Vascular Reconstruction Device Research Articles

Use of Contralateral Trans-Anterior Communicating Artery Snare to Rescue Lost Access to a Pipeline Embolization Device Unsheathed in an Aneurysm.

A pipeline embolization device (PED; Medtronic, Minneapolis, MI, USA) is a new vascular reconstruction device used to treat large internal carotid artery (ICA) aneurysms in Japan. We herein present a PED-related complication and describe its rescue strategy. Rescue therapy using a snare via the posterior communicating artery from the contralateral side has already been reported. However, this is the first report of therapy via the anterior communicating artery (AcomA). A 49-year-old woman underwent vascular reconstruction with a PED for a large cavernous ICA aneurysm. During the placement of the PED, the proximal side of the PED slipped into the aneurysm. It was impossible to enter the true lumen of the PED from the proximal side because the orifice of the stent faced the aneurysmal wall. Contralateral trans-AcomA access to the PED was obtained through the distal ICA. The microwire from the distal ICA was connected with Goose Neck snares (Medtronic) from the proximal ICA. Pulling the snares to the proximal side, the PED was straightened and distal access was regained. Another PED was deployed such that it overlapped with the first PED to achieve vascular reconstruction. The patient finally recovered from aphasia, but paralysis of the right upper limb remained after rehabilitation. If the stent slips into the aneurysm, distal access through the true stent lumen may be very difficult. We presented a rescue technique for this complication, through the AcomA from the contralateral side.

Thromboembolic Events with Enterprise Versus Pipeline: Porcine In Vivo Experiment

Thromboembolic complications are serious adverse events associated with stenting of intracranial aneurysms. For the development of novel devices, currently no practical model exists to evaluate distal embolic events. The purpose of the current study was 2-fold: 1) assess the feasibility of a porcine carotid bifurcation model for invivo testing of stent thrombogenicity and 2) compare the thrombogenicity of the Enterprise vascular reconstruction device versus the Pipeline embolization device (PED). Six Yorkshire pigs underwent implantation of size-matched devices across the carotid bifurcation. Each animal received 1 Enterprise and 1 PED contralaterally. Baseline and 2-week follow-up angiography were performed. Images were analyzed including detailed measurements of the rete mirabile, a small-vessel conglomerate supplied by branches of the common carotid artery. In the absence of thromboembolic events at 2 weeks (n= 8), the perfused rete area measured 134.4 ± 6.9 mm2. In the presence of thromboembolic events (n= 4), theperfused rete was reduced to an area covering 37.1 ± 8.6 mm2 (P < 0.01). There was no difference in thrombogenicity between Enterprise and PED with a thromboembolic event rate of 33.3% for both devices (P > 0.99). The swine carotid stent model allows invivo analysis of device-related thrombogenicity and distal embolic event rates. Size reduction of the perfused rete mirabile indicates the presence of thromboembolic events. Both Enterprise and PED were associated with similar thrombogenicity in this experiment.

The Barrel vascular reconstruction device for endovascular coiling of wide-necked intracranial aneurysms: a multicenter, prospective, post-marketing study

Background and purposeThe Barrel vascular reconstruction device (Barrel VRD) is a novel stent with design features that allow endovascular coiling of wide-necked bifurcation aneurysms while preserving adjacent branches, without necessitating...

Risk factors for coil protrusion into the parent artery and associated thrombo-embolic events following unruptured cerebral aneurysm embolization.

Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications. We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI). Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk (P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained. Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy.

Abstract W P86: The Barrel Vascular Reconstruction Device for the Treatment of Wide-Neck Bifurcation Aneurysms

PURPOSE: Complex wide-necked bifurcation aneurysms by using a single-stent and double (X and Y) stenting remain challenging. The purpose of the French Barrel™ Prospective Registry, an intention to treat study, is to evaluate the safety and probable benefit of the Barrel VRD when used to facilitate endovascular coiling of wide-neck bifurcating. METHODS: The Barrel VRD was intended for use with embolic coils for the treatment of wide-neck bifurcating intracranial aneurysms arising from a parent vessel with a diameter of ≥ 2mm and ≤ 4 mm. A wide-neck is defined as having a neck width ≥ 4 mm or a dome-to-neck ratio &lt; 2. Patients (all harboring unruptured aneurysms) were placed on a double anti-platelet protocol (Clopidogrel and ASA) prior to treatment. RESULTS: From December 2013 to June 2014, 18 patients harboring 18 aneurysms (7 MCA, 4 basilar tip, 4 AcoA, 3 ICA termination) were enrolled within the French Barrel Registry thus far. One patient was enrolled, but not treated due to being a low anti-platelet responder. Aneurysm necks ranged from 3.1 to 8.0 mm (mean: 4.8) and dome/neck ratio ranged from 0.6 to 1.7 (mean : 1.2). Trans-cell microcatheter placement was obtained in all cases. Technical success was 88.2% (15/17). In 1 case, 2 coil loops protruded outside the Barrel within the parent vessel, in another case the Barrel moved slightly during coil delivery microcatheter placement into the sac. Discharge mRS was 0 for all but 1 patients (this patient was mRS 2 at admission). Adverse events included 1 groin hematoma, and 1 aneurysm coil perforation, related to the procedure, but not the Barrel VRD. CONCLUSIONS: The initial French Barrel Registry results demonstrate that the Barrel VRD device is new tool for the endovascular treatment of wide neck bifurcation aneurysms.

O-030 Preliminary French Registry Clinical Experience with the Barrel Bifurcation Vascular Reconstruction Device

Background/purposeEndovascular Stent-assisted coiling is a well establish technique for treatment of wide-necked intracranial aneurysms. However, it remains a challenge to successfully treat complex wide-necked bifurcate aneurysms by using a single-stent...

Enterprise stenting for intracranial aneurysm treatment induces dynamic and reversible age-dependent stenosis in cerebral arteries

BackgroundAlthough intracranial stenting has been associated with in-stent stenosis, the vascular response of cerebral vessels to the deployment of the Enterprise vascular reconstruction device is poorly defined.ObjectiveTo evaluate the change...

Stent recanalization of carotid tonsillar loop dissection using the Enterprise vascular reconstruction device

Although advances in endovascular techniques have permitted reconstruction of intimal dissections and related pseudoaneurysms of the extracranial cervical internal carotid artery, highly tortuous tonsillar loop anatomic variants still pose an obstacle to conventional extracranial self-expanding carotid stents. During a 12year period, nine of 48 cases with cervical carotid dissections were associated with a tonsillar loop. Five patients required endovascular treatment, which was performed using a microcatheter-based technique with the low-profile Enterprise vascular reconstruction device (Codman Neurovascular, Raynham, MA, USA). Technical, radiographic, and clinical outcomes were analyzed for each patient. Dissection etiology was spontaneous in three patients, iatrogenic in one, and traumatic in one. Four near-occlusive tonsillar loop dissections were successfully recanalized during the acute phase. Dissection-related stenosis improved from 90±22% to 31±13%, with tandem stents needed in three instances to seal the inflow zone. There were no procedure-related transient ischemic attacks (TIA), minor/major strokes, or deaths. Angiographic follow-up for a mean of 28.0±21.6months showed all stents were patent, with average stenosis of 25.2±12.2%. Focal ovalization and kinking of the closed-cell design was noted at the sharpest curve in one patient. Clinical outcome (follow-up of 28.1±21.5months) demonstrated overall improvement with no clinical worsening, new TIA, or stroke. Tonsillar loop-associated carotid dissections can be successfully and durably recanalized using the low-profile Enterprise stent with an excellent long-term patency rate and low procedural risk. The possibility of stent kinking and low radial force should be considered when planning reconstruction with this device.

Primary stenting for acute ischemic stroke using the Enterprise vascular reconstruction device: early results

ObjectivePrimary stenting for acute ischemic stroke (AIS) using the Wingspan stent delivery system has been reported. Major technical limitations in that study were difficulties in delivering the device and a...

O-017 Preliminary Experience with a New Barrel Shaped Bifurcation Aneurysm Bridging Device

PurposeTo test the feasibility of a novel fully retrievable barrel-shaped vascular reconstruction device for stent assisted endovascular treatment of wide-necked bifurcation aneurysms.Methods16 Canine were utilised to assess the acute technical...

E-028 Intracranial Stenting without Angioplasty for Cerebral Aneurysms with Adjacent Vessel Stenoses

IntroductionIntracranial stenting is currently not routinely recommended for intracranial stenotic disease based on recent clinical trial results. However, wide-necked cerebral aneurysms with adjacent vascular stenoses may require stent placement to...

Disappearance of a small intracranial aneurysm as a result of vessel straightening and in-stent stenosis following use of an Enterprise vascular reconstruction device

In-stent stenosis after stent-assisted coil embolization is a rare but well-known complication. A 32-year-old woman with an unruptured wide-necked left internal carotid artery (ICA) terminus aneurysm and an ipsilateral very...

Analysis of Closed-Cell Intracranial Stent Characteristics Using Cone-Beam Computed Tomography With Contrast Material

The intracranial nitinol stent named the Enterprise Vascular Reconstruction Device has poor radiographic visibility. The characteristics of closed-cell intracranial stents were investigated and the efficacy of intraoperative stent visualization examined with the 80 kV high-resolution XperCT protocol, which is a flat detector C-arm volume acquisition functionality system integrated with the angiography equipment. We treated 39 aneurysms with stent-assisted coil embolization. The aneurysms were located on the internal carotid artery in 24 cases, the anterior communicating artery (AcomA) in three, the basilar artery (BA) in 10, and the vertebral artery in two. Intraoperative 80 kV XperCT was performed in all cases after deposition of the stent. We evaluated the coverage of the aneurysm neck, incomplete stent apposition (ISA), and shift of vessels. Accurate stent visualization was achieved in 29 of the 39 cases without coil and delivery wire artifact. Coverage of the aneurysm neck succeeded in 28 cases; there was one case of BA top Y-configuration stenting in which the stent was dislocated into the aneurysm. ISA was detected in nine cases, including seven kinks and one flattening in the carotid siphon and one kink in the BA top. We detected linearization of vessels due to stent deployment in three AcomA cases and three BA top cases. We conclude that intraoperative 80 kV XperCT is an efficient modality for the evaluation of ISA. Stent kinking in the carotid siphon and linearization in distal vessels can be detected with this protocol.

6FrセルリアンカテーテルDD6を用いたtriple coaxial system

【目的】今回我々が新たに開発した6FrセルリアンカテーテルDD6の有用性について報告する．【方法】未破裂前交通動脈瘤に対するコイル塞栓術，および破裂左中大脳動脈瘤のコイル塞栓術において，8Frガイディングカテーテルのintermediate catheterとして6FrセルリアンカテーテルDD6を使用した．【結果】親血管のアクセス困難を解決し，ガイディングカテーテルのサポートを向上させると同時に，balloonあるいはstent assist techniqueを併用したコイル塞栓術が可能であった．【結論】4Frセルリアンカテーテルを用いたtriple coaxial systemではsimple techniqueによる塞栓術のみが可能であるが，新たに開発した6FrセルリアンカテーテルDD6を用いたtriple coaxial systemであればバルーン併用あるいはEnterprise VRD併用によるコイル塞栓術が可能である．

O-013 The pulsar vascular aneurysm neck reconstruction device for bifurcation aneurysms: in vitro study and first clinical experience

IntroductionWe present the in vitro and first clinical results of a novel aneurysm neck reconstruction device specifically designed to treat bifurcation aneurysms.MethodThe Pulsar Vascular Aneurysm Neck Reconstruction Device (ANRD) is...

E-019 Novel aneurysm neck reconstruction device: initial experience in an experimental pre-clinical bifurcation aneurysm model

IntroductionTreatment of wide necked bifurcation aneurysms often poses procedural and long-term outcome challenges. We describe the initial preclinical experience with the Pulsar Vascular Aneurysm Neck Reconstruction Device (PVANRD) in a...

E-047 Novel treatment of isolated P1 segment “blister” aneurysm with telescoping stents

PurposeDissecting posterior cerebral artery aneurysms are rare lesions that pose difficult treatment options. The purpose of this case is to describe the complications of stenting of a posterior cerebral artery...

Novel aneurysm neck reconstruction device: initial experience in an experimental preclinical bifurcation aneurysm model

IntroductionTreatment of wide-necked bifurcation aneurysms often poses procedural and long-term outcome challenges. The initial preclinical experience with the Pulsar Vascular Aneurysm Neck Reconstruction Device (PVANRD) in a canine bifurcation model...

Long-term Results of Enterprise Stent-Assisted Coiling of Cerebral Aneurysms

The Enterprise Vascular Reconstruction Device and Delivery System (Cordis; the Enterprise stent) was approved for use in conjunction with coiling of wide-necked aneurysms in 2007. No published long-term aneurysm occlusion or complication data exist for the Enterprise system. We compiled data on consecutive patients treated with Enterprise stent-assisted coiling of aneurysms from 9 high-volume neurointerventional centers. A 9 center registry was created to evaluate large volume data on the delayed safety and efficacy of the Enterprise stent system. Pooled data were compiled for consecutive patients undergoing Enterprise stent-assisted coiling at each institution prior to May 2009. Two-hundred twenty-nine patients with 229 aneurysms, 32 of which were ruptured aneurysms, were included in the study. Mean clinical and angiographic follow-up was 619.6 ± 26.4 days and 655.7 ± 25.2 days, respectively. Mean aneurysm size was 9.2 ± 0.4 mm. Fifty-nine percent of patients demonstrated 100% coil obliteration and 81% had 90% or higher occlusion at last follow-up angiography. A total of 19 patients (8.3%) underwent retreatment of their aneurysms during the follow-up period. Angiographic in-stent stenosis was seen in 3.4% and thromboembolic events occurred in 4.4%. Overall, 90% of patients who underwent Enterprise-assisted coiling had a modified Rankin Scale score of 2 or less at last follow-up. A poor modified Rankin Scale score was strongly associated with rupture status (P < .001). Although this study is limited by its retrospective nature, the Enterprise stent system appears to be an effective, safe, and durable treatment for intracranial aneurysms when used in conjunction with coiling.

P-032 Vascular reconstruction devices shrink small cerebral aneurysms

Endovascular treatment of intracranial aneurysms (IAs) often includes the deployment of a vascular reconstruction device (VRD), particularly if the aneurysm has a wide neck or unfavorable dome to neck ratio,...