Pipeline for Distal Cerebral Circulation Aneurysms

Neurosurgery ◽  
2019 ◽  
Vol 85 (3) ◽  
pp. E477-E484 ◽  
Author(s):  
Elias Atallah ◽  
Hassan Saad ◽  
Nikolaos Mouchtouris ◽  
Kimon Bekelis ◽  
Jackson Walker ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Clinical Outcome ◽  
Cerebral Artery ◽  
Cerebral Circulation ◽  
Posterior Inferior Cerebellar Artery ◽  
Good Clinical Outcome ◽  
Multivariable Logistic Regression ◽  
Aneurysm Occlusion ◽  
The Mean

Abstract BACKGROUND Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms. OBJECTIVE To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes. METHODS Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning. RESULTS A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up. CONCLUSION Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

The Use of the Pipeline Embolization Device in the Management of Recurrent Previously Coiled Cerebral Aneurysms

Neurosurgery ◽  
2015 ◽  
Vol 77 (5) ◽  
pp. 692-697 ◽  
Author(s):  
Badih Daou ◽  
Robert M. Starke ◽  
Nohra Chalouhi ◽  
Stavropoula Tjoumakaris ◽  
Jean Khoury ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Aneurysms ◽  
Good Clinical Outcome ◽  
Cerebral Angiogram ◽  
Pipeline Embolization Device ◽  
Aneurysm Occlusion ◽  
The Mean ◽  
Mean Time ◽  
Aneurysm Coiling

Abstract BACKGROUND: The biggest downside of cerebral aneurysm coiling is the high rates of recurrence and retreatments. With the increasing number of aneurysm recurrences after failed coiling procedures, the best retreatment strategy remains unknown. OBJECTIVE: To assess the efficacy and safety of the Pipeline Embolization Device (PED) in the treatment of recurrent previously coiled aneurysms. METHODS: Thirty-three patients who underwent treatment with the PED of a recurrent previously coiled aneurysm were retrospectively identified. Efficacy was assessed in terms of angiographic occlusion at the latest cerebral angiogram, recurrence and retreatment rates after PED placement, and clinical outcome at the latest follow-up. Safety was assessed by looking at the complications, morbidity, and mortality after PED treatment. RESULTS: The mean patient age was 53 years. The mean percent recurrence from coiling to PED placement was 34%. The mean time from coiling to PED placement was 40 months. PED treatment resulted in complete aneurysm occlusion in 76.7% of patients and near-complete aneurysm occlusion (≥90%) in 10%, for a total rate of complete and near-complete aneurysm occlusion of 86.7%. All patients, including those with incomplete aneurysm occlusion, had a significant reduction in aneurysm size. Two aneurysms required another retreatment after PED placement (6.2%). Ninety-seven percent of patients had a good clinical outcome. Complications were observed in 1 patient (3%), who suffered an intracerebral hemorrhage. There were no mortalities. CONCLUSION: The use of the PED in the management of recurrent, previously coiled aneurysms is safe and effective in achieving aneurysm occlusion.

Flow diversion treatment for acutely ruptured aneurysms

2019 ◽  
Vol 12 (3) ◽  
pp. 283-288 ◽  
Author(s):  
Michelle F M ten Brinck ◽  
Maike Jäger ◽  
Joost de Vries ◽  
J André Grotenhuis ◽  
René Aquarius ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Flow Diverter ◽  
Poor Clinical Outcome ◽  
Good Clinical Outcome ◽  
Ruptured Aneurysms ◽  
Secondary Endpoints ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Ruptured Intracranial Aneurysms

Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

scholarly journals Clipping of previously coiled cerebral aneurysms: efficacy, safety, and predictors in a cohort of 111 patients

2016 ◽  
Vol 125 (6) ◽  
pp. 1337-1343 ◽  
Author(s):  
Badih Daou ◽  
Nohra Chalouhi ◽  
Robert M. Starke ◽  
Guilherme Barros ◽  
Lina Ya'qoub ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Aneurysms ◽  
Endovascular Coiling ◽  
Good Clinical Outcome ◽  
Surgical Clipping ◽  
Anterior Circulation ◽  
Intraoperative Angiography ◽  
Aneurysm Size ◽  
Aneurysm Occlusion ◽  
The Mean

OBJECTIVE With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure. METHODS One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes. RESULTS The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018). CONCLUSIONS Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

Endovascular treatment of fusiform cerebral aneurysms with the Pipeline Embolization Device

2014 ◽  
Vol 120 (4) ◽  
pp. 945-954 ◽  
Author(s):  
Stephen J. Monteith ◽  
Asterios Tsimpas ◽  
Aaron S. Dumont ◽  
Stavropoula Tjoumakaris ◽  
L. Fernando Gonzalez ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Cerebral Aneurysms ◽  
Morbidity And Mortality ◽  
Complex Nature ◽  
Stent Deployment ◽  
Pipeline Embolization Device ◽  
Aneurysm Occlusion ◽  
The Mean

Object Despite advances in surgical and endovascular techniques, fusiform aneurysms remain a therapeutic challenge. Introduction of flow-diverting stents has revolutionized the treatment of aneurysms with wide necks and of complex morphology. The authors report their experience with the endovascular treatment of fusiform aneurysms using the Pipeline Embolization Device. Methods A retrospective review of 146 patients with cerebral aneurysms treated with the Pipeline Embolization Device between June 2011 and January 2013 was performed. Twenty-four patients were identified as having fusiform aneurysms. Twenty-four aneurysms in these 24 patients were treated. The mean patient age was 59 years. There were 9 men and 15 women. Angiographic and clinical data (including the modified Rankin Scale [mRS] score) were recorded at the time of treatment and at follow-up. The aneurysms were located in the internal carotid artery in 8 patients (33.3%), middle cerebral artery in 8 patients (33.3%), anterior cerebral artery in 1 patient (4%), and vertebrobasilar circulation in 7 patients (29%). The aneurysms were smaller than 10 mm in 3 patients, 10–25 mm in 16 patients, and larger than 25 mm in 5 patients. The mean largest dimension diameter was 18 mm. Results Stent deployment was successful in all cases. The minor procedural morbidity was 4% (1 case). Morbidity and mortality related to aneurysm treatment were 4.2% and 4.2%, respectively. The mean mRS scores preoperatively and at clinical follow-up (median 6.0 months, mean 6.9 months) were 0.71 and 1.2, respectively (91.7% presented with an mRS score of 2 or better, and 79.2% had an mRS score of 2 or better at the 6.0-month follow-up). At clinical follow-up, 82.6% of patients were stable or had improved, 13.0% worsened, and 4.2% had died. Twenty-two (91.7%) of 24 patients had follow-up angiography available (mean follow-up time 6.3 months); 59% had excellent angiographic results (> 95% or complete occlusion), 31.8% had complete aneurysm occlusion, 27.3% had greater than 95% aneurysm occlusion, 18.2% had a moderate decrease in size (50%–95%), 4.5% had a minimal decrease in size (< 50%), 13.6% had not changed, and 4.5% had an increase in size. Conclusions This series demonstrates that endovascular treatment of fusiform cerebral aneurysms with flow diversion was a safe and effective treatment. Procedural complications were low. Long-term morbidity and mortality rates were acceptable given the complex nature of these lesions.

scholarly journals LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience

2018 ◽  
Vol 7 (5) ◽  
pp. 271-283 ◽  
Author(s):  
Edgar A. Samaniego ◽  
Aldo A. Mendez ◽  
Thanh N. Nguyen ◽  
Vladimir Kalousek ◽  
Waldo R. Guerrero ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Posterior Cerebral Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Case Series ◽  
Neurological Complications ◽  
Anterior Communicating Artery ◽  
The Mean ◽  
Wide Neck

Background and Purpose: Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for “Y-stent”-assisted coiling embolization of wide-neck bifurcation aneurysms. Methods: Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. Results: Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro­cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I–II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I–II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. Conclusions: In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

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