Repeat Flow Diversion for Previously Failed Flow Diversion in A Multicenter Cohort

Abstract INTRODUCTION Aneurysmal persistence after pipeline embolization device (PED) treatment occurs in a small subset of treated aneurysms which might necessitate further treatment. Most cases are managed by deploying another PED in a telescoping fashion within the existing PED. There is no existing data in the literature regarding the efficacy of such strategy. METHODS A retrospective review of repeated attempts at flow diversion in 7 North-American cerebrovascular centers was performed. Patients were included if the repeat flow diversion occurred at least 6 months after initial treatment. Patients with no radiological follow up after second treatment were excluded. Clinical and radiographic data was collected from the records. The primary outcome was aneurysm occlusion at last follow-up with secondary outcomes of clinical status and complications. RESULTS A total of 58 patients (median age 57 yr, 89.7% females) harboring 58 aneurysms underwent 122 treatment procedures. Majority of aneurysms were unruptured (91.3%); 82.8% were saccular and 91.4% were located in the internal carotid artery with a mean maximal diameter of 9.5 mm. 52 patients were treated twice while 6 patients were treated 3 times. A single device was used in 87.9% of the patients in the initial treatment procedure, and in 94.8% of the patients in the subsequent treatment attempt. Mean elapsed-time between first and second treatment was 13.5 mo. Last imaging follow-up was performed at median of 33.4 mo after initial treatment, showing complete occlusion in 53.4%, and near complete occlusion (90%-99%) in 15.5% of aneurysms. Transient ischemic neurologic complications were encountered in 3.4% of patients, with no permanent complications. Last follow up mRS of 0-2 were noted in 100% of patients, with mean clinical follow up of 37 mo. 57 (98.3%) patients had a final disposition to their own home. CONCLUSION Repeat flow diversion for persistent aneurysms is associated with a reasonable chance of success and acceptable safety profile.

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Very delayed discontinuation of telescoped Pipeline embolization devices: a case report

Interventional Neuroradiology ◽

10.1177/1591019918809932 ◽

2018 ◽

Vol 25 (2) ◽

pp. 182-186

Author(s):

Manoj Bohara ◽

Kosuke Teranishi ◽

Kenji Yatomi ◽

Takashi Fujii ◽

Takayuki Kitamura ◽

...

Keyword(s):

Internal Carotid ◽

Flow Diversion ◽

Total Occlusion ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Radiological Features ◽

Long Term Follow Up ◽

Aneurysm Occlusion

Background Flow diversion with the Pipeline embolization device (PED) is a widely accepted treatment modality for aneurysm occlusion. Previous reports have shown no recanalization of aneurysms on long-term follow-up once total occlusion has been achieved. Case description We report on a 63-year-old male who had a large internal carotid artery cavernous segment aneurysm. Treatment with PED resulted in complete occlusion of the aneurysm. However, follow-up angiography at four years revealed recurrence of the aneurysm due to disconnection of the two PEDs placed in telescoping fashion. Conclusion Herein, we present the clinico-radiological features and discuss the possible mechanisms resulting in the recanalization of aneurysms treated with flow diversion.

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Reconstructive endovascular treatment of basilar artery fenestration aneurysms: A multi-centre experience and literature review

The Neuroradiology Journal ◽

10.1177/19714009211042877 ◽

2021 ◽

pp. 197140092110428

Author(s):

Hanna Styczen ◽

Sebastian Fischer ◽

Matthias Gawlitza ◽

Lukas Meyer ◽

Lukas Goertz ◽

...

Keyword(s):

Endovascular Treatment ◽

Basilar Artery ◽

Flow Diversion ◽

High Rate ◽

Complete Occlusion ◽

Secondary Endpoints ◽

Aneurysm Occlusion ◽

Complications Rate ◽

Woven Endobridge

Background Data on outcome after endovascular treatment of basilar artery fenestration aneurysms (BAFAs) is limited. This study presents our multi-centre experience of BAFAs treated by different reconstructive techniques including coils, stent-assisted coiling (SAC), flow diversion and intra-saccular flow disruption with the Woven Endobridge (WEB). Methods Retrospective analysis of 38 BAFAs treated endovascularly between 2003 and 2020. The primary endpoint was complete aneurysm obliteration defined as Raymond–Roy occlusion classification (RROC) I on immediate and follow-up (FU) angiography. The secondary endpoints were procedure-related complications, rate of re-treatment, and clinical outcome. Results Endovascular treatment was feasible in 36/38 aneurysms (95%). The most frequent strategy was coiling (21/36, 58%), followed by SAC (7/36, 19%), WEB embolization (6/36, 17%) and flow diversion (2/36, 6%). A successful aneurysm occlusion (defined as RROC 1 and 2) on the final angiogram was achieved in 30/36 (83%) aneurysms including all patients presenting with baseline subarachnoid haemorrhage and 25/36 (69%) were occluded completely. Complete occlusion (RROC 1) was more frequently achieved in ruptured BAFAs (15/25, 60% v. 2/11, 18%; p = 0.031). Procedure-related complications occurred in 3/36 (8%) aneurysms. Re-treatment was executed in 12/36 (33%) aneurysms. After a median angiography FU of 38 months, 30/31 (97%) BAFAs were occluded successfully and 25/31 (81%) showed complete occlusion. Conclusion Reconstructive endovascular treatment of BAFAs is technically feasible with a good safety profile. Although in some cases re-treatment was necessary, a high rate of final aneurysm occlusion was achieved.

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Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up

Journal of Neurosurgery ◽

10.3171/2017.11.jns171738 ◽

2018 ◽

Vol 130 (1) ◽

pp. 259-267 ◽

Cited By ~ 16

Author(s):

Matthew T. Bender ◽

Geoffrey P. Colby ◽

Li-Mei Lin ◽

Bowen Jiang ◽

Erick M. Westbroek ◽

...

Keyword(s):

Cerebral Artery ◽

Flow Diversion ◽

Single Institution ◽

Anterior Circulation ◽

Complete Occlusion ◽

Aneurysm Size ◽

Branch Vessel ◽

Aneurysm Occlusion ◽

Anterior Circulation Aneurysms

OBJECTIVEFlow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence.METHODSData from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors’ institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence.RESULTSFollow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used.CONCLUSIONSThis is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.

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Abstract WMP34: Low Yield of Further Angiographic Follow-up in Adequately Occluded Aneurysms After Flow Diversion

Stroke ◽

10.1161/str.48.suppl_1.wmp34 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Nohra Chalouhi ◽

Guilherme Barros ◽

Stavropoula Tjoumakaris ◽

Ayan Kumar ◽

Michael Lang ◽

...

Keyword(s):

Diagnostic Yield ◽

New Technology ◽

Cerebral Aneurysms ◽

Flow Diversion ◽

Inclusion Criteria ◽

Short Term ◽

Complete Occlusion ◽

Aneurysm Occlusion ◽

Repeat Angiography

Background: Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. Flow diversion has emerged as a promising treatment for intracranial aneurysms. The safety and efficacy of this new technology is under investigation. The current study assesses the yield of further angiographic follow-up in aneurysms that have achieved adequate occlusion after treatment with the Pipeline Embolization Device (PED). Methods: Inclusion criteria were as follows: 1) treatment of one or more aneurysms with the PED, 2) available short-term (<12 months) follow-up digital subtraction angiography (DSA), 3) complete (100%) or near-complete (>95%) occlusion on short-term follow-up DSA, and 4) available further angiographic follow-up (DSA or MRA). Results: A total of 175 patients matching the inclusion criteria were identified. Aneurysm size was 9.0 mm on average. Mean angiographic follow-up was 23.4 months. On short-term follow-up DSA images, 154 (88%) had complete aneurysm occlusion and 21 (12%) had near-complete occlusion. Seven patients (4%) had further DSA follow-up alone, 39 patients (22%) had further DSA and MRA follow-up, and 129 patients (74%) had further MRA follow-up alone. On further angiographic follow-up (DSA or MRA), no patient had a decrease in the degree of aneurysm occlusion (recurrence) or required retreatment. Of the 21 patients with near-complete occlusion on initial DSA images, 5 patients (24%) progressed to complete aneurysm occlusion on further angiographic follow-up. No patient had evidence of new in-stent stenosis on further angiographic follow-up. Conclusion: In this study, the diagnostic yield of repeat angiography in adequately occluded aneurysms with the PED was very low. Based on these findings, we do not recommend further angiographic follow-up once aneurysms have achieved adequate occlusion with the PED.

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The Use of Single Stent-Assisted Coiling in Treatment of Bifurcation Aneurysms: A Multicenter Cohort Study With Proposal of a Scoring System to Predict Complete Occlusion

Neurosurgery ◽

10.1093/neuros/nyx310 ◽

2017 ◽

Vol 82 (5) ◽

pp. 710-718 ◽

Cited By ~ 7

Author(s):

Nimer Adeeb ◽

Christoph J Griessenauer ◽

Apar S Patel ◽

Paul M Foreman ◽

Carlos E Baccin ◽

...

Keyword(s):

Scoring System ◽

Alpha Angle ◽

Class Iii ◽

Multicenter Cohort Study ◽

Complete Occlusion ◽

Neck Size ◽

Maximal Diameter ◽

Bifurcation Aneurysm ◽

Aneurysm Occlusion

Abstract BACKGROUND The development of stent-assisted coiling has allowed for the endovascular treatment of wide-necked bifurcation aneurysms. A variety of options exist, and little is known about the optimal stent configuration in this setting. We report a large multicenter experience of stent-assisted coiling of bifurcations aneurysms using a single stent, with attention to factors predisposing to aneurysm recanalization. OBJECTIVE To assess the safety and efficacy of single stent-assisted coiling, in addition to analyzing the factors associated with recanalization, and proposal of a predictive scoring scale. METHODS A multicenter retrospective analysis of bifurcation aneurysms treated with a single stent-assisted coiling technique between 2007 and 2015 was performed. Clinical and radiographic data were collected and used to develop a scoring system to predict aneurysm occlusion. RESULTS A total of 74 bifurcation aneurysms were treated with single stent-assisted coiling. At a median follow-up of 15.2 mo, complete occlusion or remnant neck was achieved in 90.6% of aneurysms. Aneurysm location, maximal diameter, neck size, and alpha angle were predictive of aneurysm occlusion at last follow-up. A scoring system to predict complete occlusion based on these factors was developed. An increasing score correlated with a higher rate of complete occlusion. CONCLUSION The treatment of bifurcation aneurysm using single stent technique for stent-assisted coiling is safe and effective. Complete occlusion or remnant neck occlusion was achieved in 90.6% of cases. Class III aneurysms can be effectively treated using a single stent, while class I may require Y-stent technique.

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Standalone Flow Diversion Therapy Effectively Controls Rebleeding of Acutely Ruptured Internal Carotid Artery Trunk (Nonbranching) Microaneurysms

Journal of Clinical Medicine ◽

10.3390/jcm10225249 ◽

2021 ◽

Vol 10 (22) ◽

pp. 5249

Author(s):

José E. Cohen ◽

Hans Henkes ◽

John Moshe Gomori ◽

Gustavo Rajz ◽

Ronen Leker

Keyword(s):

Pulmonary Embolism ◽

Subarachnoid Hemorrhage ◽

Carotid Artery ◽

Internal Carotid ◽

Flow Diversion ◽

Maximal Diameter ◽

Mean Diameter ◽

Aneurysm Occlusion ◽

Spontaneous Subarachnoid Hemorrhage

Flow diversion is a promising option in selected patients with acutely ruptured microaneurysms. In this article, we reviewed our experience. Patients with acute spontaneous subarachnoid hemorrhage (SAH) after rupture of a blister-like or saccular microaneurysm (≤2 mm maximal diameter) at a nonbranching ICA site treated from January 2016 to June 2019 using flow diversion as standalone therapy were included in this study. An EVD was usually placed preventively. Antiplatelet effects of pre-procedure DAPT were evaluated (target PRU, 80–160). After the intervention, DAPT was continued for ≥6 months, aspirin—indefinitely. Angiographic controls were obtained. Fifteen patients (12 female; mean age, 46.4 years) with 15 ruptured ICA microaneurysms (mean diameter, 1.8 mm) were included. An EVD was placed in 12 patients (75%) before DAPT administration and stenting. PRU values immediately before FDS were 1–134 (mean, 72.1). One patient died 27 days after flow diversion due to a suspected fulminant pulmonary embolism. Aneurysms were completely occluded at the 6–12-month angiographic follow-up in 14/14 surviving patients, with no rebleeding at a mean of 14 months. Late mRS was 0–2 in 13/14 patients and 3 in one due to sequelae of the original hemorrhage. Flow diversion provided robust aneurysm rebleeding control. Angiographic follow-up confirmed complete aneurysm occlusion in all the cases.

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Pipeline-assisted coil embolization of a large middle cerebral artery pseudoaneurysm in a 9-month-old infant: experience from the youngest flow diversion case

Journal of Neurosurgery Pediatrics ◽

10.3171/2018.6.peds18165 ◽

2018 ◽

Vol 22 (5) ◽

pp. 532-540 ◽

Cited By ~ 5

Author(s):

Geoffrey P. Colby ◽

Bowen Jiang ◽

Matthew T. Bender ◽

Narlin B. Beaty ◽

Erick M. Westbroek ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Coil Embolization ◽

Pediatric Population ◽

Flow Diversion ◽

Left Middle Cerebral Artery ◽

Artery Pseudoaneurysm ◽

First Case ◽

Aneurysm Occlusion

Intracranial aneurysms in the pediatric population are rare entities. The authors recently treated a 9-month-old infant with a 19-mm recurrent, previously ruptured, and coil-embolized left middle cerebral artery (MCA) pseudoaneurysm, which was treated definitively with single-stage Pipeline-assisted coil embolization. The patient was 5 months old when she underwent resection of a left temporal Grade 1 desmoplastic infantile ganglioglioma at an outside institution, which was complicated by left MCA injury with a resultant 9-mm left M1 pseudoaneurysm. Within a month, the patient had two aneurysmal rupture events and underwent emergency craniectomy for decompression and evacuation of subdural hematoma. The pseudoaneurysm initially underwent coil embolization; however, follow-up MR angiography (MRA) revealed aneurysm recanalization with saccular enlargement to 19 mm. The patient underwent successful flow diversion–assisted coil embolization at 9 months of age. At 7 months after the procedure, follow-up MRA showed complete aneurysm occlusion without evidence of in-stent thrombosis or stenosis. Experience with flow diverters in the pediatric population is still in its early phases, with the youngest reported patient being 22 months old. In this paper the authors report the first case of such a technique in an infant, whom they believe to be the youngest patient to undergo cerebral flow diversion treatment.

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Help-Seeking in Depressed Out-patients Following Maintenance Therapy

The British Journal of Psychiatry ◽

10.1192/bjp.129.3.252 ◽

1976 ◽

Vol 129 (3) ◽

pp. 252-260 ◽

Cited By ~ 7

Author(s):

Myrna M. Weissman ◽

Stanislav V. Kasl

Keyword(s):

Maintenance Therapy ◽

Help Seeking ◽

Maintenance Treatment ◽

Suicide Attempts ◽

Clinical Status ◽

Subsequent Treatment ◽

Access To Treatment ◽

One Year

SummaryThis paper reports on the clinical status, help-seeking and subsequent treatment experiences of 150 women one year after they had completed out-patient maintenance treatment by amitriptyline and/or psychotherapy for a depressive episode.While the majority of patients were asymptomatic at follow-up, a substantial minority had a return of acute symptoms and 2 per cent made minor suicide attempts during the year. Admission to hospital was rare. However, only 30 per cent of the patients did not seek any treatment during the year and the majority received some psychotropic medication.The findings support the long-term need for prompt access to treatment by patients who have recovered from an acute depression.

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Regrowth of a Large Intracranial Aneurysm after On-Label Use of the Pipeline Embolization Device

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_273_18 ◽

2019 ◽

Vol 10 (01) ◽

pp. 142-144 ◽

Cited By ~ 2

Author(s):

Ching-Jen Chen ◽

M. Rao Patibandla ◽

Min S. Park ◽

M. Yashar Kalani

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Intracranial Aneurysm ◽

Internal Carotid ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Residual Component ◽

First Case ◽

Aneurysm Occlusion

ABSTRACTDespite the widespread use of the pipeline embolization device (PED), no complete aneurysm regrowth after its placement has been reported in the literature. We report the first case of aneurysm regrowth after the initial follow-up angiography demonstrating near-complete occlusion of the aneurysm and remodeling of the vessel with on-label PED use for a large 20 mm × 24 mm × 22 mm (width × depth × height) cavernous segment internal carotid artery (ICA) aneurysm. The patient was treated with two overlapping PED (4.5 mm × 20 mm and 5 mm × 20 mm). Follow-up angiogram at 4 months after treatment demonstrated remodeling of the ICA with a small residual component measuring approximately 7 mm × 8 mm × 7 mm. However, at 10 months after treatment, there was a complete regrowth of the aneurysm with interval growth, now measuring 25 mm × 28 mm × 18 mm. Despite the high aneurysm occlusion rates reported with the PED, persistent aneurysm filling and aneurysm regrowth, although rare, should not be overlooked.

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Pipeline embolization device for recurrence of previously treated aneurysms

Neurosurgical FOCUS ◽

10.3171/2017.3.focus1744 ◽

2017 ◽

Vol 42 (6) ◽

pp. E8 ◽

Cited By ~ 10

Author(s):

David Dornbos ◽

Constantine L. Karras ◽

Nicole Wenger ◽

Blake Priddy ◽

Patrick Youssef ◽

...

Keyword(s):

Flow Diversion ◽

High Rate ◽

Endovascular Coiling ◽

Vessel Occlusion ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Microsurgical Clipping ◽

Previously Treated ◽

Angiographic Evidence

OBJECTIVEThe utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms.METHODSThe authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group.RESULTSAll PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months.CONCLUSIONSThe treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

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