Ultrasound for the evaluation of stenosis after flow diversion

2017 ◽  
Vol 10 (3) ◽  
pp. 297-300 ◽  
Author(s):  
Cameron M McDougall ◽  
Khurshid Khan ◽  
Maher Saqqur ◽  
Andrew Jack ◽  
Jeremy Rempel ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Transcranial Doppler Ultrasound ◽  
Flow Diversion ◽  
Clinical Implications ◽  
Optimal Method ◽  
Pipeline Embolization Device ◽  
New Strategy ◽  
Flow Diverters ◽  
Stent Stenosis

Background and purposeFlow diversion is a relatively new strategy used to treat complex cerebral aneurysms. The optimal method for radiographic follow-up of patients treated with flow diverters has not been established. The rate and clinical implications of in-stent stenosis for these devices is unclear. We evaluate the use of transcranial Doppler ultrasound (TCD) for follow-up of in-stent stenosis.Materials and methodsWe analyzed 28 patients treated with the Pipeline embolization device (PED) over the course of 42 months from January 2009 to June 2012. Standard conventional cerebral angiograms were performed in all patients. TCD studies were available in 23 patients.ResultsAngiographic and TCD results were compared and found to correlate well.ConclusionsTCD is a potentially useful adjunct for evaluating in-stent stenosis after flow diversion.

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.

scholarly journals Update on flow diverters for the endovascular management of cerebral aneurysms

2017 ◽  
Vol 42 (6) ◽  
pp. E2 ◽  
Author(s):  
Gary Rajah ◽  
Sandra Narayanan ◽  
Leonardo Rangel-Castilla
Keyword(s):  
Treatment Effect ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Significant Treatment Effect ◽  
Endovascular Management ◽  
Significant Treatment ◽  
Future Directions ◽  
Pipeline Embolization Device ◽  
And Function ◽  
Flow Diverters

Flow diversion has become a well-accepted option for the treatment of cerebral aneurysms. Given the significant treatment effect of flow diverters, numerous options have emerged since the initial Pipeline embolization device studies. In this review, the authors describe the available flow diverters, both endoluminal and intrasaccular, addressing nuances of device design and function and presenting data on complications and outcomes, where available. They also discuss possible future directions of flow diversion.

scholarly journals Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel

2021 ◽  
Author(s):  
Ehsan Dowlati ◽  
Kory B. Dylan Pasko ◽  
Jiaqi Liu ◽  
Charles A. Miller ◽  
Daniel R. Felbaum ◽  
...  
Keyword(s):  
Dual Antiplatelet Therapy ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Vasodilatory Effect ◽  
Smooth Muscle Proliferation ◽  
Unruptured Cerebral Aneurysms ◽  
Treatment For Cerebral Aneurysms ◽  
Stent Stenosis

In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.

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.

Fate of the Ophthalmic Artery After Treatment With the Pipeline Embolization Device

Neurosurgery ◽  
2015 ◽  
Vol 77 (4) ◽  
pp. 581-584 ◽  
Author(s):  
Nohra Chalouhi ◽  
Badih Daou ◽  
David Kung ◽  
Mario Zanaty ◽  
Jessica L. Phillips ◽  
...  
Keyword(s):  
Ophthalmic Artery ◽  
Clinical Symptoms ◽  
Multivariable Analysis ◽  
Cerebral Aneurysms ◽  
Crucial Issue ◽  
Pipeline Embolization Device ◽  
Strong Trend ◽  
Younger Age ◽  
Flow Diverters

Abstract BACKGROUND: Flow diverters have emerged as a major tool in the treatment of cerebral aneurysms. A crucial issue with the use of flow diverters is the patency of side branches covered by the device, most importantly the ophthalmic artery (OA). OBJECTIVE: To assess the patency of the OA after coverage with the pipeline embolization device (PED). METHODS: All patients who had a PED covering the OA and in whom angiographic follow-up was available were included in the study. The patency of the OA at follow-up was systematically evaluated by 2 authors who were not involved in the procedure. RESULTS: Of 95 treated patients, the OA was covered by 1 PED in 81 patients (85%) and by 2 PEDs in 14 patients (15%). Mean angiographic follow-up was 7.5 months, ranging from 3 to 24 months. At the latest follow-up, the OA remained patent in 85 patients (89%), showed diminished flow in 4 patients (4%), and was occluded in 6 patients (7%). Only 1 patient had clinical symptoms related to OA occlusion. In multivariable analysis, larger aneurysm size predicted OA occlusion (P = .04). There was also a strong trend for younger age (P = .06) and coverage by more than 1 device (P = .07). CONCLUSION: Treatment of internal carotid artery aneurysms with the PED preserves the patency of the OA in most cases. The occlusion of the OA in the few cases where it occurs is usually a clinically irrelevant event. Minimizing the number of PEDs across the OA is crucial to preserve its patency.

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.

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.

scholarly journals Abciximab (ReoPro) Dosing Strategy for the Management of Acute Intraprocedural Thromboembolic Complications during Pipeline Flow Diversion Treatment of Intracranial Aneurysms

2018 ◽  
Vol 7 (5) ◽  
pp. 218-232 ◽  
Author(s):  
Li-Mei Lin ◽  
Bowen Jiang ◽  
Jessica K. Campos ◽  
Narlin B. Beaty ◽  
Matthew T. Bender ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Thrombus Formation ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Thromboembolic Complications ◽  
Limited Experience ◽  
Residual Thrombus ◽  
Dosing Strategy

Background: Flow diversion with the Pipeline embolization device (PED) is an effective neuro­endovascular method and increasingly accepted for the treatment of cerebral aneurysms. Acute in situ thrombosis is a known complication of PED procedures. There is limited experience in the flow diversion literature on the use of abciximab (ReoPro) for the management of acute thrombus formation in PED cases. Methods: Data were collected retrospectively on patients who received intra-arterial (IA) ReoPro with or without subsequent intravenous (IV) infusion during PED flow diversion treatment of intracranial aneurysms. Results: A total of 30 cases in patients with a mean age of 56.7 years (range 36–84) and a mean aneurysm size of 8.6 mm (range 2–25) were identified to have intraprocedural thromboembolic complications during PED treatment. IA ReoPro was administered in all cases, with 20 cases receiving increments of 5-mg boluses and 10 cases receiving a 0.125 mg/kg IA bolus (half cardiac dosing). Complete or partial recanalization was achieved in 100% of the cases. IV ReoPro infusion at 0.125 μg/kg/min for 12 h was administered postprocedurally in 22 cases with a residual thrombus. Postprocedurally, 18 patients were transitioned from clopidogrel (Plavix) to prasugrel (Effient). The majority of the cases (23/30; 77%) were discharged home. Periprocedural intracranial hemorrhage was noted in 2 cases (7%) and radiographic infarct was noted in 4 cases (13%), with an overall mortality of 0% at the time of initial discharge. Clinical follow-up was available for 28/30 patients. The average duration of follow-up was 11.7 months, at which time 23/28 (82%) of the patients had a modified Rankin Scale score of 0. Conclusions: IA ReoPro administration is an effective and safe rescue strategy for the management of acute intraprocedural thromboembolic complications during PED treatment. Using a dosing strategy of either 5-mg increments or a 0.125 mg/kg IA bolus (half cardiac dosing) can provide high rates of recanalization with low rates of hemorrhagic complications and long-term morbidity.

Flow Diversion for Intracranial Aneurysm Treatment: Trials Involving Flow Diverters and Long-Term Outcomes

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S36-S45 ◽  
Author(s):  
Bree Chancellor ◽  
Eytan Raz ◽  
Maksim Shapiro ◽  
Omar Tanweer ◽  
Erez Nossek ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Long Term Outcomes ◽  
Complex Aneurysms ◽  
Aneurysm Treatment ◽  
Endovascular Methods ◽  
Cure Rates ◽  
Flow Diverters

Abstract Flow diverters (FDs) have changed the management of brain aneurysms; not only for complex aneurysms (giant, fusiform and blister) refractory to conventional therapies, but also for unruptured lesions previously managed by traditional surgical or coil-based endovascular methods. Since 2011 when the PipelineTM Embolization Device (Medtronic) was cleared by the Food and Drug Administration for adults with large or giant wide-neck intracranial aneurysms of the internal carotid artery proximal to the posterior communicating segment, the role of flow diversion for aneurysm treatment has expanded—supported by favorably low complication and high cure rates compared with alternative treatments. Here we review the key clinical trials and the long term outcomes that have demonstrated safety and efficacy of minimized porosity endoluminal devices in the treatment of cerebral aneurysms.

scholarly journals Application of flow diverters in the treatment of aneurysms in the internal carotid artery bifurcation region

2020 ◽  
Vol 33 (4) ◽  
pp. 297-305
Author(s):  
Mostafa Mahmoud ◽  
Ahmed Farag ◽  
Mostafa Farid ◽  
Ahmed Elserwi ◽  
Amr Abdelsamad ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Case Reports ◽  
Therapeutic Option ◽  
Case Series ◽  
Flow Diversion ◽  
Occlusion Rate ◽  
Flow Diverters

Introduction The treatment of aneurysms in the internal carotid bifurcation region (ICABR), including aneurysms of the true internal carotid artery (ICA) terminus, those inclined on the proximal A1 or M1 segments or at the most distal pre-bifurcation (ICA) segment, is often challenging in microsurgical clipping and endovascular surgery. Few reports had discussed flow diversion as a therapeutic option for this group. Methods This was a retrospective study analysing flow diversion in treating ICABR aneurysms. Seven patients harbouring eight aneurysms in the ICABR were treated with flow diversion. Five aneurysms were inclined on the proximal A1 segment, and three were located at the most distal pre-bifurcation segment. Patients’ demographics, presentation, procedure technical description, angiographic and clinical follow-up were recorded. PubMed and Ovid MEDLINE were also reviewed for articles published in English, including case series or case reports, for ICABR aneurysms treated with flow diverters. Results All patients except one underwent angiographic follow-up. The Karman–Byrne occlusion scale was used to determine the occlusion rate. All six patients with documented angiographic follow-up had a class IV occlusion score. No permanent or transient neurological or non-neurological complications were encountered in this study. Conclusion Treating ICABR aneurysms using flow diversion is feasible, with a promising angiographic occlusion rate. Further studies are needed to analyse long-term clinical and angiographic results.

Sign in / Sign up

Export Citation Format

Share Document