pCONUS for Distal Artery Protection During Complex Aneurysm Treatment by Endovascular Parent Vessel Occlusion—A Technical Nuance

We present two cases of 17-year-old man and 10-year-old boy presenting with subarachnoid haemorrhage and a history of road traffic accident. One patient had dissecting aneurysm of the posterior cerebral artery (PCA), and the other patient had partially thrombosed aneurysm on CT angiography. On digital subtraction angiography of the second patient, there was formation of PCA pontomesencephalic vein pial arteriovenous fistula (PAVF). Both the patients underwent endovascular treatment: stent-assisted coiling for aneurysm and coiling with parent vessel occlusion for PAVF. There were no procedural complications. Follow-up angiography showed no residual aneurysm or fistula. Trauma is one of the recognised causes of dissection, and intracranial dissections can present as stenotic lesions, aneurysms or fistulas, depending on the pathology. Traumatic dissecting PCA aneurysm has been reported in only two case reports previously, and post-traumatic PAVF in PCA has not been reported.

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Flow diversion in the treatment of aneurysms: a randomized care trial and registry

Journal of Neurosurgery ◽

10.3171/2016.4.jns152662 ◽

2017 ◽

Vol 127 (3) ◽

pp. 454-462 ◽

Cited By ~ 34

Author(s):

Jean Raymond ◽

Jean-Christophe Gentric ◽

Tim E. Darsaut ◽

Daniela Iancu ◽

Miguel Chagnon ◽

...

Keyword(s):

Standard Treatment ◽

Flow Diversion ◽

Parent Vessel ◽

Management Options ◽

Vessel Occlusion ◽

Clinical Trial Registration ◽

Safety Outcome ◽

Standard Management ◽

Efficacy Outcome ◽

Parent Vessel Occlusion

OBJECTIVEThe Flow Diversion in the Treatment of Intracranial Aneurysm Trial (FIAT) was designed to guide the clinical use of flow diversion, an innovative method to treat intracranial aneurysms, within a care trial and to study safety and efficacy.METHODSFIAT, conducted in 3 Canadian hospitals, proposed randomized allocation to flow diversion or standard management options (observation, coil embolization, parent vessel occlusion, or clip placement), and a registry of non-randomized patients treated with flow diversion. The primary safety outcome was death or dependency (modified Rankin Scale score > 2) at 3 months, to be determined for all patients who received flow diversion at any time. The primary efficacy outcome was angiographic occlusion at 3–12 months combined with an independent clinical outcome.RESULTSOf 112 participating patients recruited between May 2, 2011, and February 25, 2015, 78 were randomized (39 in each arm), and 34 received flow diversion within the registry. The study was halted due to safety concerns. Twelve (16%) of 75 patients (95% CI 8.9%–26.7%) who were allocated to or received flow diversion at any time were dead (n = 8) or dependent (n = 4) at 3 months or more, crossing a predefined safety boundary. Death or dependency occurred in 5 (13.2%) of 38 patients randomly allocated and treated by flow diversion (95% CI 5.0%–28.9%) and in 5 (12.8%) of 39 patients allocated to standard treatment (95% CI 4.8%–28.2%). Efficacy was below expectations of the trial hypothesis: 16 (42.1%) of 38 patients (95% CI 26.7%–59.1%) randomly allocated to flow diversion failed to reach the primary outcome, as compared with 14 (35.9%) of 39 patients allocated to standard treatment (95% CI 21.7%–52.9%).CONCLUSIONSFlow diversion was not as safe and effective as hypothesized. More randomized trials are needed to determine the role of flow diversion in the management of aneurysms.Clinical trial registration no.: NCT01349582 (clinicaltrials.gov)

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Endovascular treatment of intracranial ‘blister’ and dissecting aneurysms

The Neuroradiology Journal ◽

10.1177/1971400919861406 ◽

2019 ◽

Vol 32 (5) ◽

pp. 353-365 ◽

Cited By ~ 1

Author(s):

Marius G Kaschner ◽

Bastian Kraus ◽

Athanasios Petridis ◽

Bernd Turowski

Keyword(s):

Endovascular Treatment ◽

Favourable Outcome ◽

Modified Rankin Scale ◽

Parent Vessel ◽

Vessel Occlusion ◽

Parent Vessel Occlusion ◽

Aneurysm Occlusion ◽

Vessel Reconstruction ◽

Dissecting Aneurysms

IntroductionBlister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging.PurposeThe purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms.MethodsWe retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004–2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed.ResultsThirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy ( n = 9), stent-assisted coiling ( n = 7), flow diverting stents ( n = 13) and coiling + Onyx embolization ( n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%.ConclusionTreatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.

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Routine intraoperative angiography during aneurysm surgery

Journal of Neurosurgery ◽

10.3171/jns.2002.96.6.0988 ◽

2002 ◽

Vol 96 (6) ◽

pp. 988-992 ◽

Cited By ~ 134

Author(s):

Veronica L. Chiang ◽

Phillipe Gailloud ◽

Kieran J. Murphy ◽

Daniele Rigamonti ◽

Rafael J. Tamargo

Keyword(s):

Surgical Treatment ◽

False Negative ◽

Anterior Communicating Artery ◽

Parent Vessel ◽

Vessel Occlusion ◽

Intraoperative Angiography ◽

Content Type ◽

Negative Results ◽

Parent Vessel Occlusion ◽

Fine Print

Object. The routine use of intraoperative angiography as an aid in the surgical treatment of aneurysms is uncommon. The advantages of the ability to visualize residual aneurysm or unintended occlusion of parent vessels intraoperatively must be weighed against the complications associated with repeated angiography and prolonged vascular access. The authors reviewed the results of their routine use of intraoperative angiography to determine its safety and efficacy. Methods. Prospectively gathered data from all aneurysm cases treated surgically between January 1996 and June 2000 were reviewed. A total of 303 operations were performed in 284 patients with aneurysms; 24 patients also underwent postoperative angiography. Findings on intraoperative angiographic studies prompted reexploration and clip readjustment in 37 (11%) of the 337 aneurysms clipped. Angiography revealed parent vessel occlusion in 10 cases (3%), residual aneurysm in 22 cases (6.5%), and both residual lesion and parent vessel occlusion in five cases (1.5%). When compared with subsequent postoperative imaging, false-negative results were found on two intraoperative angiograms (8.3%) and a false-positive result was found on one (4.2%). Postoperative angiograms obtained in both false-negative cases revealed residual anterior communicating artery aneurysms. Both of these aneurysms also subsequently rebled, requiring reoperation. In the group that underwent intraoperative angiography, in 303 operations eight patients (2.6%) suffered complications, of which only one was neurological. Conclusions. In the surgical treatment of intracranial aneurysms, the use of routine intraoperative angiography is safe and helpful in a significant number of cases, although it does not replace careful intraoperative inspection of the surgical field.

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Long-Term Clinical and Imaging Follow-Up of Complex Intracranial Aneurysms Treated by Endovascular Parent Vessel Occlusion

American Journal of Neuroradiology ◽

10.3174/ajnr.a3079 ◽

2012 ◽

Vol 33 (10) ◽

pp. 1991-1997 ◽

Cited By ~ 16

Author(s):

C.C. Matouk ◽

Z. Kaderali ◽

K.G. terBrugge ◽

R.A. Willinsky

Keyword(s):

Intracranial Aneurysms ◽

Parent Vessel ◽

Vessel Occlusion ◽

Parent Vessel Occlusion

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Treatment outcomes in cerebral artery dissection and literature review

Interventional Neuroradiology ◽

10.1177/1591019918755692 ◽

2018 ◽

Vol 24 (3) ◽

pp. 254-262 ◽

Cited By ~ 8

Author(s):

Karanarak Urasyanandana ◽

Dittapong Songsang ◽

Taweesak Aurboonyawat ◽

Ekawut Chankaew ◽

Pattarawit Withayasuk ◽

...

Keyword(s):

Cerebral Artery ◽

Functional Outcomes ◽

Carotid Arteries ◽

Internal Carotid ◽

Parent Artery ◽

Parent Vessel ◽

Vessel Occlusion ◽

Parent Vessel Occlusion ◽

Internal Carotid Arteries ◽

Spontaneous Dissection

Methods Patients with cerebral artery dissections were reviewed in a hospital setting from 2008 to 2015. Clinical presentations, lesion locations, treatment modalities, functional outcomes, and mortality were reviewed. Parent artery occlusion was the first choice for surgery or endovascular treatment of a hemorrhagic dissecting cerebral artery. Endovascular or surgical reconstructive treatment was indicated in patients whose parent artery could not be occluded. Favorable functional outcomes were determined using modified Rankin Scale (mRS) scores of 0–2. Results In total, 61 patients with cerebral artery dissections were admitted to the hospital. Seven (11.5%) had traumatic dissections. All traumatic dissections were located in the internal carotid arteries. Overall favorable outcome rate was about 57% (4/7). Spontaneous cerebral artery dissections were found in 54 patients. No difference in favorable outcomes was observed between parent vessel occlusion and selective occlusion with parent vessel preservation (or vessel reconstruction) (70% and 63%, respectively, p = 1.000). Patients who presented with spontaneous dissection without intracranial hemorrhage had more favorable outcomes than those with intracranial hemorrhage (79% and 52%, respectively, p = 0.045). The mortality rate of patients with spontaneous dissection was 7.4%. Conclusions Most of the traumatic dissections were located on the internal carotid arteries and spontaneous dissections were commonly located on vertebral arteries. Nonhemorrhagic spontaneous cerebral dissections had better functional outcomes after treatment. Endovascular and surgical management were effective treatments by parent vessel occlusion or reconstructions.

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Treatment of a Giant Aneurysm of the Right Middle Cerebral Artery with GDCs after Extracranial to Intracranial Bypass

Interventional Neuroradiology ◽

10.1177/159101999900500109 ◽

1999 ◽

Vol 5 (1) ◽

pp. 51-56 ◽

Cited By ~ 2

Author(s):

E. Castro ◽

F. Fortea ◽

F. Villoria ◽

L. Muñoz ◽

C Benito ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Giant Aneurysm ◽

Endovascular Procedure ◽

Parent Vessel ◽

Vessel Occlusion ◽

Balloon Test Occlusion ◽

Parent Vessel Occlusion ◽

Detachable Coils ◽

The Right

A case of a giant aneurysm of the right middle cerebral artery treated with Guglielmi detachable coils is reported. Extracranial to intracranial bypass had previously been performed and surgical trapping had been attempted. During the endovascular procedure, balloon test occlusion of the middle cerebral artery was performed in order to demonstrate clinical and angiographic tolerance to parent vessel occlusion. A previous occlusion test in the right common carotid artery did not show sufficient flow through the bypass to perform safe parent vessel occlusion. Diagnostic imaging, the endovascular procedure, and haemodynamic aspects in cases in which parent vessel occlusion is required after extracranial-intracranial bypass are described and the literature is reviewed.

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Parent vessel occlusion for P2 dissecting aneurysms of the posterior cerebral artery

Surgical Neurology ◽

10.1016/j.surneu.2008.01.047 ◽

2009 ◽

Vol 71 (3) ◽

pp. 319-325 ◽

Cited By ~ 16

Author(s):

Xianli Lv ◽

Youxiang Li ◽

Chuhan Jiang ◽

Xinjian Yang ◽

Zhongxue Wu

Keyword(s):

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Parent Vessel ◽

Vessel Occlusion ◽

Parent Vessel Occlusion ◽

Dissecting Aneurysms

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Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation

Journal of Neurosurgery ◽

10.3171/2016.9.jns152638 ◽

2017 ◽

Vol 127 (6) ◽

pp. 1333-1341 ◽

Cited By ~ 4

Author(s):

Matthew B. Potts ◽

Maksim Shapiro ◽

Daniel W. Zumofen ◽

Eytan Raz ◽

Erez Nossek ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Parent Artery ◽

Parent Vessel ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Complex Aneurysms ◽

Aneurysm Size ◽

Parent Vessel Occlusion ◽

Anterior Circulation Aneurysms

OBJECTIVEThe Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).METHODSThe authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.RESULTSAmong 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.CONCLUSIONSIn this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

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F.04 Flow diversion in the treatment of aneurysms: A randomized care trial and registry

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.99 ◽

2016 ◽

Vol 43 (S2) ◽

pp. S19-S19

Author(s):

T Darsaut ◽

J Gentric ◽

D Iancu ◽

M Chow ◽

J Rempel ◽

...

Keyword(s):

Primary Outcome ◽

Standard Treatment ◽

Flow Diversion ◽

Parent Vessel ◽

Vessel Occlusion ◽

Safety Outcome ◽

Standard Management ◽

Efficacy Outcome ◽

Parent Vessel Occlusion ◽

Safety Boundary

Background: The Flow diversion in the treatment of Intracranial Aneurysm (FIAT) trial was designed to guide the clinical use of flow diversion. Methods: FIAT proposed randomized allocation flow diversion or standard management (observation, coiling, parent vessel occlusion, or clipping), and a registry of non-randomized patients treated with flow diversion. Primary safety outcome was death or dependency (mRS > 2) at 3 months. Primary efficacy outcome was angiographic occlusion at 3-12 months combined with independent clinical outcome. Results: Of 112 participating patients recruited, 78 were randomized, and 34 received flow diversion within the registry. The study was halted for safety concerns. Twelve of 73 patients (16.4%; CI [9.7% -26.7%]) who were allocated or received flow diversion at any time were dead (n=8) or dependent (n=4) at 3 months or more, crossing a predefined safety boundary. Death or dependency occurred in 5 of 36 patients randomly allocated flow diversion and in 5 of 36 patients allocated standard treatment (13.9%; [6.1%-28.7%]). Efficacy was below hypothesized expectations: 15 of 36 patients (41.7%; [27.1%-57.8%]) randomly allocated flow diversion failed to reach the primary outcome, as compared to 11 of 36 patients allocated standard treatment (30.1%; [18.0%-46.9%]). Conclusions: Flow diversion was not as safe and effective as hypothesized. More randomized trials are needed.

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