Flow diversion of large internal carotid artery aneurysms with the surpass device: impressions and technical nuance from the initial North American experience

BackgroundFlow diversion is an important tool for treatment of cerebral aneurysms, particularly large and giant aneurysms. The Surpass flow diverter is a new system under evaluation in the USA.ObjectiveTo report our initial experience of 20 cases with the Surpass flow diverter to demonstrate its basic properties, the required triaxial delivery platform, and the methodologies used to deploy it during treatment of large internal carotid artery (ICA) aneurysmsMethodsTwenty patients with ICA aneurysms ≥10 mm with ≥4 mm neck treated as part of the Surpass IntraCranial Aneurysm Embolization System Pivotal Trial (the SCENT trial; Stryker) were included. Details of patient demographics, aneurysm characteristics, and technical procedures were collected.ResultsTwenty patients (mean age 63.3±1.3 years; range 51–72) with 20 unruptured aneurysms (mean size 13.4±0.9 mm; range 10–21 mm) were treated. For proximal access, 60% of cases had aortic arch ≥grade II, 55% had significant cervical ICA tortuosity, and 60% had cavernous ICA ≥grade II. The Surpass device was implanted in 19/20 (95%) cases. Of 19 cases, a single device was used in 18 cases (95%) and 2 devices in only 1 case (5%). Balloon angioplasty was performed in 8/19 cases (42%). Complete aneurysm neck coverage and adequate vessel wall apposition was obtained in all 19 cases.ConclusionsSurpass is a next-generation flow diverter with unique device-specific and delivery-specific features compared with clinically available endoluminal flow diverters. Our initial experience demonstrates a favorable technical profile in treatment of large and giant ICA aneurysms.Trial registration numberNCT01716117.

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Endovascular treatment of unruptured aneurysms of cavernous and ophthalmic segment of internal carotid artery with flow diverter device Pipeline

Radiology and Oncology ◽

10.1515/raon-2016-0049 ◽

2016 ◽

Vol 50 (4) ◽

pp. 378-384 ◽

Cited By ~ 4

Author(s):

Marko Jevsek ◽

Charbel Mounayer ◽

Tomaz Seruga

Keyword(s):

Blood Flow ◽

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Treatment Success ◽

Giant Aneurysm ◽

Flow Diverter ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Flow Diverter Device

Abstract Background Intra-arterial treatment of aneurysms by redirecting blood flow is a newer method. The redirection is based on a significantly more densely braided wire stent. The stent wall keeps the blood in the lumen of the stent and slows down the turbulent flow in the aneurysms. Stagnation of blood in the aneurysm sac leads to the formation of thrombus and subsequent exclusion of the aneurysm from the circulation. The aim of the study was to evaluate flow diverter device Pipeline for broad neck and giant aneurysm treatment. Methods Fifteen patients with discovered aneurysm of the internal carotid artery were treated between November 2010 and February 2014. The majority of aneurysms of the internal carotid artery were located intradural at the ophthalmic part of the artery. The patients were treated using a flow diverter device Pipeline, which was placed over the aneurysm neck. Treatment success was assessed clinically and angiographically using O’Kelly Marotta scale. Results Control angiography immediately after the release of the stent showed stagnation of the blood flow in the aneurysm sac. In none of the patients procedural and periprocedural complications were observed. 6 months after the procedure, control CT or MR angiography showed in almost all cases exclusion of the aneurysm from the circulation and normal blood flow in the treated artery. Neurological status six months after the procedure was normal in all patients. Conclusions Treatment of aneurysms with flow diverter Pipeline device is a safe and significantly less time consuming method in comparison with standard techniques. This new method is a promising approach in treatment of broad neck aneurysms.

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Endovascular Treatment of Aneurysms Using Flow-Diversion Embolization: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opaa462 ◽

2021 ◽

Author(s):

Daniel D Cavalcanti ◽

Peter Kim Nelson ◽

Eytan Raz ◽

Maksim Shapiro ◽

Erez Nossek ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Cranial Nerves ◽

Giant Aneurysm ◽

Flow Diverter ◽

Flow Diversion ◽

Neck Infection ◽

The Right ◽

Lower Cranial Nerves

Abstract Initially developed for large and giant wide-necked aneurysms of the internal carotid artery, flow diverter devices are now used in almost every location safely and with effectiveness.1-5 This video demonstrates a unique case of a giant aneurysm of the right petrous internal carotid artery in a 20-yr-old patient. This is an extremely rare location, and most of patients are asymptomatic.3-6 Signs of compression of the seventh and eight cranial nerves can be present and even Horner syndrome and lower cranial nerves neuropathies. Nevertheless, rupture can lead to epistaxis and otorrhagia, and ultimately to hemorrhagic shock. The patient in the current report was otherwise healthy but presented with lightheadedness and dizziness for 10 d. The patient consented to the procedure. There was no history of major trauma or head and neck infection. A transradial endovascular flow diversion embolization of a giant aneurysm of the petrous internal carotid artery is herein demonstrated in a stepwise manner. A triaxial system was used to deploy 3 overlapping devices. Concepts of J-wire technique, multiple coverage,1 and the so-called weld technique are emphasized. The role of adjunctive coiling and main reasons for failure are also discussed.7,8 Brief cases of flow diversion embolization of aneurysms of different morphologies at different locations are used to highlight the importance of assessing vessel wall apposition and follow-up imaging.

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Treatment of Anterior Circulation Aneurysms in the Internal Carotid Artery With Flow Diverters

Neurosurgery ◽

10.1093/neuros/nyz315 ◽

2019 ◽

Vol 86 (Supplement_1) ◽

pp. S55-S63

Author(s):

Kunal Vakharia ◽

Stephan A Munich ◽

Muhammad Waqas ◽

Elad I Levy ◽

Adnan H Siddiqui

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diverter ◽

Flow Diversion ◽

Anterior Circulation ◽

Technological Advances ◽

Posterior Circulation Aneurysms ◽

Surgical Options ◽

Flow Diverters

Abstract Several studies have shown the efficacy and feasibility of flow diversion for the endovascular treatment of wide-necked and otherwise anatomically challenging intracranial aneurysms (IA). Technological advances have led to successful long-term occlusion rates and a safety profile for flow-diverter stents that parallels other endovascular and open surgical options for these lesions. With growing indications for use of the Pipeline Embolization Device (PED, Medtronic, Dublin, Ireland) to include IAs up to the internal carotid artery (ICA) terminus, understanding the nuances of this technology is increasingly relevant. Furthermore, there is a growing body of literature on the use of flow diversion to treat distal (up to A2, M2, and P2), ruptured, and posterior circulation aneurysms, although these applications are “off-label” at present. In this manuscript, we discuss the expanding role of flow diversion in the ICA and compare this technique with other endovascular options for the treatment of ICA IAs. We also discuss technical nuances of the deployment of flow diverters for the treatment of challenging lesions and in difficult and tortuous anatomy.

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Flow modification on the internal carotid artery bifurcation region and A1 segment after M1-internal carotid artery flow diverter deployment

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-016051 ◽

2020 ◽

pp. neurintsurg-2020-016051

Author(s):

Federico Cagnazzo ◽

Raed Ahmed ◽

Pierre-Henri Lefevre ◽

Imad Derraz ◽

Cyril Dargazanli ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diversion ◽

Anterior Communicating Artery ◽

Slow Flow ◽

Unruptured Aneurysms ◽

Flow Modification ◽

Flow Diverters

BackgroundClinical and hemodynamic consequences of flow diverters extending from the M1 to the internal carotid artery (ICA), covering the A1 segment, have rarely been investigated. We aimed to provide angiographic and clinical data about flow modifications on the covered A1.MethodsConsecutive patients receiving M1-ICA flow diverters for unruptured aneurysms were collected from our prospective database (2014–2020).Results42 A1 arteries covered with a single device were studied. All patients had an angiographic detected contralateral flow from the anterior communicating artery (AcomA). Immediately after flow diversion, 20 (47.6%) covered A1 showed slow flow. During a mean angiographic follow-up of 14 months, 13 (31%) and 22 (52.3%) A1 arteries were occluded and narrowed, respectively. Flow changes were asymptomatic in all cases. Vascular risk factors, sex, oversized compared with not oversized stents, immediate A1 slow flow, age, diameter of the A1, length of follow-up, and platelet inhibition rate were tested as prognosticators of A1 occlusion. Length of the angiographic follow-up was the only predictor of A1 occlusion (p=0.005, OR=3, CI=1.4 to 6.7). There were two device related ischemic events with a 2.3% rate of morbidity (one basal ganglia infarct after coverage of the M1 perforators and one transient acute instent thrombosis).ConclusionsCovering the A1 segment during M1-ICA flow diversion seems relatively safe, if the contralateral flow is assured by the AcomA. Approximately 31% and 52% of the covered A1 showed asymptomatic occlusions and narrowing, respectively. The likelihood of flow modification was proportional to the length of follow-up. Morbidity associated with flow diversion in the ICA terminus region was 2.3%.

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Visual complications after coil embolization of internal carotid artery aneurysms at the ophthalmic segment

Interventional Neuroradiology ◽

10.1177/1591019921996886 ◽

2021 ◽

pp. 159101992199688

Author(s):

Shotaro Michishita ◽

Toshihiro Ishibashi ◽

Ichiro Yuki ◽

Mitsuyoshi Urashima ◽

Kostadin Karagiozov ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Coil Embolization ◽

Internal Carotid ◽

Visual Outcome ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Significant Difference ◽

Aneurysmal Neck ◽

The Relationship

Background Coil embolization of aneurysms of the ophthalmic segment of the internal carotid artery (ICA-OphA ANs) has potential risks of visual complications. We analyzed this risk and focused on the relationship of the ophthalmic artery (OphA) origin with the aneurysm neck. Methods From January 2003 to April 2018, 179 unruptured ICA-OphA ANs were treated with endovascular surgery in our institution. Two ruptured and four aneurysms with missing data were excluded. Finally, 173 unruptured aneurysms were included in this study. The aneurysms were classified into three groups according to the location of the OphA origin: Separate, Shared, and Dome type. We retrospectively assessed visual complications based on the relationship between types of aneurysm and postoperative angiographic findings for the OphA. Results Visual deficits remained permanent in eleven cases (6.4%). In the Dome type, visual complications were significantly more frequent compared to the Separate type. Change in the OphA flow was significantly associated with a higher complication rate of 2.9%, but patients with changed OphA flow had a significant rate of 7.5% ( p = 0.020). We found no significant difference in the incidence of visual complications concerning the use of perioperative antithrombotic therapy. Conclusions The location of OphA origin regarding the aneurysmal neck and postoperative OphA flow were significantly correlated with the visual outcome after coil embolization for ICA-OphA ANs. Post-procedural flow in the OphA was an important factor affecting the rate of ischemic retinal complications. Retinal embolic events occurred with preserved flow in the OphA, albeit at a lower rate.

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Three-Dimensional Intraarterial Vaso Computed Tomography Depiction of Pipeline Flex with Shield Technology Flow Diverter Stent in Ruptured Blister Aneurysm of Supraclinoid Internal Carotid Artery

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0041-1732847 ◽

2021 ◽

Author(s):

Rasmiranjan Padhi ◽

Sathish Kandasamy ◽

BalaSenthil Kumaran

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Treatment Options ◽

Three Dimensional ◽

Significant Risk ◽

Flow Diverter ◽

Aneurysm Neck ◽

Flow Diverter Stent ◽

Supraclinoid Internal Carotid Artery

AbstractBlister aneurysms are intracranial arterial lesions originating at nonbranching sites of the dorsal supraclinoid internal carotid artery and basilar artery.1 Among different treatment options, the use of flow-diverting devices is gaining popularity and has the potential for becoming the standard of care.2 Radiological evaluation of flow diverter braid expansion and vessel wall apposition during procedure has become useful in preventing life-threatening complications. Incomplete coverage of an aneurysm neck, kinking, or incomplete expansion and malapposition of a stent carries a significant risk for thromboembolic events.3 4

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Supraclinoid internal carotid artery blister-like aneurysms: hypothesized pathogenesis and microsurgical clipping outcomes

Chinese Neurosurgical Journal ◽

10.1186/s41016-020-00226-w ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Shanwen Chen ◽

Xin Chen ◽

Bo Ning ◽

Yong Cao ◽

Shuo Wang

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Treatment Guidelines ◽

Treatment Strategies ◽

Neurological Dysfunction ◽

Parent Artery ◽

Unruptured Aneurysms ◽

Aneurysm Neck ◽

Microsurgical Clipping

Abstract Background Blister-like aneurysms (BLAs) on the supraclinoid segment of the internal carotid artery (ICA) are an enigma of cerebrovascular disease. Neither has a definite pathogenesis been so far identified, nor have uniform treatment guidelines been established for them. Our aim was to develop a hypothesis regarding the evolution of BLAs according to their macroscopic morphologies and to evaluate the efficacy of microsurgical clipping. Methods The clinical data and morphological features of 15 consecutive patients with 16 BLAs on the supraclinoid ICA were retrospectively reviewed. The treatment strategies were analyzed, and functional outcomes were evaluated using the modified Rankin scale (mRS). Favorable outcomes were defined as a mRS score of 0–2. Results Morphologically, aneurysm growth with expansion of the aneurysm neck before the surgical procedure occurred in two ruptured and one unruptured aneurysm. Daughter bleb formation was observed in two ruptured and five unruptured aneurysms. A varied degree of parent artery sclerosis was observed in nine patients. Thirteen patients were treated with direct surgical clipping, one patient was treated with clipping and wrapping, and the remaining patient was treated with an encircling clipping graft. Favorable and unfavorable outcomes were observed in 13 and two cases, respectively. Follow-up angiograms revealed 4 cases of stenosis with respective degree of mild, 30%, 50%, and 80% without any neurological dysfunction. Conclusions We suggest a hypothesis that BLAs on the supraclinoid ICA may share different evolving mechanisms between ruptured and unruptured lesions. A majority of them can be reliably and safely obliterated by direct clipping technique, except for the aneurysms accompanied with severely atherosclerotic parent walls.

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Flow-diverting Stent-assisted Coil Embolization of a Ruptured Internal Carotid Artery Blister Aneurysm with the Pipeline Flex Embolization Device

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_336_17 ◽

2017 ◽

Vol 08 (04) ◽

pp. 664-667 ◽

Cited By ~ 2

Author(s):

Dale Ding ◽

Robert M. Starke ◽

Ayton Hope ◽

Stefan Brew

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Flow Diverter ◽

High Grade ◽

Parent Vessel ◽

Future Studies ◽

Aneurysm Neck ◽

Flow Diverting Stent

ABSTRACTInternal carotid artery (ICA) blister aneurysms are rare and challenging to successfully treat, using contemporary surgical or endovascular approaches, without partial or complete compromise of the parent vessel. We describe the use of a resheathable flow diverter, the Pipeline Flex Embolization Device (PFED) to perform stent-assisted coiling of a ruptured supraclinoid ICA blister aneurysm in a 56-year-old female who presented with a high-grade subarachnoid hemorrhage (SAH). The first PFED was deployed across the aneurysm neck to jail a microcatheter within the aneurysm dome, and then, two small coils were delivered into the aneurysm. After removing the coiling microcatheter, the second PFED was telescoped into the first PFED. There were no postprocedural complications, and follow-up magnetic resonance angiography 15 months after embolization showed complete aneurysm obliteration. Flow-diverting stent-assisted coiling should be considered as a reconstructive, vessel-preserving, endovascular treatment option for appropriately selected patients with ruptured ICA blister aneurysms. However, future studies are necessary to assess the periprocedural safety in the setting of acute SAH.

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Transcavernous Resection of a Giant Extensive Chondrosarcoma with Endoscopic Assistance

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1727124 ◽

2021 ◽

Author(s):

Walid Elshamy ◽

Burcak Soylemez ◽

Sima Sayyahmelli ◽

Nese Keser ◽

Mustafa K. Baskaya

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Skull Base ◽

Internal Carotid ◽

Gross Total Resection ◽

Petrous Apex ◽

Left Internal Carotid Artery ◽

Total Resection ◽

Complete Occlusion ◽

Grade Ii

AbstractChondrosarcomas are one of the major malignant neoplasms which occur at the skull base. These tumors are locally invasive. Gross total resection of chondrosarcomas is associated with longer progression-free survival rates. The patient is a 55-year-old man with a history of dysphagia, left eye dryness, hearing loss, and left-sided facial pain. Magnetic resonance imaging (MRI) showed a giant heterogeneously enhancing left-sided skull base mass within the cavernous sinus and the petrous apex with extension into the sphenoid bone, clivus, and the cerebellopontine angle, with associated displacement of the brainstem (Fig. 1). An endoscopic endonasal biopsy revealed a grade-II chondrosarcoma. The patient was then referred for surgical resection. Computed tomography (CT) scan and CT angiogram of the head and neck showed a left-sided skull base mass, partial destruction of the petrous apex, and complete or near-complete occlusion of the left internal carotid artery. Digital subtraction angiography confirmed complete occlusion of the left internal carotid artery with cortical, vertebrobasilar, and leptomeningeal collateral development. The decision was made to proceed with a left-sided transcavernous approach with possible petrous apex drilling. During surgery, minimal petrous apex drilling was necessary due to autopetrosectomy by the tumor. Endoscopy was used to assist achieving gross total resection (Fig. 2). Surgery and postoperative course were uneventful. MRI confirmed gross total resection of the tumor. The histopathology was a grade-II chondrosarcoma. The patient received proton therapy and continues to do well without recurrence at 4-year follow-up. This video demonstrates steps of the combined microsurgical skull base approaches for resection of these challenging tumors.The link to the video can be found at: https://youtu.be/WlmCP_-i57s.

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Rerupture of a Blister Aneurysm After Treatment With a Single Flow-Diverting Stent

Neurosurgery ◽

10.1227/neu.0000000000001412 ◽

2016 ◽

Vol 79 (5) ◽

pp. E634-E638 ◽

Cited By ~ 25

Author(s):

Marcus D. Mazur ◽

Philipp Taussky ◽

Joel D. MacDonald ◽

Min S. Park

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Successful Treatment ◽

Internal Carotid ◽

Case Reports ◽

Treatment Strategies ◽

Artery Aneurysm ◽

Flow Diversion ◽

Multiple Treatment ◽

Internal Carotid Artery Aneurysm

Abstract BACKGROUND AND IMPORTANCE: As the use of flow-diverting stents (FDSs) for intracranial aneurysms expands, a small number of case reports have described the successful treatment of blister aneurysms of the internal carotid artery with flow diversion. Blister aneurysms are uncommon and fragile lesions that historically have high rates of morbidity and mortality despite multiple treatment strategies. We report a case of rebleeding after treatment of a ruptured blister aneurysm with deployment of a single FDS. CLINICAL PRESENTATION: A 29-year-old man presented with subarachnoid hemorrhage and a ruptured dorsal variant internal carotid artery aneurysm. Despite a technically successful treatment with a single FDS, a second catastrophic hemorrhage occurred during the course of his hospitalization. CONCLUSION: This case highlights the risk of hemorrhage during the period after deployment of a single FDS. Ruptured aneurysms, especially of the blister type, are at risk for rehemorrhage while the occlusion remains incomplete after flow diversion.

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