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 First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

2021 ◽  
Vol 12 ◽  
Author(s):  
Helge Winters ◽  
Marie-Sophie Schüngel ◽  
Cordula Scherlach ◽  
Dirk Mucha ◽  
Jörg Thalwitzer ◽  
...  
Keyword(s):  
Cerebral Arteries ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Low Profile ◽  
Procedural Complications ◽  
Caroticocavernous Fistula ◽  
Treatment For Cerebral Aneurysms

Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter.Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM).Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity.Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.

scholarly journals Indirect Flow Diversion for Off-Centered Bifurcation Aneurysms and Distant Small-Vessel Aneurysms, a Retrospective Proof of Concept Study From Five Neurovascular Centers

2022 ◽  
Vol 12 ◽  
Author(s):  
Stefan Schob ◽  
Richard Brill ◽  
Eberhard Siebert ◽  
Massimo Sponza ◽  
Marie-Sophie Schüngel ◽  
...  
Keyword(s):  
Average Distance ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Small Vessel ◽  
Parent Vessel ◽  
Therapeutic Success ◽  
Subsequent Formation ◽  
Procedural Complications

Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms–off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels–oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion–a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm–can be a viable treatment strategy, but clinical evidence is lacking in this regard.Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded.Results: Seventeen patients (mean age: 60.5 years, range: 35–77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4–2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case.Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted.

Flow Modification of Cerebral Aneurysm by Flow Diverter (Pipeline) With Different Packing Densities

2012 ◽  
Author(s):  
Jianping Xiang ◽  
Ding Ma ◽  
Adnan Siddiqui ◽  
Hui Meng
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
High Recurrence Rate ◽  
Parent Vessel ◽  
Novel Device ◽  
Flow Modification ◽  
Fine Mesh ◽  
High Flexibility ◽  
Vessel Reconstruction ◽  
Packing Densities

Flow diverter, a braided fine mesh stent, is emerging as a novel device to treat wide-necked, fusiform, and giant cerebral aneurysms since these types of aneurysms are either untreatable otherwise or have high recurrence rate treated by endovascular coils. Flow diverter devices represent a major paradigm shift in the endovascular treatment of aneurysms from filling the aneurysm cavity to diverting blood flow away from aneurysm sac with parent vessel reconstruction. Due to its high flexibility, a flow diverter can be manipulated during deployment process to achieve better results; for example, an experienced neuro-interventionalist can manipulate the stent’s local metal coverage through coordinated movement of catheter pull-back, pusher advancement, and distal coil release to pack higher density for the aneurysm orifice region to divert more flow away from aneurysm, making aneurismal thrombosis quicker and easier. Pipeline embolization device is the first flow diverter approved by FDA. In this study, we investigate the flow modification of a wide-necked aneurysm by Pipeline with different packing densities.

In Reply: Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

2019 ◽  
Vol 17 (2) ◽  
pp. E92-E92
Author(s):  
Fawaz Al-Mufti ◽  
Krishna Amuluru ◽  
Eric Cohen ◽  
Vikas Patel ◽  
Mohammad El-Ghanem ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Cerebral Aneurysms ◽  
Procedural Complications

scholarly journals Mid-term and long-term follow-up of intracranial aneurysms treated by the p64 Flow Modulation Device: a multicenter experience

2016 ◽  
Vol 9 (1) ◽  
pp. 70-76 ◽  
Author(s):  
Francesco Briganti ◽  
Giuseppe Leone ◽  
Lorenzo Ugga ◽  
Mariano Marseglia ◽  
Antonio Macera ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Stent Thrombosis ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Aneurysm Rupture ◽  
High Rate ◽  
Parent Vessel ◽  
Flow Modulation ◽  
Long Term Follow Up ◽  
Ischemic Complications

BackgroundExperience with the endovascular treatment of cerebral aneurysms using the p64 Flow Modulation Device is still limited. This study discusses the results and complications of this new flow diverter device.Methods40 patients (30 women, 10 men) with 50 cerebral aneurysms treated in six Italian neurointerventional centers with the p64 Flow Modulation Device between April 2013 and September 2015 were retrospectively reviewed.ResultsComplete occlusion was obtained in 44/50 aneurysms (88%) and partial occlusion in 3 (6%). In the other three aneurysms (6%), two cases of asymptomatic in-stent thrombosis and one intraprocedural occlusion of the parent vessel occurred. Technical complications were observed in eight procedures (16%). Permanent morbidity due to acute in-stent thrombosis and consequent ischemic stroke occurred in one patient (2.5%). No delayed aneurysm rupture, subarachnoid or intraparenchymal hemorrhage, or ischemic complications occurred and there were no deaths.ConclusionsEndovascular treatment with the p64 Flow Modulation Device is a safe treatment for unruptured cerebral aneurysms, resulting in a high rate of occlusion. As with other flow diverter devices, we recommend this treatment mainly for large-necked aneurysms of the internal carotid artery siphon. However, endovascular treatment with the p64 device should also be encouraged in difficult cases such as aneurysms of the posterior circulation and beyond the circle of Willis.

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 Thrombin–Fibrinogen In Vitro Flow Model of Thrombus Growth in Cerebral Aneurysms

TH Open ◽  
2021 ◽  
Vol 05 (02) ◽  
pp. e155-e162
Author(s):  
Malebogo N. Ngoepe ◽  
Etheresia Pretorius ◽  
Ilunga J. Tshimanga ◽  
Zahra Shaikh ◽  
Yiannis Ventikos ◽  
...  
Keyword(s):  
Cerebral Aneurysm ◽  
Computational Models ◽  
Flow Model ◽  
Three Dimensional ◽  
Significant Risk ◽  
Cerebral Aneurysms ◽  
Parent Vessel ◽  
Risk Of Rupture ◽  
Aneurysm Thrombosis

AbstractCerebral aneurysms are balloon-like structures that develop on weakened areas of cerebral artery walls, with a significant risk of rupture. Thrombi formation is closely associated with cerebral aneurysms and has been observed both before and after intervention, leading to a wide variability of outcomes in patients with the condition. The attempt to manage the outcomes has led to the development of various computational models of cerebral aneurysm thrombosis. In the current study, we developed a simplified thrombin–fibrinogen flow system, based on commercially available purified human-derived plasma proteins, which enables thrombus growth and tracking in an idealized cerebral aneurysm geometry. A three-dimensional printed geometry of an idealized cerebral aneurysm and parent vessel configuration was developed. An unexpected outcome was that this phantom-based flow model allowed us to track clot growth over a period of time, by using optical imaging to record the progression of the growing clot into the flow field. Image processing techniques were subsequently used to extract important quantitative metrics from the imaging dataset, such as end point intracranial thrombus volume. The model clearly demonstrates that clot formation, in cerebral aneurysms, is a complex interplay between mechanics and biochemistry. This system is beneficial for verifying computational models of cerebral aneurysm thrombosis, particularly those focusing on initial angiographic occlusion outcomes, and will also assist manufacturers in optimizing interventional device designs.

Numerical Modeling of the Flow in Cerebral Aneurysms Can Predict Thrombus Deposition Regions Following Vascular Interventions

2013 ◽  
Author(s):  
V. L. Rayz ◽  
G. Acevedo-Bolton ◽  
M. T. Lawton ◽  
V. Halbach ◽  
J. R. Leach ◽  
...  
Keyword(s):  
Treatment Options ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Patient Specific ◽  
Interventional Treatment ◽  
Shear Stresses ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Flow Diverter Stent ◽  
Proximal Occlusion

Giant intracranial aneurysms present a grave danger of hemorrhage, cerebral compression, and thromboembolism. Fusiform aneurysms present a particular challenge for interventional treatment since these lesions cannot be completely removed from the circulation by clipping or coiling without sacrificing flow to the distal vasculature. In some cases, these lesions can be treated by interventions eliminating pathological hemodynamics, such as indirect aneurysm occlusion or deployment of a flow diverter stent (FDS). The first approach consists of proximal occlusion, distal occlusion, or trapping, sometimes performed with a bypass supplying flow from collateral circulation. In the second approach, a flow diverter device is used to reconstruct the parent vessel geometry and redirect the flow away from the aneurysmal sac. This is achieved due to the denser struts of an FDS relative to a standard stent, which provide resistance to the flow across its walls. Both interventional approaches often result in thrombus deposition (TD) in the aneurysm sac that is considered protective. Despite their advantages, these treatments introduce complications related to thrombotic occlusion of vital perforators or branch arteries. A virtual model, that could predict TD regions that result from flow alteration could help evaluate various treatment options. In addition to biochemical factors, an important role in the TD process may be played by hemodynamics. Previous studies demonstrated that flow regions with elevated TD potential are characterized by low velocities and near-wall shear stresses as well as increased flow residence time [1, 2]. The current study extends this patient-specific CFD methodology to predict TD regions following vascular interventions, such as proximal vessel occlusion and FDS deployment.

scholarly journals Efficacy of the Flow Re-direction Endoluminal Device for cerebral aneurysms and causes of failed deployment

2021 ◽  
Author(s):  
Kenichiro Suyama ◽  
Ichiro Nakahara ◽  
Shoji Matsumoto ◽  
Yoshio Suyama ◽  
Jun Morioka ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Vessel Diameter ◽  
Flow Diversion ◽  
Parent Vessel ◽  
Failure Group ◽  
Retrospective Data Analysis ◽  
Vessel Injury ◽  
Success Group ◽  
Grading Scale

Abstract Purpose The Flow Re-direction Endoluminal Device (FRED) has recently become available for flow diversion in Japan. We have encountered cases that failed to deploy the FRED. In this study, we report our initial experience with the FRED for cerebral aneurysms and clarify the causes of failed FRED deployment. Methods A retrospective data analysis was performed to identify patients treated with the FRED between June 2020 and March 2021. Follow-up digital subtraction angiography was performed at 3 and 6 months and assessed using the O’Kelly-Marotta (OKM) grading scale. Results Thirty-nine aneurysms in 36 patients (average age: 54.4 years) were treated with the FRED. The average sizes of the dome and neck were 9.9 mm and 5.2 mm, respectively. In nine patients, additional coiling was performed. In one patient (2.6%), proximal vessel injury caused direct carotid-cavernous fistula during deployment. Ischaemic complications were encountered in one patient (2.6%) with transient symptoms. Angiographic follow-up at 6 months revealed OKM grade C or D in 86.6% of patients. FRED deployment was successful in 35 (92.1%) procedures. In the failure group, the differences between the FRED and the minimum vessel diameter (P = 0.04) and the rate of the parent vessel having an S-shaped curve (P = 0.04) were greater than those in the success group. Conclusions Flow diversion using the FRED is effective and safe for treating cerebral aneurysms. The use of the FRED for patients with an S-shaped curve in the parent vessel and oversizing of more than 2 mm should be considered carefully.

Sign in / Sign up

Export Citation Format

Share Document