Balloon-Mounted Stents for Treatment of Refractory Flow Diverting Device Wall Malapposition

Abstract BACKGROUND As indications for flow diversion (FD) have expanded, new challenges in deployment of flow diverting devices (FDDs) have been encountered. We present 4 cases with aneurysms in which deployment of FDDs were complicated by device malapposition and compromised opening in regions of parent vessel stenosis. In all 4 cases, a balloon-mounted stent was ultimately deployed within the FDD. OBJECTIVE To describe the use of balloon-mounted stents (BMS) within FDDs for correction of flow-limiting stenosis and device malapposition. METHODS Patients undergoing FD for treatment of aneurysms complicated by refractory flow-limiting stenosis were identified through multi-center retrospective review. Those cases requiring use of BMS were identified. Further investigation in one of the cases was performed with a simulated pulsatile blood flow model. RESULTS After attempts to perform balloon angioplasty proved unsuccessful, BMS deployment successfully opened the stenotic parent artery and improved FDD wall apposition in all 4 cases. Simulated pulsatile blood flow modeling confirmed improvements in the distribution of velocity, wall shear stress, oscillatory shear index, and flow pattern structure after stent deployment. One case was complicated by asymptomatic in-stent thrombosis. CONCLUSION In cases of FDD deployment complicated by flow-limiting stenosis refractory to conventional techniques, a BMS deployed within the FD can provide radial support to open both the stenotic device and parent artery. Resulting improvements in device wall apposition may portend greater long-term efficacy of FD. In-stent occlusion can occur and may reflect a thrombogenic interaction between the devices.

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Endovascular Treatment of Small Ruptured Intracranial Aneurysms (<5 mm)

Clinical Neuroradiology ◽

10.1007/s00062-019-00835-8 ◽

2019 ◽

Vol 30 (4) ◽

pp. 817-826

Author(s):

Fei Peng ◽

Xin Feng ◽

Xin Tong ◽

Baorui Zhang ◽

Luyao Wang ◽

...

Keyword(s):

Endovascular Treatment ◽

Intracranial Aneurysms ◽

Cox Proportional Hazards ◽

Parent Artery ◽

Parent Vessel ◽

Fisher Grade ◽

Wide Neck ◽

Ruptured Intracranial Aneurysms

Abstract Purpose To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (<5 mm) ruptured intracranial aneurysms (SRA). Methods The study retrospectively reviewed patients with SRAs who underwent EVT between September 2011 and December 2016 in two Chinese stroke centers. Medical charts and telephone call follow-up were used to identify the overall unfavorable clinical outcomes (OUCO, modified Rankin score ≤2) and any recanalization or retreatment. The independent predictors of OUCO and recanalization were studied using univariate and multivariate analyses. Multivariate Cox proportional hazards models were used to identify the predictors of retreatment. Results In this study 272 SRAs were included with a median follow-up period of 5.0 years (interquartile range 3.5–6.5 years) and 231 patients with over 1171 aneurysm-years were contacted. Among these, OUCO, recanalization, and retreatment occurred in 20 (7.4%), 24 (12.8%), and 11 (7.1%) patients, respectively. Aneurysms accompanied by parent vessel stenosis (AAPVS), high Hunt-Hess grade, high Fisher grade, and intraoperative thrombogenesis in the parent artery (ITPA) were the independent predictors of OUCO. A wide neck was found to be a predictor of recanalization. The 11 retreatments included 1 case of surgical clipping, 6 cases of coiling, and 4 cases of stent-assisted coiling. A wide neck and AAPVS were the related predictors. Conclusion The present study demonstrated relatively favorable clinical and angiographic outcomes in EVT of SRAs in long-term follow-up of up to 5 years. THE AAPVS, as a morphological indicator of the parent artery for both OUCO and retreatment, needs further validation.

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A Case of an Obstructive Intramural Haematoma during Percutaneous Coronary Intervention Successfully Treated with Intima Microfenestrations Utilising a Cutting Balloon Inflation Technique

Case Reports in Cardiology ◽

10.1155/2018/4875041 ◽

2018 ◽

Vol 2018 ◽

pp. 1-5

Author(s):

Osama Alsanjari ◽

Aung Myat ◽

James Cockburn ◽

Grigoris V. Karamasis ◽

David Hildick-Smith ◽

...

Keyword(s):

Blood Flow ◽

Coronary Blood Flow ◽

Coronary Intervention ◽

Intramural Haematoma ◽

Balloon Inflation ◽

Cutting Balloon ◽

Stent Deployment ◽

Stent Expansion ◽

Percutaneous Coronary

During percutaneous coronary interventions (PCI), good lesion preparation with adequate balloon predilatation is a fundamental step before stent deployment in order to achieve optimal stent expansion and favourable long-term outcomes post PCI. During PCI, inadvertent vessel tearing can occur, resulting in coronary dissections and formation of intramural haematomas. The latter might be associated with compression of the vessel lumen and significant compromise of the coronary blood flow leading to myocardial ischaemia and infarction. Herein, we present a case of intramural haematoma that occurred after PCI of the left anterior descending artery resulting in occlusion of the vessel and the subsequent use of a cutting balloon inflation technique to resolve the haematoma and restore the normal coronary blood flow.

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Early Experiences of Neuroform Stent-Assisted Coiling in Ruptured Intracranial Aneurysms

Interventional Neuroradiology ◽

10.1177/159101990701300104 ◽

2007 ◽

Vol 13 (1) ◽

pp. 31-44 ◽

Cited By ~ 8

Author(s):

Young-Joon Kim

Keyword(s):

Intracranial Aneurysms ◽

Three Dimensional ◽

Parent Artery ◽

Parent Vessel ◽

Single Center Experience ◽

Early Experiences ◽

Detachable Coils ◽

Neuroform Stent ◽

Ruptured Intracranial Aneurysms

Endovascular treatment of ruptured intracranial aneurysms with detachable coils has proven a favorable alternative to surgical clipping. However, coiling has limitations in the treatment of complex or broad neck aneurysms because of possible coil prolapse or coil migration into the parent vessel and long-term angiographic recurrences. To achieve reconstruction of intracranial vessels with preservation of the parent artery, the use of stents has the greatest potential for assisted coil embolization. Three-dimensional coils and reconstructive techniques such as balloon-assisted remodeling may overcome these problems. But these methods had some drawbacks. The Neuroform stent is the most recently developed endovascular stent with self-expandable and micro-delivery properties that are specially designed for the treatment of unruptured intracranial broad neck aneurysms. Aim of the following working is to report a single center experience of stent-assisted coiling on ruptured intracranial aneurysms with assessment of its efficacy and safety, and follow-up findings.

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Treatment of broad-based intracranial aneurysms with low profile braided stents: a single center analysis of 101 patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014488 ◽

2019 ◽

Vol 11 (6) ◽

pp. 591-597 ◽

Cited By ~ 3

Author(s):

Tanja Djurdjevic ◽

Victoria Young ◽

Rufus Corkill ◽

Dennis Briley ◽

Wilhelm Küker

Keyword(s):

Intracranial Aneurysms ◽

Guide Wire ◽

Neurological Deficits ◽

Anterior Communicating Artery ◽

Parent Artery ◽

Stent Deployment ◽

Stent Occlusion ◽

Neck Size ◽

Aneurysm Neck ◽

Low Profile

Background and purposeLow profile braided stents have facilitated the endovascular treatment of broad-based intracranial aneurysms.MethodsBetween 2013 and June 2018, we attempted 104 Leo baby stent placements in 101 patients. Locations were the anterior communicating artery (AcomA) (37 aneurysms, 35.6%), middle cerebral artery (MCA) bifurcation (29 aneurysms, 27.9%) and basilar artery (23aneurysms, 22.1%). Mean neck size was 4.9 mm (2.2–8.2). 60 aneurysms were incidental, 31 of 37 recurrent aneurysms had ruptured before.ResultsStent deployment was successful in 89.4% of cases. Common reasons for failure were inability to access the parent artery (n=5) or to deploy the stent across the aneurysm neck (n=4). Two patients had poor outcomes within 24 hours. One patient developed a brain hemorrhage caused by guide wire perforation (MRS 5), the other an early thrombotic stent occlusion (MRS 4). No patient died. Nine (8.7%) patients experienced transient neurological deficits with ischemic lesions on diffusion weighted imaging (DWI). Initially Raymond-Roy class 1 occlusion was achieved in 23 aneurysms (24.7%), class 2 occlusion in 40 (43%), class 3a occlusion in 14 (15.0%), and 3b occlusion in 16 aneurysms (17.2%). Follow-up imaging in 87 patients showed stable or improved occlusion grades in 76%. Six patients required retreatment while the rest were managed conservatively. Four delayed stent occlusions occurred in three patients, with severe morbidity in one patient (MRS 5). There were no aneurysm ruptures or deaths.ConclusionStent assisted treatment of broad-based aneurysms with the Leo baby stent is safe and effective. The frequency of delayed thrombotic complications is low and similar to other stents.

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BALLOON-ASSISTED CLIPPING OF A LARGE PARACLINOIDAL ANEURYSM

Neurosurgery ◽

10.1227/01.neu.0000357324.86905.dc ◽

2009 ◽

Vol 65 (6) ◽

pp. E1210-E1211 ◽

Cited By ~ 6

Author(s):

Mohamed Samy Elhammady ◽

Peter Nakaji ◽

Hamad Farhat ◽

Jacques J. Morcos ◽

Mohammad Ali Aziz-Sultan

Keyword(s):

Parent Artery ◽

Salvage Procedure ◽

Parent Vessel ◽

Intraoperative Angiography ◽

Paraclinoid Aneurysm ◽

Paraclinoid Aneurysms ◽

Vessel Stenosis ◽

Intraoperative Rupture ◽

Vessel Reconstruction ◽

Wide Neck

Abstract OBJECTIVE Surgical clipping and parent vessel reconstruction of wide-neck paraclinoid aneurysms can be very challenging. We report a case of a ruptured paraclinoid aneurysm which failed standard clipping techniques. We were able to reconstruct this aneurysm while providing proximal and distal control using an adjuvant endovascular balloon. CLINICAL PRESENTATION We report the case of a 45-year-old woman presenting with a ruptured large paraclinoidal aneurysm, which involved a significant portion of the internal carotid artery wall. INTERVENTION Repeated attempts at fenestrated clip placement resulted in slipping of the clip and occlusion of the parent artery. Ultimately, the aneurysm ruptured at the neck, and, despite trapping and direct aneurysmal suction decompression, significant bleeding was encountered. The bleeding point was packed, and, subsequently, endovascular access was obtained. A balloon was navigated and then inflated across the neck of the aneurysm using C-arm fluoroscopic guidance. The aneurysm was successfully clipped, and intraoperative angiography demonstrated no parent vessel stenosis. CONCLUSION This case demonstrates a salvage procedure in the event of intraoperative rupture and inadequate interruption of local blood flow. Balloon inflation resulted in adequate hemostasis and provided intraluminal support for optimal clip placement while preserving the parent artery.

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