scholarly journals Mechanical Thrombectomy of Acutely Occluded Flow Diverters

2019 ◽  
Vol 17 (5) ◽  
pp. 491-496 ◽  
Author(s):  
Edgar A Samaniego ◽  
Sudeepta Dandapat ◽  
Jorge A Roa ◽  
Mario Zanaty ◽  
Daichi Nakagawa ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Intracranial Aneurysms ◽  
Mechanical Thrombectomy ◽  
Dual Antiplatelet Therapy ◽  
Additional Treatment ◽  
Limited Evidence ◽  
Pipeline Embolization Device ◽  
Best Management ◽  
Optimal Deployment ◽  
Flow Diverters

Abstract BACKGROUND Embolization of intracranial aneurysms with the pipeline embolization device (PED; Medtronic, Dublin, Ireland) is a widely used technique. Despite adequate dual antiplatelet therapy and intraprocedural anticoagulation, in-stent thrombosis has been described. There is limited evidence for best management of this complication. OBJECTIVE To describe in detail the technique used to perform thrombectomy of a recently placed PED with in-stent thrombosis. The aim of the procedure is to leave the PED in place and only perform thrombectomy of the luminal clot. METHODS We describe two cases of successful thrombectomy with a stentriever of acutely occluded PEDs. A total of 2 patients underwent PED embolization of 2 previously clipped aneurysms. Despite optimal deployment of the PEDs and excellent angiographic results, both patients developed symptoms of right hemispheric stroke within 1 h of the procedure. A thrombectomy was performed in each patient with the stentriever within the newly deployed PED. Thrombectomy was successful and there was no evidence of PED displacement of vascular injury. RESULTS Stentriever thrombectomy of intraluminal clot can be performed effectively when the entire stentriever device is deployed within the PED. We did not experience any PED displacement, vessel damage, spasm, or device malfunction using this technique. CONCLUSION We report the use of a stentriever to perform thrombectomy for in-stent thrombosis after PED placement as an additional treatment option of acute occlusion. This technique has not been previously described.

Aneurysms with persistent patency after treatment with the Pipeline Embolization Device

2016 ◽  
Vol 126 (6) ◽  
pp. 1894-1898 ◽  
Author(s):  
Peter Kan ◽  
Visish M. Srinivasan ◽  
Nnenna Mbabuike ◽  
Rabih G. Tawk ◽  
Vin Shen Ban ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Artery Aneurysm ◽  
Superior Cerebellar Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Pipeline Embolization Device ◽  
Cerebellar Artery ◽  
Middle Cerebral Artery Aneurysms ◽  
Flow Diverters

The Pipeline Embolization Device (PED) was approved for the treatment of intracranial aneurysms from the petrous to the superior hypophyseal segment of the internal carotid artery. However, since its approval, its use for treatment of intracranial aneurysms in other locations and non-sidewall aneurysms has grown tremendously. The authors report on a cohort of 15 patients with 16 cerebral aneurysms that incorporated an end vessel with no significant distal collaterals, which were treated with the PED. The cohort includes 7 posterior communicating artery aneurysms, 5 ophthalmic artery aneurysms, 1 superior cerebellar artery aneurysm, 1 anterior inferior cerebellar artery aneurysm, and 2 middle cerebral artery aneurysms. None of the aneurysms achieved significant occlusion at the last follow-up evaluation (mean 24 months). Based on these observations, the authors do not recommend the use of flow diverters for the treatment of this subset of cerebral aneurysms.

Use of flow-diverting stents as salvage treatment following failed stent-assisted embolization of intracranial aneurysms

2015 ◽  
Vol 8 (7) ◽  
pp. 692-695 ◽  
Author(s):  
Daniel M Heiferman ◽  
Joshua T Billingsley ◽  
Manish K Kasliwal ◽  
Andrew K Johnson ◽  
Kiffon M Keigher ◽  
...  
Keyword(s):  
Blood Flow ◽  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Salvage Treatment ◽  
Endovascular Techniques ◽  
Pipeline Embolization Device ◽  
Wall Apposition ◽  
Flow Diverters

Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms.

scholarly journals Safety of tirofiban and dual antiplatelet therapy in treating intracranial aneurysms

2019 ◽  
Vol 4 (1) ◽  
pp. 36-42 ◽  
Author(s):  
Edgar A Samaniego ◽  
Emilee Gibson ◽  
Daichi Nakagawa ◽  
Santiago Ortega-Gutierrez ◽  
Mario Zanaty ◽  
...  
Keyword(s):  
Platelet Count ◽  
Endovascular Treatment ◽  
Antiplatelet Therapy ◽  
Intracranial Aneurysms ◽  
Dual Antiplatelet Therapy ◽  
Concomitant Administration ◽  
Thromboembolic Complications ◽  
Ruptured Aneurysms ◽  
Increase Rate ◽  
Flow Diverters

BackgroundEndovascular treatment of intracranial aneurysms usually involves stent-assisted coiling (SAC) and flow diverters. Glycoprotein IIb/IIIa inhibitors such as tirofiban and dual antiplatelet therapy (DAPT) are required to prevent thromboembolic complications afterwards. We sought to determine the safety of tirofiban and DAPT in these cases.MethodsWe conducted a retrospective analysis of our database for patients with intracranial aneurysms who underwent SAC or flow diversion. The tirofiban-DAPT protocol used is described. Data regarding duration of infusion, placement of external ventricular devices (EVDs), complications, haemoglobin levels and platelet count before and 24 hours after antiplatelet therapy were collected and analysed.ResultsOne-hundred and forty-one patients with 148 aneurysms/procedures were included. 110 aneurysms were treated acutely and 38 electively. Minor and major haemorrhagic events were recognised in 20% (30/148) aneurysms. Only 5 (3.4%) intracerebral haemorrhages were symptomatic: 3 cortical/SAH and 2 EVD-related. The average blood volume in symptomatic haemorrhages was 24.8 cc versus 5.42 cc in asymptomatic haemorrhages (p=0.002). The rate of EVD-related haemorrhages was 15.7% (19/121) and only 2 (1.7%) were symptomatic. Most haemorrhagic events occurred in ruptured aneurysms (90.1%, p=0.01). No significant change in platelet count or haemoglobin levels before and 24 hours after administration of tirofiban and DAPT was documented. Concomitant administration of heparin did not increase haemorrhagic events.ConclusionThe use of the GP IIb/IIIa inhibitors tirofiban and DAPT in this series was safe. Tirofiban and DAPT did not affect platelet count or haemoglobin levels and did not increase rate of symptomatic haemorrhages or thromboembolic complications.

Mechanical Thrombectomy of Acutely Occluded Flow-Diverters – Neuroendovascular Surgical Technique Demonstration: 2-Dimensional Operative Video

2019 ◽  
Vol 19 (2) ◽  
pp. E176-E177
Author(s):  
Jorge A Roa ◽  
David M Hasan ◽  
Edgar A Samaniego
Keyword(s):  
Surgical Technique ◽  
Intracranial Aneurysms ◽  
Mechanical Thrombectomy ◽  
Aspiration Thrombectomy ◽  
Pharmacological Agents ◽  
Intravenous Tissue Plasminogen Activator ◽  
Vessel Injury ◽  
Technical Report ◽  
Tissue Plasminogen ◽  
Flow Diverters

Abstract Flow-diversion with pipeline embolization devices (PED, Medtronic, Dublin, Ireland) is widely used for embolization of complex intracranial aneurysms.1 In-stent thrombosis can be a dreadful complication after PED deployment. Intra-arterial glycoprotein IIb-IIIa inhibitors and intravenous tissue plasminogen activator have been used in an attempt to achieve recanalization.2 However, large clots may not be effectively dissolved by pharmacological agents, thus requiring mechanical thrombectomy (MT).3 Our group recently published the first technical report on successful MT of acutely occluded PEDs in 2 patients.4 Here, we showcase the successful MT of a patient who sustained acute in-stent PED thrombosis. Informed written consent was obtained. In this case, we combined stentriever and contact aspiration thrombectomy techniques. We highlight important pitfalls and tips to prevent PED displacement, removal or vessel injury during endovascular manipulation. The most important consideration is to deploy the distal end of the stentriever inside the PED but also as distally as possible. Thus, correct apposition and alignment of the distal markers of both devices is performed under “native” unsubstracted fluoroscopic view (for better PED visualization) before MT. In this surgical video we describe the technique in detail.

scholarly journals Malignant stroke in a ticagrelor non-responder as a complication following aneurysm treatment with the Pipeline Embolization Device™

2017 ◽  
Vol 23 (3) ◽  
pp. 297-300 ◽  
Author(s):  
Pegah Ghamasaee ◽  
Kevin Carr ◽  
Jeremiah Johnson ◽  
Ramesh Grandhi
Keyword(s):  
Active Metabolite ◽  
Intracranial Aneurysms ◽  
Interventional Procedures ◽  
Internal Carotid ◽  
Dual Antiplatelet Therapy ◽  
Pipeline Embolization Device ◽  
Adp Receptor ◽  
Ischemic Events ◽  
Neurointerventional Procedures ◽  
Flow Diverting Stent

The Pipeline Embolization Device™ (PED; Covidien Neurovascular Inc, Irvine, CA, USA) is a flow-diverting stent often used for the endovascular treatment of large or giant, wide-necked intracranial aneurysms of the internal carotid artery. Because of the inherent thrombogenicity of intracranial stents, dual-antiplatelet therapy is initiated after placement, which has been shown to decrease morbidity and mortality related to perioperative ischemic events in neurointerventional procedures. However, in some series, as much as 50% of patients demonstrate clopidogrel non-responsiveness. In these non-responders, alternate agents such as ticagrelor can be used to achieve adequate anticoagulation. Compared with clopidogrel, a prodrug requiring Cytochrome P450 enzymolysis for activation, ticagrelor directly and reversibly inhibits the P2Y12 ADP receptor. The absorption of the prodrug and the formation of its active metabolite is comparatively quicker ( tmax 1.3–2 hours; 1.5–3 hours, respectively). To date, there have been no documented cases of ticagrelor non-responsiveness involving patients undergoing placement of flow-diverting stents or other endovascular neuro-interventional procedures.

Optical coherence tomography for elucidation of flow-diversion phenomena: The concept of endothelized mural thrombus behind reversible in-stent stenosis in flow-diverters

2021 ◽  
pp. 159101992110034
Author(s):  
Andre Monteiro ◽  
Demetrius K Lopes ◽  
Amin Aghaebrahim ◽  
Ricardo Hanel
Keyword(s):  
Optical Coherence Tomography ◽  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
Optical Coherence ◽  
Recurrence Rates ◽  
Oct Imaging ◽  
Intravascular Optical Coherence Tomography ◽  
Stenotic Area ◽  
Flow Diverters ◽  
Stent Stenosis

Purpose Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms, offering a durable solution to aneurysms with high recurrence rates after conventional stent-assisted coiling. Events that occur after treatment with flow-diversion, such as in-stent stenosis (ISS) are not well understood and require further assessment. After assessing an animal model with Optical Coherence Tomography (OCT), we propose a concept that could explain the mechanism causing reversible ISS after treatment of intracranial aneurysms with flow-diverters. Methods Six Pipeline Flex embolization devices (PED-Flex), six PED with Shield technology (PED-Shield), and four Solitaire AB devices were implanted in the carotid arteries (two stents per vessel) of four pigs. Intravascular optical coherence tomography (OCT) and digital subtraction angiography (DSA) images obtained on day 21 were compared to histological specimens. Results A case of ISS in a PED-Flex device was assessed with OCT imaging. Neointima with asymmetrical topography completely covering the PED struts was observed. Histological preparations of the stenotic area demonstrated thrombus on the surface of device struts, covered by neointima. Conclusion This study provides a plausible concept for reversible ISS in flow-diverters. Based on an observation of a previous experiment, we propose that similar cases of ISS are related to thrombus presence underneath endothelization, but further experiments focused on this phenomenon are needed. Optical Coherence Tomography will be useful tool when available for clinical use.

L-Arginine reduces downstream vascular contractility after flow-diverting device deployment: A preliminary study in a rabbit model

2021 ◽  
pp. 159101992110251
Author(s):  
Jennifer Ayers-Ringler ◽  
Praveen Kolumam Parameswaran ◽  
Zenith Khashim ◽  
Daying Dai ◽  
Yong-Hong Ding ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Rabbit Model ◽  
Organ Bath ◽  
Potential Mechanism ◽  
Vascular Contractility ◽  
Arginine Hydrochloride ◽  
Preliminary Study ◽  
Cox 2 ◽  
Device Deployment ◽  
Flow Diverters

Background Flow diverters (FDs) are an effective treatment for intracranial aneurysms, though not free from hemorrhagic complications. A previous study demonstrated increased vascular contractility after FD-implantation as a potential mechanism of distal complications. Our study aimed to investigate whether L-arginine medication affects vascular contractility following FD deployment in a rabbit model. Methods FDs were implanted in the aorta of normal rabbits (+FD, n = 10), with sham-operated aorta as controls (n = 5). L-Arginine was given in the drinking water (2.25% L-arginine hydrochloride) of half of the +FD animals (+FD/+Arg). Force contraction vascular contractility studies were performed on the aortic rings proximal and distal to the FD using an organ bath. Total eNOS, eNOS(pS1177), eNOS(pT495), COX-2, and S100A4 were quantified by western analysis on total protein lysates from aortic segments, normalizing to GAPDH. Results Mean vascular contractility was 53% higher in distal relative to proximal aortic segments (P = 0.0038) in +FD animals, but were not significantly different in +FD/+Arg animals, or in sham-operated controls. The +FD animals expressed significantly reduced levels of eNOS(pS1177) than sham-operated controls (P = 0.0335), while both the +FD and +FD/+Arg groups had reduced levels of eNOS(pT495) relative to sham-operated controls (P = 0.0331 and P = 0.0311, respectively). Conclusion These results suggest that L-arginine medication reduces distal vascular contractility after FD treatment via nitric oxide production and thus might mitigate risk for downstream complications.

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