Endovascular treatment of previously clipped aneurysms: continued evolution of hybrid neurosurgery

2016 ◽  
Vol 9 (2) ◽  
pp. 169-172 ◽  
Author(s):  
Bradley A Gross ◽  
Felipe C Albuquerque ◽  
Karam Moon ◽  
Andrew F Ducruet ◽  
Cameron G McDougall
Keyword(s):  
Endovascular Treatment ◽  
Treatment Approach ◽  
Flow Diversion ◽  
Digital Subtraction ◽  
Narrow Neck ◽  
Neurological Morbidity ◽  
Aneurysm Occlusion ◽  
Digital Subtraction Angiographic ◽  
Therapy Treatment

Background/objectiveThe optimal management of residual or recurrent clipped aneurysms is infrequently addressed in the literature.MethodsWe reviewed our endovascular database from January 1998 to May 2016 to identify patients with clipped aneurysms undergoing subsequent endovascular treatment, evaluating treatment approach, and clinical and angiographic outcomes.Results60 patients underwent endovascular treatment of residual/recurrent clipped aneurysms; 7 rebled prior to endovascular therapy. Treatment was via coiling alone (n=25, 42%), stent assisted coiling (n=15, 25%), balloon assisted coiling (n=8, 13%), flow diversion (n=8, 13%), stenting alone (n=3, 5%), or flow diversion with coiling (n=1, 2%). The procedural permanent neurological morbidity and mortality rates were 3% and 2%, respectively. Over a clinical follow-up of 253.4 patient years (median 3.9 years), there was one rebleed in a patient who had declined further treatment. For 43 patients with at least 1 month of digital subtraction angiographic follow-up (median 3.4 years), complete aneurysm occlusion was seen in 79% of cases. Neck remnants were observed in 14%, and stable small dome remnants were observed in 7% of cases. In a subgroup of 18 patients with ‘clip induced’ narrow neck aneurysms, all domes were initially coil occluded (Raymond 1 or 2); there was no permanent procedural morbidity and no aneurysms required retreatment or recanalized over a median follow-up of 3.9 years.ConclusionsEndovascular treatment of residual or recurrent clipped aneurysms is an excellent treatment approach in well selected patients; ‘clip induced’ narrow neck aneurysms fare particularly well after treatment both angiographically and clinically.

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

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.

125 Staged Endovascular Treatment of Ruptured Intracranial Aneurysms: Acute Coiling Followed By Delayed Flow Diversion

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 228-228
Author(s):  
Erick Michael Westbroek ◽  
Matthew Bender ◽  
Narlin B Beaty ◽  
Bowen Jiang ◽  
Risheng Xu AB ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Complication Rate ◽  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Major Complication ◽  
Flow Diversion ◽  
Neurological Deficits ◽  
Major Complication Rate ◽  
Ruptured Intracranial Aneurysms

Abstract INTRODUCTION ISAT demonstrated that coiling is effective for aneurysm treatment in subarachnoid hemorrhage (SAH); however, complete occlusion of wide-necked aneurysms frequently requires adjuvants relatively contraindicated in SAH. As such, a limited “dome occlusive” strategy is often pursued in the setting of SAH. We report a single institution series of coiling of acutely ruptured aneurysms followed by delayed flow diversion for definitive, curative occlusion. METHODS A prospectively collected IRB-approved database was screened for patients with aneurysmal SAH who were initially treated by coil embolization followed by planned flow diversion at a single academic medical institution. Peri-procedural outcomes, complications, and angiographic follow-up were analyzed. RESULTS >50 patients underwent both acute coiling followed by delayed, planned flow diversion. Average aneurysm size on initial presentation was 9.5 mm. Common aneurysm locations included Pcomm (36%), Acomm (30%), MCA (10%), ACA (10%), and vertebral (5%). Dome occlusion was achieved in all cases following initial coiling. Second-stage implantation of a flow diverting stent was achieved in 49/50 cases (98%). Follow-up angiography was available for 33/50 patients (66%), with mean follow-up of 11 months. 27 patients (82%) had complete angiographic occlusion at last follow up. All patients with residual filling at follow-up still had dome occlusion. There were no mortalities (0%). Major complication rate for stage I coiling was 2% (1 patient with intra-procedural aneurysm re-rupture causing increase in a previous ICH). Major complication rate for stage 2 flow diversion was 2% (1 patient with ischemic stroke following noncompliance with dual antiplatelet regimen). Minor complications occurred in 2 additional patients (4%) with transient neurological deficits. CONCLUSION Staged endovascular treatment of ruptured intracranial aneurysms with acute dome-occlusive coil embolization followed by delayed flow diversion is a safe and effective treatment strategy.

scholarly journals Pipeline embolization device retraction and foreshortening after internal carotid artery blister aneurysm treatment

2017 ◽  
Vol 23 (6) ◽  
pp. 614-619 ◽  
Author(s):  
Jeremy J Heit ◽  
Nicholas A Telischak ◽  
Huy M Do ◽  
Robert L Dodd ◽  
Gary K Steinberg ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
High Morbidity ◽  
Case Description ◽  
Digital Subtraction ◽  
Pipeline Embolization Device ◽  
Aneurysm Occlusion ◽  
New Treatment

Background Subarachnoid hemorrhage (SAH) secondary to rupture of a blister aneurysm (BA) results in high morbidity and mortality. Endovascular treatment with the pipeline embolization device (PED) has been described as a new treatment strategy for these lesions. We present the first reported case of PED retraction and foreshortening after treatment of a ruptured internal carotid artery (ICA) BA. Case description A middle-aged patient presented with SAH secondary to ICA BA rupture. The patient was treated with telescoping PED placement across the BA. After 5 days from treatment, the patient developed a new SAH due to re-rupture of the BA. Digital subtraction angiography revealed an increase in caliber of the supraclinoid ICA with associated retraction and foreshortening of the PED that resulted in aneurysm uncovering and growth. Conclusions PED should be oversized during ruptured BA treatment to prevent device retraction and aneurysm regrowth. Frequent imaging follow up after BA treatment with PED is warranted to ensure aneurysm occlusion.

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

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.

Detection of the Residual Lumen of Intracranial Aneurysms Immediately after Coil Embolization by Three-dimensional Digital Subtraction Angiographic Virtual Endoscopic Imaging

Neurosurgery ◽  
2002 ◽  
Vol 50 (3) ◽  
pp. 476-485 ◽  
Author(s):  
Hiro Kiyosue ◽  
Mika Okahara ◽  
Shuichi Tanoue ◽  
Takaharu Nakamura ◽  
Hirofumi Nagatomi ◽  
...  
Keyword(s):  
Coil Embolization ◽  
Intracranial Aneurysms ◽  
Cerebral Arteries ◽  
Three Dimensional ◽  
Digital Subtraction ◽  
Aneurysm Volume ◽  
Digital Subtraction Angiographic ◽  
Incomplete Occlusion ◽  
Coil Volume

Abstract OBJECTIVE: Detection of a small residual lumen after coil embolization is often difficult because of the coil mass and the overlap of the cerebral arteries. The purpose of this study was to assess the usefulness of virtual endoscopic (VE) analysis of three-dimensional digital subtraction angiographic (DSA) images for evaluation of aneurysmal occlusion immediately after the procedure. METHODS: Twenty-seven intracranial aneurysms were treated with coil embolization using a three-dimensional DSA system. Biplane and rotational DSA scanning was performed before and immediately after the procedures. VE images were obtained at a separate workstation, after transfer of the rotational images. Two-dimensional (2D) DSA images and VE images obtained after the procedure were assessed with respect to aneurysmal occlusion. Morphological outcomes and other factors, including location, size, volumetric ratio (coil volume/aneurysm volume), and residual sites, were also evaluated. RESULTS: Seven aneurysms were evaluated as complete occlusion (CO) on both 2D DSA images and VE images. Twelve aneurysms exhibited residual lumina on both 2D DSA images and VE images. Five aneurysms were evaluated as CO on 2D DSA images and as incomplete occlusion on VE images. There were no recurrences among the aneurysms that were evaluated as CO on VE images. Two of five aneurysms that were evaluated as CO on 2D DSA images and as incomplete occlusion on VE images demonstrated regrowth in follow-up examinations. Residual sites and volumetric ratios were correlated with aneurysmal regrowth. CONCLUSION: VE imaging can demonstrate a residual lumen more frequently than can 2D DSA imaging and is useful for evaluating aneurysmal occlusion after coil embolization.

Single-center experience with the new generation Derivo Embolization Device in ruptured dissecting and blister aneurysms

2019 ◽  
Vol 61 (1) ◽  
pp. 37-46 ◽  
Author(s):  
Marius Georg Kaschner ◽  
Athanasios Petridis ◽  
Bernd Turowski
Keyword(s):  
Digital Subtraction Angiography ◽  
Flow Diverter ◽  
High Morbidity ◽  
Digital Subtraction ◽  
Related Complication ◽  
Single Center Experience ◽  
Flow Diverter Stent ◽  
Aneurysm Occlusion ◽  
New Generation

Background Treatment of ruptured dissecting and blister aneurysms is technically challenging with potentially high morbidity and mortality. The Derivo Embolisation Device (Derivo) is a flow diverter stent designed for the treatment of intracranial aneurysms. Purpose To assess the safety and feasibility of the Derivo in the treatment of ruptured dissecting and blister aneurysms. Material and Methods We retrospectively analyzed all patients with ruptured dissecting and blister aneurysms treated with the Derivo between February 2016 and July 2018. Procedural details, complications, morbidity within 30 days, and angiographic aneurysm occlusion rates, initially and after six months, were assessed. Results In 10 patients 11 ruptured dissecting and blister aneurysms were treated with 12 Derivos as monotherapy. No aneurysm rebleeding was observed at follow-up. One treatment-related complication occurred including a coil perforation of an additionally treated aneurysm. One patient died due to brain edema. Initial digital subtraction angiography revealed complete (O’Kelly–Marotta [OKM] classification D) and favorable (OKM D+C) occlusion rate in three aneurysms. Six-month follow-up for digital subtraction angiography and clinical evaluation was available in 6/9 patients with complete (OKM D) occlusion in all aneurysms (6/6). Favorable (modified Rankin Scale [mRS] ≤ 2) and moderate (mRS 3) clinical outcome after a mean follow-up of 10 months was observed in six and two patients, respectively. Conclusion Endovascular treatment with the Derivo in ruptured dissecting and blister aneurysms revealed a sufficient initial division of aneurysms from the circulation without rebleeding. The Derivo is associated with high procedural and clinical short-term safety.

scholarly journals Endovascular treatment of intracranial ‘blister’ and dissecting aneurysms

2019 ◽  
Vol 32 (5) ◽  
pp. 353-365 ◽  
Author(s):  
Marius G Kaschner ◽  
Bastian Kraus ◽  
Athanasios Petridis ◽  
Bernd Turowski
Keyword(s):  
Endovascular Treatment ◽  
Favourable Outcome ◽  
Modified Rankin Scale ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Parent Vessel Occlusion ◽  
Aneurysm Occlusion ◽  
Vessel Reconstruction ◽  
Dissecting Aneurysms

IntroductionBlister and dissecting aneurysms may have a different pathological background but they are commonly defined by instability of the vessel wall and bear a high risk of fatal rupture and rerupture. Lack of aneurysm sack makes treatment challenging.PurposeThe purpose of this study was to assess the safety and feasibility of endovascular treatment of intracranial blister and dissecting aneurysms.MethodsWe retrospectively analysed all patients with ruptured and unruptured blister and dissecting aneurysms treated endovascularly between 2004–2018. Procedural details, complications, morbidity/mortality, clinical favourable outcome (modified Rankin Scale ≤2) and aneurysm occlusion rates were assessed.ResultsThirty-four patients with endovascular treatment of 35 aneurysms (26 dissecting aneurysms and 9 blister aneurysms) were included. Five aneurysms were treated by parent vessel occlusion, and 30 aneurysms were treated by vessel reconstruction using stent monotherapy ( n = 9), stent-assisted coiling ( n = 7), flow diverting stents ( n = 13) and coiling + Onyx embolization ( n = 1). No aneurysm rebleeding and no procedure-related major complications or deaths occurred. There were five deaths in consequence of initial subarachnoid haemorrhage. Complete occlusion (79.2%) was detected in 19/24 aneurysms available for angiographic follow-up, and aneurysm recurrence in 2/24 (8.3%). The modified Rankin Scale ≤2 rate at mean follow-up of 15.1 months was 64.7%.ConclusionTreatment of blister and dissecting aneurysms developed from coil embolization to flow diversion with multiple stents to the usage of flow diverting stents. Results using modern flow diverting stents encourage us to effectively treat this aneurysm entity endovascularly by vessel reconstruction. Therefore, we recommend preference of vessel reconstructive techniques to parent vessel occlusion.

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

2018 ◽  
Vol 22 (5) ◽  
pp. 532-540 ◽  
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.

scholarly journals Endovascular treatment of blister aneurysms

2017 ◽  
Vol 42 (6) ◽  
pp. E12 ◽  
Author(s):  
Geoffrey W. Peitz ◽  
Christopher A. Sy ◽  
Ramesh Grandhi
Keyword(s):  
Endovascular Treatment ◽  
Treatment Options ◽  
Flow Diversion ◽  
Success Rates ◽  
Cerebrovascular Lesions ◽  
Promising Alternative ◽  
Treatment Methods ◽  
Aneurysm Occlusion ◽  
Open Surgical Treatment ◽  
Reconstructive Methods

Blister aneurysms are rare cerebrovascular lesions for which the treatment methods are reviewed here, with a focus on endovascular options. The reported pathogenesis of blister aneurysms varies, and hemodynamic stress, arterial dissection, and arteriosclerotic ulceration have all been described. There is consensus on the excessive fragility of blister aneurysms and their parent vessels, which makes clipping technically difficult. Open surgical treatment is associated with high rates of complications, morbidity, and mortality; endovascular treatment is a promising alternative. Among endovascular treatment options, deconstructive treatment has been associated with higher morbidity compared with reconstructive methods such as direct embolization, stent- or balloon-assisted direct embolization, stent monotherapy, and flow diversion. Flow diversion has been associated with higher technical success rates and similar clinical outcomes compared with non–flow diverting treatment methods. However, delayed aneurysm occlusion and the need for antiplatelet therapy are potential drawbacks to flow diversion that must be considered when choosing among treatment methods for blister aneurysms.

scholarly journals Residuals, recurrences and re-treatment after endovascular repair of intracranial aneurysms: A retrospective methodological comparison

2019 ◽  
Vol 26 (1) ◽  
pp. 45-54 ◽  
Author(s):  
Jens J Froelich ◽  
Nicholas Cheung ◽  
Johan AB de Lange ◽  
Jessica Monkhorst ◽  
Michael W Carr ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Medical Records ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Flow Diversion ◽  
Unruptured Aneurysms ◽  
Ruptured Aneurysms ◽  
Unruptured Intracranial Aneurysms ◽  
Methodological Comparison

Objective Incomplete aneurysm occlusions and re-treatment rates of 52 and 10–30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia. Methods Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion. Results Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05). Conclusions Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.

Sign in / Sign up

Export Citation Format

Share Document