Endovascular Techniques for Achievement of Better Flow Diverter Wall Apposition: Telescopic Device Placement

Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms.

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Endovascular techniques for achievement of better flow diverter wall apposition

Interventional Neuroradiology ◽

10.1177/1591019918815294 ◽

2018 ◽

Vol 25 (3) ◽

pp. 344-347 ◽

Cited By ~ 4

Author(s):

Anna L Kühn ◽

Katyucia de Macedo Rodrigues ◽

Ajay K Wakhloo ◽

Ajit S Puri

Keyword(s):

Flow Diverter ◽

Aneurysm Rupture ◽

Endovascular Techniques ◽

Flow Diverter Stent ◽

Life Threatening ◽

Wall Apposition ◽

Device Deployment ◽

Technical Complication ◽

Good Flow

Flow diverter malapposition has been described as a technical complication during endovascular procedures and can be associated with, potentially delayed, life-threatening aneurysm rupture or ischemic events. We performed a retrospective review of our flow diverter database to identify all patients in whom device malapposition was detected on follow-up angiogram immediately after device deployment. Feasibility and technical success of different endovascular approaches aiming to correct the inadequate vessel wall apposition were evaluated. Successful endovascular techniques for manipulation of the flow diverter included use of wires, catheters and additional flow diverter/stent devices. In our practice, we found six successful endovascular techniques for device manipulation, which allowed us to safely achieve good flow diverter wall apposition.

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E-070 Endovascular Techniques for Achievement of Better Flow Diverter Wall Apposition

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012589.142 ◽

2016 ◽

Vol 8 (Suppl 1) ◽

pp. A79.1-A79

Author(s):

A Kuhn ◽

K de Macedo Rodrigues ◽

M Gounis ◽

P Kan ◽

M Marosfoi ◽

...

Keyword(s):

Flow Diverter ◽

Endovascular Techniques ◽

Wall Apposition

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Flow diverter for endovascular treatment of intracranial mirror segment internal carotid artery aneurysms

Interventional Neuroradiology ◽

10.1177/1591019918792536 ◽

2018 ◽

Vol 25 (1) ◽

pp. 4-11 ◽

Cited By ~ 2

Author(s):

Anna Luisa Kühn ◽

Peter Kan ◽

Visish Srinivasan ◽

David E Rex ◽

Katyucia de Macedo Rodrigues ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Temporal Artery ◽

Flow Diverter ◽

Post Treatment ◽

Pipeline Embolization Device ◽

Device Placement ◽

Aneurysm Occlusion

Background To evaluate the feasibility and efficacy of the pipeline embolization device in the treatment of unruptured intracranial mirror segment aneurysms. Methods Out of a total of 338 subjects, 14 were identified harboring a total of 32 internal carotid artery mirror segment aneurysms that were treated with the pipeline embolization device and were consecutively enrolled into our study. We collected data on patient demographics, modified Rankin scale (mRS) at admission, aneurysm characteristics, clinical outcome at discharge, 3–9 and at 12–18 months as well as angiography results at follow-up. Results Patients’ mean age was 52.9 years; baseline mRS was 0 in all subjects. Pipeline embolization device placement was successful in all cases. Post-treatment mRS remained 0 in 13/14 patients. One patient experienced a small intraparenchymal hemorrhage and subarachnoid hemorrhage, associated with a frontoparietal infarction resulting in right upper extremity weakness and aphasia (post-treatment mRS 3). His mRS evaluation remained stable at the 3–9-month follow-up. Three to 9-month follow-up angiography (13/14 subjects) showed complete aneurysm occlusion in 24/30 aneurysms (80%), near complete and partial occlusion in three of 30 (10%) aneurysms each. At the 9-month follow-up, one patient experienced a complete occlusion of the anterior temporal artery branch but did not present with any clinical deficits. No mRS changes were encountered over a median 6-month follow-up period. Mid-term follow-up angiography (12–18 months) available in eight of 14 subjects showed complete aneurysm occlusion in all patients. Mild intimal hyperplasia was observed in one patient. Conclusions Flow diversion technology can be used for the treatment of unruptured mirror segment aneurysms in selected patients.

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E-216 The effect of omeprazole on patients taking clopidogrel after flow diverter device placement

10.1136/neurintsurg-2020-snis.247 ◽

2020 ◽

Author(s):

J Catapano ◽

V Fredrickson ◽

A Wakim ◽

J Lundberg ◽

B Hendricks ◽

...

Keyword(s):

Flow Diverter ◽

Device Placement ◽

Flow Diverter Device

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Treatment of an internal carotid artery aneurysm with a flow diverter through a double lumen balloon catheter

Interventional Neuroradiology ◽

10.1177/1591019917691238 ◽

2017 ◽

Vol 23 (3) ◽

pp. 255-259

Author(s):

José M Amorim ◽

Santiago Rosati ◽

Ronit Agid ◽

Vítor Mendes Pereira ◽

Timo Krings

Keyword(s):

Carotid Artery ◽

Internal Carotid ◽

Artery Aneurysm ◽

Flow Diverter ◽

Double Lumen ◽

Carotid Artery Aneurysm ◽

Internal Carotid Artery Aneurysm ◽

Procedural Complications ◽

Wall Apposition ◽

Flow Diverters

Background Double lumen balloon catheters (DLBCs) are currently used in the treatment of intracranial aneurysms, especially when involving balloon or stent-assisted coiling. The existing DLBCs allow the delivery of self-expandable stents but do not offer the possibility to deploy flow-diverters. Despite the increasing use and success of flow-diverters, there have been numerous reports of procedural complications such as early in-stent thrombosis or delayed distal embolization. It seems that these complications can be avoided by correct stent positioning and adequate wall apposition, achieved either by manoeuvres with the microguidewire and/or microcatheter or by performing balloon angioplasty following an exchange guidewire manoeuvre. Objective Report the use of a new DLBC able to deliver a flow-diverter. Methods A 41-year-old woman presented to our hospital with binocular horizontal diplopia for two weeks and reduced visual acuity. A left internal carotid artery aneurysm involving the cavernous and ophthalmic segments was found, with a maximum height of 19 mm and a broad 8 mm neck. It presented extra- and intra-dural components and the parent vessel was significantly narrowed. A decision was made to perform endovascular treatment of the aneurysm with placement of a flow diverter through a DLBC. Results Patency and adequate expansion of the flow diverter with evident intra-aneurysmal contrast stasis was observed in the final angiogram. No peri-procedural complications were observed. Conclusion This is a technical note demonstrating the feasibility of a new device to deploy a flow diverter, aiming to improve wall apposition and stent configuration without the need of additional devices or exchange manoeuvres.

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Dual Microwire Rail Technique to Advance a Microcatheter Past the Ostium of a Dissecting Carotid Artery Aneurysm for Flow Diverter Deployment: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz251 ◽

2019 ◽

Author(s):

Kunal Vakharia ◽

Stephan A Munich ◽

Muhammad Waqas ◽

Matthew J McPheeters ◽

Elad I Levy

Keyword(s):

Carotid Artery ◽

Video Recording ◽

Artery Aneurysm ◽

Flow Diverter ◽

Flow Diversion ◽

Carotid Artery Aneurysm ◽

Institutional Review Board Approval ◽

Institutional Review ◽

Wall Apposition ◽

Flow Diverters

Abstract Flow diversion using a Pipeline embolization device (PED; Medtronic, Dublin, Ireland) is an effective therapy for treating cavernous aneurysms. Currently, flow diverters require a 0.027-inch microcatheter for deployment. To navigate across these aneurysms, a 0.014-inch microwire is used, which often does not offer a sturdy enough rail to advance a 0.027-inch microcatheter past dissecting artery aneurysm ostia. We present a patient with a right cavernous dissecting carotid artery aneurysm. A step off between the 0.027-inch VIA microcatheter (MicroVention Terumo, Tustin, California) and 0.014-inch Synchro 2 microwire (Stryker Neurovascular, Fremont, California) resulted in difficulty with navigation of the microcatheter across the dissected portion of the aneurysm. A dual microwire rail technique involving two 0.014-inch Synchro 2 microwires was used to advance the VIA microcatheter past the dissecting artery aneurysm ostia for PED deployment. The introduction of the second microwire eliminated the step off between the microwire and microcatheter, providing a stronger rail and easier navigation of the microcatheter, without aggressive pushing. Postembolization runs showed optimal wall apposition and contrast stasis within the aneurysm, with successful flow diversion of the aneurysm. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary.

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Deployment of distal posterior cerebral artery flow diverter in tortuous anatomy

Neurosurgical FOCUS ◽

10.3171/2019.1.focusvid.18481 ◽

2019 ◽

Vol 46 (Suppl_1) ◽

pp. V9 ◽

Cited By ~ 1

Author(s):

Kunal Vakharia ◽

Stephan A. Munich ◽

Muhammad Waqas ◽

Swetadri Vasan Setlur Nagesh ◽

Elad I. Levy

Keyword(s):

Cerebral Artery ◽

Current Flow ◽

Posterior Cerebral Artery ◽

Artery Aneurysm ◽

Flow Diverter ◽

Pipeline Embolization Device ◽

Wall Apposition ◽

Artery Flow ◽

Cerebral Artery Aneurysm ◽

Flow Diverters

Progressive deconstruction with flow diversion using a Pipeline embolization device (PED; Medtronic) can be utilized to promote thrombosis of broad-based fusiform aneurysms. Current flow diverters require a 0.027-inch microcatheter for deployment. The authors present a patient with a fusiform P2–3 junction posterior cerebral artery aneurysm in which they demonstrate the importance of haptics in microwire manipulation to recognize large-vessel anatomy versus perforator anatomy that may overlap, especially when access is needed in distal tortuous circulations. In addition, the authors demonstrate the need for appropriate visualization before PED deployment. Postembolization runs demonstrated optimal wall apposition with contrast stasis within the aneurysm dome.The video can be found here: https://youtu.be/8kfsSvN3XqM.

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Use of the 0.027-inch VIA microcatheter for delivery of Pipeline Flex: a technical note

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012971 ◽

2017 ◽

Vol 9 (7) ◽

pp. 689-693 ◽

Cited By ~ 10

Author(s):

Li-Mei Lin ◽

Geoffrey P Colby ◽

Matthew T Bender ◽

Risheng Xu ◽

Judy Huang ◽

...

Keyword(s):

Vessel Wall ◽

Internal Carotid ◽

Large Diameter ◽

Flow Diverter ◽

Technical Note ◽

Posterior Circulation ◽

Anterior Circulation ◽

Patient Demographics ◽

Limited Support ◽

Wall Apposition

BackgroundThe Pipeline Embolization Device (PED; Medtronic Neurovascular, Irvine, California, USA) is designed for delivery through a 0.027″ microcatheter. Challenges with the second-generation PED Flex include limited support from the Marksman microcatheter for consistent resheathing and transmission of push forces for device delivery. The VIA27 (Sequent Medical/MicroVention Terumo, Tustin, California, USA) is an alternative 0.027″ microcatheter originally designed for intrasaccular flow diverter delivery. Here we describe our experience with the VIA27 in the delivery of PED Flex.MethodsWe retrospectively identified patients who underwent PED Flex treatment with the VIA27 microcatheter at our institution. Patient demographics, aneurysm characteristics, equipment utilized, and procedural details were documented.ResultsA total of 127 cases were completed using the VIA27 microcatheter for PED Flex implantation. Mean patient age was 56.8±12.4 years (range 21–86 years). All but one of the cases were treatments for intracranial aneurysms. Average aneurysm size was 6.5±6 mm (range 2–38 mm). Of the 127 cases, 120 (95%) were anterior circulation cases and 7 (6%) were posterior circulation cases. Significant cervical internal carotid artery (ICA) tortuosity was present in 33/120 cases (28%). Moderate to severe cavernous ICA tortuosity was present in 54/120 cases (45%). Mean fluoroscopy time was 34.1±22.7 min. Large diameter PED devices (4.5–5 mm) were used in 42/127 cases (33%). Balloon post-processing of the PED was used in 15/127 cases (12%) to improve vessel wall apposition of the PED.ConclusionsThe VIA27 is a microcatheter capable of successful PED Flex delivery in neurointervention. We have shown its utility in enhancing both resheathing and push for optimal PED Flex implantation. The VIA27 microcatheter may be a useful and safe adjunct to the traditional Marksman microcatheter in PED Flex treatment of the cerebrovasculature.

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First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017421 ◽

2021 ◽

pp. neurintsurg-2021-017421

Author(s):

Mario Martínez-Galdámez ◽

Yilmaz Onal ◽

José E Cohen ◽

Vladimir Kalousek ◽

Rodrigo Rivera ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Flow Diverter ◽

Consecutive Series ◽

Neurological Morbidity ◽

Angiographic Data ◽

Partial Opening ◽

Technical Details ◽

Wall Apposition ◽

Aneurysm Occlusion ◽

Materials Used

BackgroundThe aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide.MethodsThe study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed.Results60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O’Kelly–Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases.ConclusionsOur study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.

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