Endosaccular Flow Disruption: A New Frontier in Endovascular Aneurysm Management

Abstract Flow modification has caused a paradigm shift in the management of intracranial aneurysms. Since the FDA approval of the Pipeline Embolization Device (Medtronic, Dublin, Ireland) in 2011, it has grown to become the modality of choice for a range of carefully selected lesions, previously not amenable to conventional endovascular techniques. While the vast majority of flow-diverting stents operate from within the parent artery (ie, endoluminal stents), providing a scaffold for endothelial cells growth at the aneurysmal neck while inducing intra-aneurysmal thrombosis, a smaller subset of endosaccular flow disruptors act from within the lesions themselves. To date, these devices have been used mostly in Europe, while only utilized on a trial basis in North America. To the best of our knowledge, there has been no dedicated review of these devices. We therefore sought to present a comprehensive review of currently available endosaccular flow disruptors along with high-resolution schematics, presented with up-to-date available literature discussing their technical indications, procedural safety, and reported outcomes.

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Application of computed tomography angiography for evaluating clinical morphology in intracranial aneurysms – monocentric study

Journal of International Medical Research ◽

10.1177/0300060519894790 ◽

2019 ◽

Vol 48 (4) ◽

pp. 030006051989479

Author(s):

Ru-de Sui ◽

Chun-guo Wang ◽

Dong-wei Han ◽

Xiu-qing Zhang ◽

Qing Li ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Intracranial Aneurysms ◽

Parent Artery ◽

Neck Width ◽

Aneurysm Size ◽

Aneurysmal Neck ◽

The Relationship ◽

Accuracy Rates ◽

Guiding Effect

Objective To examine the clinical effect of computed tomography angiography (CTA) on parameters of intracranial aneurysms in different locations and with different sizes using digital subtraction angiography (DSA) as the standard. Methods Patients with intracranial aneurysms who underwent CTA examinations at the same center and received DSA examinations within 3 days were analyzed retrospectively. The morphological parameters of the aneurysms and parent arteries were measured with these two methods. Results Mean aneurysm size and parent artery diameter were not different between CTA and DSA. The size of microaneurysms was significantly smaller with DSA than with CTA. The aneurysmal neck width was not different between CTA and DSA. DSA could clearly evaluate the relationship between the aneurysmal neck and the parent artery in all cases. However, CTA had a 90% accuracy rate of visualizing this relationship. Conclusion The accuracy rates of evaluating aneurysm size and the aneurysmal neck width and parent artery diameter are similar between CTA and DSA. A DSA examination is essential for evaluating the relationship among microaneurysms, the aneurysmal neck, and the parent artery. CTA is widely applied and more safe in clinical practice, while DSA has a better guiding effect than CTA for some complicated aneurysms.

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Early Experience Studying Cerebral Aneurysms with Rotational and Three-Dimensional Angiography and Review of CT and MR Angiography Literature

Interventional Neuroradiology ◽

10.1177/159101990200800407 ◽

2002 ◽

Vol 8 (4) ◽

pp. 377-391 ◽

Cited By ~ 4

Author(s):

C.H. Castaño-Duque ◽

J. Ruscalleda-Nadal ◽

M. de Juan-Delago ◽

E. Guardia-Mas ◽

L. San Roman-Manzanera ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Three Dimensional ◽

Cerebral Aneurysms ◽

Endovascular Embolization ◽

Lower Sensitivity ◽

Parent Artery ◽

Philips Medical System ◽

Multiple Series ◽

Total Occlusion ◽

Aneurysmal Neck

From september 2000 to september 2001, 32 consecutive patients with ruptured intracranial aneurysms were examined with rotational and 3D reconstruction angiography using an Integris V5000 Philips Medical System: 39 aneurysms were detected. After a selective cerebral artery was catheterized with a 5F or 4F-catheter, 35 ml of contrast medium was intra-arterially administered at a rate of 4 ml/s and a 180° rotational angiography was performed in eight seconds. This information was transferred to a computer (Silicon Graphics Octane) with software (Integris 3DRA, Philips Integris Systems) and a three-dimensional reconstruction was made. The information provided by Angio-3D was useful for evaluating the parent artery, aneurysmal sac, aneurysmal neck and arterial branches. It was also very useful in selecting the therapeutic method. For open surgery, this technique provides preoperative images that are useful for planning microsurgical approaches, especially in cases of large aneurysm showing complex surrounding arteries. For endovascular embolization, various anatomic characteristics of the aneurysm such as neck and sac size, shape, lobularity, parent artery and arterial branches adjacent to the aneurysmal neck must be demonstrated. This is very important to determine the best projection for embolization and to avoid multiple series. This is also essential in the choice of the first coil to create a good basket producing total occlusion. Microaneurysms are demonstrated well with this technique whereas this is difficult to do with conventional arteriography. The Angio-RM and Angio-CT literature show a lower sensitivity and specificity in comparasion with our experience with 3D IA-ROT-DSA. For this reason, we believe that 3D IA-ROTDSA is now the gold standard for patients presenting intracranial aneurysms.

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Nonoverlapping Y-Configuration Stenting Technique With Dual Closed-Cell Stents in Wide-Neck Basilar Tip Aneurysms

Operative Neurosurgery ◽

10.1227/neu.0b013e31823bcdc5 ◽

2011 ◽

Vol 70 (suppl_2) ◽

pp. ons244-ons249 ◽

Cited By ~ 15

Author(s):

Young Dae Cho ◽

Sun-Won Park ◽

Jong Young Lee ◽

Jung Hwa Seo ◽

Hyun-Seung Kang ◽

...

Keyword(s):

Cerebral Artery ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Posterior Cerebral Artery ◽

Good Alternative ◽

The Other ◽

Parent Artery ◽

Closed Cell ◽

Aneurysmal Neck ◽

Wide Neck

ABSTRACT BACKGROUND: Stent-assisted coiling is increasingly used to treat wide-neck intracranial aneurysms to protect the lumen of the parent artery from coil protrusion. This technique is insufficient for treating some aneurysms, depending on their configurations. OBJECTIVE: To describe a variant of the Y-configuration stent-assisted coiling technique for the treatment of basilar tip aneurysms with wide necks. METHODS: This technique, called the nonoverlapping Y stenting technique, consists of the deployment of a closed-cell self-expandable stent from the basilar trunk to a posterior cerebral artery and then placement of a second stent from the basilar bifurcation to the other posterior cerebral artery without overlapping the first stent. The proximal flared portion of the second stent was located at the neck of the aneurysm. Coil embolization was performed under dual-stent protection. RESULTS: We successfully filled wide-neck aneurysms with coils under stent protection by forming a bridge across the aneurysmal neck without overlapping 2 closed-cell stents. Six basilar tip aneurysms were successfully treated with this technique. CONCLUSION: The nonoverlapping Y stenting technique is a good alternative to traditional stent-assisted coiling. This technique is particularly suitable for the treatment of broad-neck bifurcation aneurysms.

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Long-Term Histopathology of Intracranial Aneurysms after Endovascular Treatment with Coils

Interventional Neuroradiology ◽

10.1177/15910199990050s143 ◽

1999 ◽

Vol 5 (1_suppl) ◽

pp. 225-231 ◽

Cited By ~ 2

Author(s):

Y. Suda ◽

K. Kikuchi ◽

H. Shioya ◽

K. Shindo ◽

H. Nanjo ◽

...

Keyword(s):

Endovascular Treatment ◽

Microscopic Examination ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Electron Microscopic Examination ◽

Parent Artery ◽

Electron Microscopic ◽

Endovascular Coil Embolization ◽

Aneurysmal Neck ◽

Scanning Electron

We describe the results of electron microscopic examination in two patients with ruptured intracranial aneurysms who were successfully treated by endovascular coil embolization. The aneurysms were seen completely occluded on the follow-up angiograms. Autopsies of these patients were performed five and 26 months after endovascular treatment when they died of pneumonia and thalamic hemorrhage, respectively. The aneurysms were densely filled with the coils, which were readily identified through the thin and transparent wall of the aneurysmal dome. The orifice of the aneurysm was completely occluded so that macroscopically the coils were not directly visualized through the orifice. To examine any evidence of endothelialization across the orifice of the aneurysms, scanning electron microscopic examination was performed. In both cases, evidence of well regenerative endothelialization was observed across the aneurysmal orifice, being contiguous with the endothelial layer of the adjacent parent vessels. These ultrastructural findings indicate that the aneurysms are completely isolated from the lumen of the parent artery by a continuous lining of the regenerated endothelial cells following the endovascular treatment with coils, and further suggest that aneurysms have a potential of being cured permanently by this treatment modality. This is, to the best of our knowledge, the first report in humans verifying a complete endothelialization of the luminal surface at the aneurysmal neck after coil embolization, as evidenced by scanning electron microscopy.

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Challenges in the Endovascular Treatment of Giant Intracranial Aneurysms

Neurosurgery ◽

10.1227/01.neu.0000237559.93852.f1 ◽

2006 ◽

Vol 59 (suppl_5) ◽

pp. S3-113-S3-124 ◽

Cited By ~ 25

Author(s):

Nestor R. Gonzalez ◽

Gary Duckwiler ◽

Reza Jahan ◽

Yuichi Murayama ◽

Fernando Viñuela

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Clinical Manifestations ◽

Artery Occlusion ◽

Parent Artery ◽

Endovascular Techniques ◽

Giant Aneurysms ◽

Giant Intracranial Aneurysms ◽

Parent Artery Occlusion ◽

Hemodynamic Characteristics

Abstract OBJECTIVE: Giant intracranial aneurysms present unique therapeutic intricacies. The purpose of this study was to evaluate the anatomic and hemodynamic characteristics of these lesions and the current endovascular and combined surgical and endovascular techniques available for their treatment. METHODS: A review of the literature and the personal experiences of the authors with endovascular treatment of giant aneurysms are presented. This review included anatomic and hemodynamic features and analysis of the diverse endovascular techniques that have been reported for the management of these aneurysms. RESULTS: Anatomic features that create particular challenges in the therapeutic approach of giant aneurysms include size, shape (saccular, fusiform, serpentine), neck dimensions, branch involvement, intraluminal thrombosis, and location. Hemodynamic characteristics that affect endovascular treatment are lateral or terminal aneurysm type of flow and embolic material placement (inflow versus outflow aneurysmal region). The current endovascular therapeutic approaches include parent artery occlusion, trapping, endosaccular embolization with or without adjunctive techniques such as balloon-assisted or stent placement, and combined surgical and endovascular approaches, mainly with surgical revascularization and endovascular occlusion. CONCLUSION: Although there are a wide variety of endovascular therapeutic options for the treatment of giant intracranial aneurysms, none of the current techniques is completely successful and free of complications in the management of these complex lesions. A detailed and individualized analysis of each case in conjunction with sufficient understanding of the anatomy and hemodynamics of a particular aneurysm should guide the therapeutic decision. Further research advances will assist in elucidating the factors predisposing to genesis, progression, and aggressive clinical manifestations of these giant lesions.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017469 ◽

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

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Peripheral intracranial aneurysms: management challenges in 60 consecutive cases

Journal of Neurosurgery ◽

10.3171/2008.6.jns0814 ◽

2009 ◽

Vol 110 (1) ◽

pp. 7-13 ◽

Cited By ~ 28

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.

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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 ◽

10.1161/str.45.suppl_1.120 ◽

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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Herniated Proximal Marker of the Stent into the Meningohypophyseal Trunk after Stent-Assisted Coil Embolization for Intracranial Aneurysms

Case Reports in Neurology ◽

10.1159/000492110 ◽

2018 ◽

Vol 10 (2) ◽

pp. 213-216

Author(s):

Won-Bae Seung

Keyword(s):

Coil Embolization ◽

Intracranial Aneurysms ◽

Internal Carotid ◽

Parent Artery ◽

Horizontal Segment ◽

Optimal Position ◽

Usual Manner ◽

Pituitary Deficiency ◽

Neurovascular Remodeling ◽

Meningohypophyseal Trunk

The SolitaireTM AB Neurovascular Remodeling Device (ev3, Irvine, CA, USA) is used to retain coils within an aneurysm, reducing the risk of embolic complications from coil herniation into the parent artery. Stents are deployed after confirming the optimal position of the stent markers across the aneurysm to avoid entry into perforators or branching arteries. Stent marker position is very important to prevent perforating or branching artery infarction. We performed stent-assisted coil embolization using the Solitaire AB stent to treat 2 aneurysms simultaneously. After successful coil embolization, we detached the Solitaire stent in the usual manner. However, the proximal stent marker, which was located at the horizontal segment of the cavernous internal carotid artery, moved into the meningohypophyseal trunk and occluded it. Although the distal markers were positioned optimally, we did not expect the proximal marker to be in the position where it was located. Fortunately, cranial nerve dysfunctions and pituitary deficiency did not develop. It is important to prevent ischemic injury by occlusion of the perforators or branching vessels that can be caused by malpositioned stent markers. We consider where the proximal marker of the stent might be located after detachment.

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