scholarly journals When Two Is Better than One

2021 ◽  
Author(s):  
Tomas Dobrocky ◽  
Hubert Lee ◽  
Patrick Nicholson ◽  
Ronit Agid ◽  
Jeremy Lynch ◽  
...  
Keyword(s):  
Flow Diverter ◽  
Side Branch ◽  
Parent Artery ◽  
Aneurysm Neck ◽  
Procedural Information ◽  
Univariate Statistics ◽  
Device Deployment ◽  
Additional Support ◽  
Better Than ◽  
Buddy Wire

Abstract Background Delivery of most flow diverters (FD) requires larger, and thus stiffer microcatheters (0.021–0.027in.) which can pose challenges to intracranial navigation. The concomitant use of two microwires within one microcatheter, also known as the buddy-wire technique, may be helpful for navigation and support in challenging situations. Methods We analyzed all flow diverter procedures in our prospectively collected database. We recorded all patient-related, anatomical and procedural information. We performed univariate statistics and technical descriptions. Results In total, 208 consecutive patients treated with a FD at our institution between July 2014 and August 2020 were retrospectively analyzed. In 17 patients the buddy-wire technique was used (mean age 63 years, range 31–87 years: 16 female). Aneurysms were located at the petrous, cavernous, supraophthalmic internal carotid artery, and a proximal M2 branch in 2, 7, 7 and 1 patient(s), respectively. In all cases a 0.027in. microcatheter was used for device deployment. In 14 patients with a wide-necked aneurysm the buddy-wire provided additional support to advance the microcatheter and mitigated the ledge between the aneurysm neck and the parent artery or a side branch. In two giant cavernous aneurysms treated with telescoping FDs, the buddy-wire was used to re-enter the proximal end of the foreshortened FD. Conclusion The buddy-wire is a useful technique in FD procedures to prevent herniation of the microcatheter into the aneurysm sack, in wide-necked aneurysms to mitigate the ledge effect between the aneurysm neck and the parent artery where the microcatheter tip may get stuck, or to enable re-entry into a foreshortened FD.

scholarly journals Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

2018 ◽  
Vol 15 (6) ◽  
pp. 624-633 ◽  
Author(s):  
Fawaz Al-Mufti ◽  
Krishna Amuluru ◽  
Eric R Cohen ◽  
Vikas Patel ◽  
Mohammad El-Ghanem ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Significant Risk ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Side Branch ◽  
Parent Vessel ◽  
Vessel Injury ◽  
Procedural Complications ◽  
Background Material ◽  
Device Deployment

Abstract Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary. Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.” A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.

scholarly journals Mechanism of Action and Biology of Flow Diverters in the Treatment of Intracranial Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S13-S19 ◽  
Author(s):  
Krishnan Ravindran ◽  
Amanda M Casabella ◽  
Juan Cebral ◽  
Waleed Brinjikji ◽  
David F Kallmes ◽  
...  
Keyword(s):  
Mechanism Of Action ◽  
Flow Diverter ◽  
Parent Artery ◽  
First Line ◽  
Aneurysm Neck ◽  
First Line Therapy ◽  
Preclinical Animal Models ◽  
Computational Analyses ◽  
Flow Diverters ◽  
Present Understanding

Abstract Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.

Introduction: History and Development of Flow Diverter Technology and Evolution

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S3-S10 ◽  
Author(s):  
Anna Luisa Kühn ◽  
Matthew J Gounis ◽  
Ajit S Puri
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Parent Artery ◽  
Introduction History ◽  
United States Food ◽  
Diseased Vessel ◽  
States Food ◽  
Device Deployment ◽  
Bench Testing ◽  
Flow Diverters

Abstract The introduction of flow diverter technology to the field of neurointervention has revolutionized the treatment of intracranial aneurysms. The therapy approach has shifted from intrasaccular aneurysm treatment to exclusion of the aneurysm from the blood circulation with remodeling of the parent artery. Previously, “difficult”-to-treat aneurysms including fusiform and blister aneurysms, but also aneurysms arising from a diseased vessel segment, can now be safely and permanently treated with flow diverters.  A little over a decade ago, after extensive bench testing and refinement of the flow diverter concept, the device was eventually available for clinical use and today it has become a standard treatment for intracranial aneurysms. Currently, United States Food and Drug Administration (FDA)-approved flow diverters are the Pipeline Embolization Device (Medtronic) and the Surpass Streamline Flow Diverter (Stryker).  The devices can either be delivered or deployed via a standard femoral artery approach or a radial artery approach. Other considerations for catheter setup and device deployment strategies depending on aneurysm location or vessel anatomy are described.

scholarly journals Acute thrombus formation on phosphorilcholine surface modified flow diverters

2017 ◽  
Vol 10 (4) ◽  
pp. 406-411 ◽  
Author(s):  
Miklos Marosfoi ◽  
Frederic Clarencon ◽  
Erin T Langan ◽  
Robert M King ◽  
Olivia W Brooks ◽  
...  
Keyword(s):  
Thrombus Formation ◽  
Rabbit Model ◽  
Flow Diverter ◽  
Side Branch ◽  
Clot Formation ◽  
Neck Size ◽  
Aneurysm Neck ◽  
Before And After ◽  
Surface Modified ◽  
Flow Diverters

PurposeThromboembolic complications remain a limitation of flow diverting stents. We hypothesize that phosphorilcholine surface modified flow diverters (Pipeline Flex with Shield Technology, sPED) would have less acute thrombus formation on the device surface compared with the classic Pipeline Embolization device (cPED).MethodsElastase-induced aneurysms were created in 40 rabbits and randomly assigned to receive cPED or sPED devices with and without dual antiplatelet therapy (DAPT) (four groups, n=10/group). Angioplasty was performed to enhance apposition and create intimal injury for a pro-thrombotic environment. Both before and after angioplasty, the flow diverter was imaged with intravascular optical coherence tomography. The outcome measure was the number of predefined segments along the implant relative to the location of the aneurysm with a minimum of 0 (no clot formation) and maximum of 3 (all segments with thrombus). Clot formation over the device at ostia of branch arteries was assessed as either present or absent.ResultsFollowing angioplasty, the number of flow diverter segments with clots was significantly associated with the flow diverter (p<0.0001), but not with DAPT (p=0.3872) or aneurysm neck size (p=0.8555). The incidence rate for clots with cPED was 1.72 times more than with sPED. The clots on the flow diverter at the location corresponding to side branch ostia was significantly lower with sPED than with cPED (OR 0.180; 95% CI 0.044 to 0.734; p=0.0168), but was not associated with DAPT (p=0.3198).ConclusionIn the rabbit model, phosphorilcholine surface modified flow diverters are associated with less thrombus formation on the surface of the device.

scholarly journals Intra-aneurysmal hemodynamics: evaluation of pCONus and pCANvas bifurcation aneurysm devices using DSA optical flow imaging

2015 ◽  
Vol 8 (11) ◽  
pp. 1197-1201 ◽  
Author(s):  
Marta Aguilar Pérez ◽  
Hans Henkes ◽  
Pierre Bouillot ◽  
Olivier Brina ◽  
Lee-Anne Slater ◽  
...  
Keyword(s):  
Optical Flow ◽  
Amplitude Ratio ◽  
Frame Rate ◽  
Parent Artery ◽  
Aneurysm Neck ◽  
Optical Flow Method ◽  
Bifurcation Aneurysm ◽  
Before And After ◽  
Additional Support

BackgroundImplantation of self-expanding stents from the parent artery into the sac of a bifurcation aneurysm is regularly used to facilitate endovascular coil occlusion with the so-called waffle cone technique (WCT). Self-expanding aneurysm bridging stents like Solitaire AB, can be used; however, bifurcation devices like pCONus and pCANvas are especially designed for WCT. These devices provide additional support for coil implantation owing to intraluminal nylon fibers (pCONus) or membranes (pCANvas) covering the intracranial aneurysm neck.ObjectiveAssessment of the intra-aneurysmal hemodynamic impact of these three devices: a regular intracranial stent (Solitaire AB) and two bifurcation devices (pCONus and pCANvas).Material and methodsAn in vitro experiment was set up using a silicone model of a basilar tip aneurysm filled with blood mimicking fluid under a pulsatile circulation. Solitaire AB, pCONus, and pCANvas were successively implanted in the model for hemodynamic evaluation. High frame rate DSA series were acquired under various conditions. Intra-aneurysmal flow changes, including mean aneurysm flow amplitude ratio (R), were subsequently assessed by the optical flow method, measuring the detector velocity field before and after device implantations.ResultspCONus and Solitaire minimally reduced the intra-aneurysmal flow (R=0.96, p=0.17 and R=0.91, p=0.01, respectively), whereas pCANvas strongly diminished the intra-aneurysmal flow (R=0.41, p=5×10−12).ConclusionsWaffle cone deployment of stents and technique-specific devices had no undesirable effect on the intra-aneurysmal flow. In particular, no increased flow was redirected into the aneurysm sac. The intraluminal membrane of the pCANvas strongly reduced the intra-aneurysmal flow, potentially preventing recanalization problems.

scholarly journals Predictive score for complete occlusion of intracranial aneurysms treated by flow-diverter stents using machine learning

2020 ◽  
pp. neurintsurg-2020-016748
Author(s):  
Alexis Guédon ◽  
Cédric Thépenier ◽  
Eimad Shotar ◽  
Joseph Gabrieli ◽  
Bertrand Mathon ◽  
...  
Keyword(s):  
Feature Selection ◽  
Test Sample ◽  
Training Sample ◽  
Flow Diverter ◽  
Side Branch ◽  
Predictive Score ◽  
Parent Artery ◽  
Complete Occlusion ◽  
Class Separation ◽  
Flow Diverter Stent

BackgroundComplete occlusion of an intracranial aneurysm (IA) after the deployment of a flow-diverter stent is currently unpredictable. The aim of this study was to develop a predictive occlusion score based on pretreatment clinical and angiographic criteria.MethodsConsecutive patients with ≥6 months follow-up were included from 2008 to 2019 and retrospectively analyzed. Each IA was evaluated using the Raymond–Roy occlusion classification (RROC) and dichotomized as occluded (A) or residual (B/C); 80% of patients were randomly assigned to the training sample. Feature selection and binary outcome prediction relied on logistic regression and threshold maximizing class separation selected by a CART tree algorithm. The feature selection was addressed by a genetic algorithm selected from the 30 pretreatment available variables.ResultsThe study included 146 patients with 154 IAs. Feature selection yielded a combination of six variables with a good cross-validated accuracy on the test sample, a combination we labeled DIANES score (IA diameter, indication, parent artery diameter ratio, neck ratio, side-branch artery, and sex). A score of more than −6 maximized the ability to predict RROC=A with sensitivity of 87% (95% CI 79% to 95%) and specificity of 82% (95% CI 64% to 96%) in the training sample. Accuracy was 86% (95% CI 79% to 94%). In the test sample, sensitivity and specificity were 89% (95% CI 77% to 98%) and 60% (95% CI 33% to 86%), respectively. Accuracy was 81% (95% CI 69% to 91%).ConclusionA score was developed as a grading scale for prediction of the final occlusion status of IAs treated with a flow-diverter stent.

scholarly journals Safety and efficacy results of the Flow Redirection Endoluminal Device (FRED) stent system in the treatment of intracranial aneurysms: US pivotal trial

2021 ◽  
pp. neurintsurg-2021-017469
Author(s):  
Cameron G McDougall ◽  
Orlando Diaz ◽  
Alan Boulos ◽  
Adnan H Siddiqui ◽  
Justin Caplan ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Multicenter Trial ◽  
Parent Artery ◽  
Stent System ◽  
Safety Endpoint ◽  
Performance Benchmarks ◽  
Registration Number ◽  
The Usa ◽  
Effectiveness Endpoint

ObjectiveTo evaluate the safety and effectiveness of the Flow Redirection Endoluminal Device (FRED) flow diverter in support of an application for Food and Drug Administration approval in the USA.Methods145 patients were enrolled in a prospective, single-arm multicenter trial. Patients with aneurysms of unfavorable morphology for traditional endovascular therapies (large, wide-necked, fusiform, etc) were included. The trial was designed to demonstrate non-inferiority in both safety and effectiveness, comparing trial results with performance goals (PGs) established from peer-reviewed published literature. The primary safety endpoint was death or major stroke (National Institutes of Health Stroke Scale score ≥4 points) within 30 days of the procedure, or any major ipsilateral stroke or neurological death within the first year. The primary effectiveness endpoint was complete occlusion of the target aneurysm with ≤50% stenosis of the parent artery at 12 months after treatment, and in which an alternative treatment of the target intracranial aneurysm had not been performed.Results145 patients underwent attempted placement of a FRED device, and one or more devices were placed in all 145 patients. 135/145 (93%) had a single device placed. Core laboratory adjudication deemed 106 (73.1%) of the aneurysms large or giant. A safety endpoint was experienced by 9/145 (6.2%) patients, successfully achieving the safety PG of <15%. The effectiveness PG of >46% aneurysm occlusion was also achieved, with the effectiveness endpoint being met in 80/139 (57.6%)ConclusionAs compared with historically derived performance benchmarks, the FRED flow diverter is both safe and effective for the treatment of appropriately selected intracranial aneurysms.Clinical registration numberNCT01801007

Peripheral intracranial aneurysms: management challenges in 60 consecutive cases

2009 ◽  
Vol 110 (1) ◽  
pp. 7-13 ◽  
Author(s):  
Eric S. Nussbaum ◽  
Michael T. Madison ◽  
James K. Goddard ◽  
Jeffrey P. Lassig ◽  
Leslie A. Nussbaum
Keyword(s):  
Intracranial Aneurysms ◽  
Artery Occlusion ◽  
Neurological Deficits ◽  
Parent Artery ◽  
Branch Points ◽  
Aneurysm Neck ◽  
Vertebrobasilar System ◽  
Parent Artery Occlusion ◽  
Major Branch ◽  
Proximal Occlusion

Object The authors report the management and outcomes of 55 patients with 60 intracranial aneurysms arising distal to the major branch points of the circle of Willis and vertebrobasilar system. Methods Between July 1997 and December 2006, the authors' neurovascular service treated 2021 intracranial aneurysms in 1850 patients. The database was reviewed retrospectively to identify peripherally located intracranial aneurysms. Aneurysms that were mycotic and aneurysms that were associated with either an arteriovenous malformation or an atrial myxoma were excluded from review. Results The authors encountered 60 peripheral intracranial aneurysms in 55 patients. There were 42 small, 7 large, and 11 giant lesions. Forty-one (68%) were unruptured, and 19 (32%) had bled. Fifty-three aneurysms were treated surgically by using direct clip reconstruction in 26, trapping or proximal occlusion with distal revascularization in 21, excision with end-to-end anastomosis in 3, and circumferential wrap/clip reconstruction in 3. Coils were used to treat 6 aneurysms, and 1 was treated by endovascular parent artery occlusion. Overall, 49 patients had good outcomes, 4 were left with new neurological deficits, and 2 died. Conclusions Peripherally situated intracranial aneurysms are rare lesions that present unique management challenges. Despite the fact that in the authors' experience these lesions were rarely treatable with simple clipping of the aneurysm neck or endovascular coil occlusion, preservation of the parent artery was possible in most cases, and the majority of patients had a good outcome.

Republished: Successful treatment of ruptured multiple fusiform middle cerebral artery aneurysms with silk vista baby flow diverter in a 10-months-old infant

2021 ◽  
pp. neurintsurg-2021-017554.rep
Author(s):  
Giovanni Barchetti ◽  
Loris Di Clemente ◽  
Mauro Mazzetto ◽  
Mariano Zanusso ◽  
Paola Ferrarese ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Successful Treatment ◽  
Expectant Management ◽  
Flow Diverter ◽  
Artery Occlusion ◽  
Parent Artery ◽  
Microsurgical Clipping ◽  
Parent Artery Occlusion ◽  
The Right

We report the successful treatment of multiple ruptured fusiform middle cerebral artery (MCA) aneurysms in a 10-month-old girl. This previously healthy infant presented with subarachnoid haemorrhage and was found to have multiple irregular dilatations of the superior division branch of the right MCA. Cerebral angiography was performed and confirmed the presence of multiple fusiform aneurysms of the MCA. After multidisciplinary team discussion, it was decided to treat the aneurysms with endovascular approach, using a flow-diverter. Microsurgical clipping was deemed risky because of the high likelihood of parent artery occlusion and expectant management was also considered inappropriate because of the risk of re-bleeding. Dual antiplatelet therapy was started, and a flow-diverter was successfully delivered in the superior division branch of the right MCA. The post-operative course was uneventful, MRI at 12 months did not show any sign of recurrence and at 3 years of age the patient had a normal neurological examination.

Abstract 120: Surpass Flow Diverter for Endovascular Treatment of Intracranial Aneurysms - A Multicenter Preliminary Clinical and Angiographic Experience in 161 Patients with 186 Aneurysms

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Ajay K Wakhloo ◽  
Pedro Lylyk ◽  
Joost de Vries ◽  
Matthew J Gounis ◽  
Alexandra Biondi ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Experimental Studies ◽  
Flow Diverter ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Anterior Circulation ◽  
Neck Size ◽  
Wide Range ◽  
New Generation

Objective: Validated through experimental studies a new generation of flow diverters (Surpass™ FD) was evaluated for treatment of intracranial aneurysms (IA). We present our multicenter preliminary clinical and angiographic experience. METHODS: To achieve the calculated flow disruption between the parent artery and aneurysm for thrombosis, single FDs were placed endovascularly in parent arteries. Implants measured 2.5-5.3mm in diameter with a length of 10-80mm. Patients were enrolled harboring a wide range large and giant wide-neck, fusiform and multiple small and blister-type aneurysm. Clinical and angiographic follow-up were performed at 1-3, 6, and 12 months. RESULTS: A total of 186 consecutive IA in 161 patients (mean age 57.1 years) were treated at 33 centers. Fifty-three aneurysms were smaller than 5 mm, 64 were 5-9.9mm in diameter, 47 were 10-20mm in diameter, and 22 were larger than 20mm (10.4±0.7mm, neck size 6.0±0.5mm [mean±SEM]) . The aneurysms originated in 63.4% from the internal carotid artery; 22% and 14.5% of the lesions were located in the anterior circulation distal to Circle of Willis and posterior circulation respectively. Technical success was achieved in 182 aneurysms (98%); average number of devices used per aneurysm was 1.05. Permanent morbidity and mortality during the follow-up period of mean 8.4months (range 1-24 months) including periprocedural complications for patients with aneurysms of the anterior circulation were encountered in 5 (3.7%) and 2 (1.5 %) patients respectively and 1 (3.7%) and 4 (14.8%) respectively for patients with aneurysms of the posterior circulation location. One-hundred-ten patients (70.5%) harboring 127 (70.2%) were available for clinical and angiographic follow-up and showed a complete or near complete aneurysm occlusion in 63 (81.8%) of the ICA. Aneurysms of the ICA≥10mm that were completely covered by FD and not previously stent-treated with a minimum of 6 months follow-up available in 16 patients showed a complete obliteration in 81.3% (n=13) and >90% occlusion in remaining 3 patients. CONCLUSION: Preliminary data demonstrate high safety and efficacy of a new generation of FD for a wide range of IA of the anterior and posterior circulation with a single implant.

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