm Clinical and Angiographic Results.

Avariety of devices for treatment of wide-necked bifurcation aneurysms are emerging. Here we report our results using the new pCONus device with special emphasis on the morphological and anatomical requirements for successful implantation. In this study we treated 21patients with 22aneurysms by endovascular interventions. After providing informed consent, patients were included according to the following criteria: aneurysm dome to neck ratio <2 or neck diameter >4mm. The primary end points for clinical safety were the absence of death, absence of major or minor stroke and absence of transient ischemic attack. A total of 22 aneurysms in 21patients were treated with pCONus-assisted coiling. In 19patients harboring 20aneurysms the implantation of the device was successful and these aneurysms showed an adequate occlusion after 6months in 95 %. The complication rate was low (5 %) with one case of minor neurological stroke. Analysis of the data showed that the difference in aneurysm angulation between successful (mean45°) and failed implantations (mean71.5°) was highly significant. Use of the pCONus device and coiling in wide-necked bifurcation aneurysms is safe and provides good occlusion rates but might be limited by the angulation between the aneurysm and the parent vessel.

Solitaire AB stent-assisted coil for embolization of wide-necked cerebral aneurysms: an analysis of complications

Objective To investigate the perioperative complications and treatment measures of Solitaire AB stent for embolization of wide-necked cerebral aneurysms. Methods The clinical and imaging data of 116 patients with wide-necked cerebral aneurysms treated by using Solitaire AB stent-assisted embolization at the Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University from February 2010 to February 2014 were analyzed retrospectively. The perioperative complications were observed. Its causes of occurrence were analyzed and the corresponding treatment measures were investigated. Results All stents were successfully implanted in place. The results of immediate DSA examination revealed that 55 of 120 aneurysms were embolized completely. There were 59 residual aneurysm necks, 6 aneurysms were embolized partially. Ten patients had perioperative complications, 3 were intraoperative aneurysm rupture, the bleeding of 2 patients was stopped after emergency packing, and 1 patient died; after having intraparenchymal hemorrhage, 1 patient died of herniation at 5 h after stenting; 4 had thrombotic complications, 3 of them had blood flow recanalization after in-stent thrombolysis, and the efficacy of 1 case was poor and his blood flow was patent after a new Solitaire stent implantation; 2 had stent migration when the stent was not detached during procedure, fortunately, it did not cause significant neurological damage. After procedure, 114 patients were followed up for 3 to 37 months. Twelve patients had aneurysm recurrence and 5 were treated with intervention therapy again. Conclusions Solitaire AB stent-assisted coil embolization for the treatment of wide-necked aneurysms is a mature technique, but there are some complications. Therefore, the surgeons need to have good operative skills and rich experience. At the same time, the perioperative management should be strengthened in order to reduce the occurrence of complications and improve the prognosis of patients. Key words: Intracranial aneurysm; Intraoperative complications; Wide-necked; Stent

One-Year Angiographic Follow-Up after WEB-SL Endovascular Treatment of Wide-Neck Bifurcation Intracranial Aneurysms.

Endovascular coiling of wide-neck intracranial aneurysms is associated with low rates of initial angiographic occlusion and high rates of recurrence. The WEB intrasaccular device has been developed specifically for this indication. To date, there has been no report of the long-term follow-up of a series of patients with aneurysms treated with this type of device, to our knowledge. Our aim was to evaluate a 1-year follow-up of angiographic results in a prospective single-center series of patients treated with the WEB-Single-Layer (SL) device. All patients treated with the WEB-SL device in our center between August 2013 and May 2014 were prospectively included. One-year angiographic outcomes were assessed. Results at follow-up were graded as complete occlusion, neck remnant, or residual aneurysm. Eight patients with 8 unruptured wide-neck aneurysms were enrolled in this study. Average dome width was 7.5 mm (range, 5.4-10.7 mm), and average neck size was 4.9 mm (range, 2.6-6.5 mm). One-year angiographic follow-up obtained in all aneurysms included 1 complete aneurysm occlusion (12.5%), 6 neck remnants (75%), and 1 aneurysm remnant (12.5%). Of 8 aneurysms, worsening of aneurysm occlusion was observed in 2 (25%) by compression of the WEB device. There was no angiographic recurrence of initially totally occluded aneurysms. No bleeding was observed during the follow-up period. Endovascular therapy of intracranial aneurysms with the WEB-SL device allows treatment of wide-neck aneurysms with a high rate of neck remnant at 1 year, at least partially explained by WEB compression. Initial size selection and technologic improvements could be an option for optimization of aneurysm occlusion in WEB-SL treatment.

O-015 Double Catheter Technique : A Potential Alternative For The Stent Assisted Coil Embolisation For Wide Neck Aneurysms

Background and PurposeDouble catheter coil embolisation (DCC) technique has been used for the treatment of wide neck aneurysms. Unlike Stent assisted Coil Embolisation (SAC), DCC does not require long term...

Abstract WP85: Risk factors for Stenosis of Stents Utilized for Stent Assisted Coiling of Unruptured Intracranial Aneurysms

Introduction: Stent-assisted coil embolization facilitates the treatment of wide-necked aneurysms. In-stent stenosis, although rare, may lead to stroke by occlusion of the parent artery or by thromboembolism. To our knowledge, the risk factors for in-stent stenosis in this context have not yet been investigated. Hypothesis: We hypothesized that cardiovascular risk factors and vessel size would be associated with in-stent stenosis. Methods: Consecutive patients undergoing stent-assisted coil embolization at our institution using the Neuroform stent (Stryker, Kalamazoo, MI, USA) were identified by billing records. Medical comorbidities were extracted retrospectively from patient charts. In-stent stenosis on last angiogram and vessel size (dichotomized into &lt;2 mm or ≥2 mm) were estimated by direct review of angiography. Patients were grouped into those with and without ≥50% in-stent stenosis and the characteristics of the two groups were compared using a t-test for continuous variables and Fisher’s exact test for categorical variables. Results: A total of 224 unruptured aneurysms were treated with stent assisted-coil embolization between 2003 and 2010 utilizing the Neuroform stent. Follow-up catheter angiography was available in 196/224 (87.5%) at mean of 19 mos in those with in-stent stenosis and 24 mos in those without. In-stent stenosis occurred in 8/196 (4.1%). Mean age was 59 in those with in-stent stenosis and 62 in those without. The prevalence of cardiovascular risk factors in the groups with and without stenosis were as follows: diabetes 25% (2/8) vs. 6.9% (13/188), hypertension 42.6% (80/188) vs. 50% (4/8), hyperlipidemia 13% (1/8) vs. 5.9% (11/188), coronary artery disease 13% (1/8) vs. 3.7% (7), and smoking 38% (3/8) vs. 39% (75/188). Vessel size was &lt;2 mm in 25% (2/8) in those with in-stent stenosis and 9.6% (18/188) in those without. None of these results were statistically significant. Conclusions: The overall risk of in-stent stenosis in patients undergoing stent-assisted coil embolization was relatively low. Although cardiovascular comorbidities were numerically more common in patients with in-stent stenosis, the differences between the two groups were not statistically significant.

Wide-neck瘤に対するEnterprise VRDを用いたstent assisted coilingの初期成績

【背景】2010年1月よりEnterprise VRD（Johnson ＆ Johnson Codman, Miami, FL, USA）が薬事承認，7月より健康保険償還治療となったことから，これまで治療困難であったワイドネック瘤に対する瘤内塞栓術が試みられるようになった．当院での初期治療成績について報告する．【対象】2010年7月から2011年12月までに当院にてワイドネック瘤31例33病変に対しEnterprise VRDを用いたstent assisted coilingを行った．全例，未破裂瘤であり，コイル塞栓術後の再発がうち6例であった．動脈瘤の局在は内頚動脈 15例，中大脳動脈 2例，前交通動脈 3例，脳底動脈 12例，後大脳動脈 1例であった．動脈瘤の最大径は平均11.6mm（7-25mm），ネック径は平均6.5 mm（4-13.8mm）であった．全例アスピリン100mg+クロピドグレル75mgのdual antiplatelet therapyを術前7日前より開始した．【結果】ステント留置の手技成功率は100％であった．5例（15.2％）でProwler Select Plus（Johnson ＆ Johnson Codman, Miami, FL, USA）の直接誘導が困難であり，カテーテル交換を必要とした．1例でステント留置時のカテーテル滑落により再誘導を要した．全例塞栓術が施行でき，治療直後に完全閉塞がえられたのは25例（75.8％）であった．全例でjailing techniqueで塞栓開始したが，8例（24.2％）で塞栓途中にtrans-cell techniqueへ切り替えた．術中の有害事象としては母血管の血栓性閉塞を2例，くも膜下出血を1例経験したが，いずれも無症候性に留まった．術後12時間後に1例で穿刺部血腫を契機とした低血圧を起因とした穿通枝梗塞を経験し，morbidity ＆ mortality rateはそれぞれ3.0％と0％であった．フォローアップ期間の有症候性合併症は認めていない．フォローアップの血管撮影は術後1年目で10例に施行でき1例で無症候性のステント閉塞を認めた．【結論】Enterprise VRDを用いたstent assisted embolizationの初期成績は良好であった．Enterprise VRD導入により，治療困難であったワイドネック瘤が，より安全に治療可能となった．

Effects of flow diversion stents on rabbits' wide necked aneurysms and branches

Objective To observe the effects of flow diversion stents on rabbits' aneurysms and branches.Method 30 New Zealand white rabbits with wide necked aneurysm were randomly divided equally into three groups.In group A and B,flow diversion stents were implanted into parent vessel with metal coverage 30%～35% and 45%～ 50%,respectively.Angiography was performed at 4 weeks after stent implantation.After 3 months all animals were euthanized for pathological examination after angiography.In group C,animals were only performed for angiography without any stent implanted after grouped and at 3 months,and then animals were euthanized for pathological examination after angiography.Results Immediately after stents placement,90% and 70% aneurysms' necks covered by stents successful in group A and B,respectively.The contrast retention in aneurysms were 88.7% and 100%,respectively.intravenous digital subtraction angiography showed that 77.8% and 85.7% aneurysms were completely occluded at 4 weeks fogow -up,respectively.Artery digital subtraction angiography showed that 71.4% and 85.7% aneurysms were occluded at 3 months follow- up,respectively.All branches covered by stents were patency at angiography follow - up.Pathologic analysis showed that the dome of embolized aneurysms was full filled with thrombus and neointimas at neck and parent vessel were found.In group C,mean aneurysm dimensions were not significantly changed in angiography after grouped and before sacrificed at 3 months( P ＞ 0.05).Conclusions The flow diversion stents are effective in the treatment of wide necked aneurysms with preservation of adjacent branch vessels in angiography. Key words: Flow diversion stent; Metal coverage; Intracranial aneurysm; Branch vessel; Rabbit

O-019 Novel non-occlusive temporary endoluminal neck protection device to assist in the treatment of wide necked aneurysms in a canine model

IntroductionCurrent endovascular treatment of wide necked aneurysms often requires the use of an adjuvant device. Balloon assist technique requires temporary occlusion of the parent vessel. Intravascular stents require the use...

Retrograde crossing stent placement strategies at the basilar apex for the treatment of wide necked aneurysms: reconstructive and deconstructive opportunities

Neck remodeling devices such as the Neuroform or Enterprise greatly facilitate the endovascular treatment of wide necked basilar apex aneurysms. The complex anatomy of the basilar apex affords opportunity for...

024 Balloon remodeling technique in the treatment of wide necked aneurysms: intermediate and long term experience with identification of predictors for successful aneurysm occlusion

Objective: To present the results of retrospective analyses of aneurysms treated with the remodeling technique, and identify predictors for successful aneurysm occlusion on initial treatment and intermediate to long term...