E-028 Immediate procedural outcomes of high mesh-density flow diverter placement in the upper basilar artery/basilar apex for the treatment of cerebral aneurysms: experience with 15 consecutive SurpassTM flow diversion cases

Purpose: The flow diversion effect of an intracranial stent is closely related to its metal coverage rate (MCR). In this study, the flow diversion effects of Enterprise and low-profile visualized intraluminal support (LVIS) stents are compared with those of a Pipeline flow diverter, focusing on the MCR change. Moreover, the changes in the flow diversion effect caused by the additional manipulations of overlapping and compaction are verified using computational fluid dynamics (CFD) analysis.Methods: CFD analysis was performed using virtually generated stents mounted in an idealized aneurysm model. First, the flow diversion effects of single Enterprise, LVIS, and Pipeline devices were analyzed. The Enterprise and LVIS were sequentially overlapped and compared with a Pipeline, to evaluate the effect of stent overlapping. The effect of compacting a stent was evaluated by comparing the flow diversion effects of a single and two compacted LVIS with those of two overlapped, uncompacted LVIS and uncompacted and compacted Pipeline. Quantitative analysis was performed to evaluate the hemodynamic parameters of energy loss, average velocity, and inflow rate.Results: Statistically significant correlations were observed between the reduction rates of the hemodynamic parameters and MCR. The single LVIS without compaction induced a reduction in all the hemodynamic parameters comparable to those of the three overlapped Enterprise. Moreover, the two overlapped, uncompacted LVIS showed a flow diversion effect as large as that induced by the single uncompacted Pipeline. Compacted stents induced a better flow diversion effect than uncompacted stents. The single compacted LVIS induced a flow diversion effect similar to that induced by the two uncompacted LVIS or single uncompacted Pipeline.Conclusions: The MCR of a stent correlates with its flow diversion effect. Overlapping and compaction can increase the MCR of an intracranial stent and achieve a flow diversion effect as large as that observed with a flow diverter.

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Abstract 1122‐000158: Flow Diversion of Cerebral Aneurysms via Direct Carotid Artery Cutdown: A Case Series

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000158 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Yahia M Lodi ◽

Varun V Reddy ◽

Adam Cloud ◽

Zara T Lodi ◽

Ravi Pande

Keyword(s):

Carotid Artery ◽

Case Series ◽

Cerebral Aneurysms ◽

Flow Diverter ◽

Flow Diversion ◽

Vascular Surgeon ◽

Clinical Events ◽

History Of ◽

Severity Of The Disease ◽

Arch Aneurysm

Introduction : Flow diversion (FD) of the cerebral aneurysms (CA) are performed either by trans femoral or transradial approach. Safety and feasibility of an alternative option such as direct Carotid artery Cutdown (DCAC) and FD for the treatment of the CA in a situation when tradition approaches are not feasible is not well described. Methods : Retrospective review. Results : First patient; 67 years old man with history of hypertension, hyperlipidemia, smoking, and stenting of the aortic arch aneurysm was diagnosed with symptomatic bilateral ICA DSA buy a CT angiography. Right ICA DSA was in multi‐level extending from cervical carotid artery to the skull base measured 19 × 15 × 20 mm and the left was 16 × 9 × 22 mm. Considering the severity of the disease and the presence of symptoms, planned for a DCAC by vascular surgeon followed by FD by neurovascular surgeon (NES) in a staged fashion. A 6F sheath was placed from right common carotid artery (CCA) to right ICA by a vascular surgeon. A CAT5 catheter was navigated to the ICA beyond DSA. FD was achieved using Surpass streamline measuring 4 × 50 mm x2 and a 5 × 40 mm. The DCAC site was sutured by vascular surgeon and patient was extubated. Using similar techniques, Left‐sided DPA was repaired using 5 × 50 mm surpass streamline flow diverter in 3 months. Second patient; 75 years old women’s let ICA opththalmic (ICA‐O) aneurysm grown from 8 mm to 12 mm with headaches. TF and TR approaches failed, underwent DCAC and FD with pipeline flex (PF) 5 × 30 mm using phenom plus and phenom XT27 microcatheter. Third patient; 65 years old women with LICA‐0 9 mm symptomatic aneurysm with occlusions femoral and radial arteries due to smoking underwent FD with PF of 4 × 30 mm. There were no clinical events, first patient’s right ICA radiographic dissection was repaired by VS prior to extubation. Patients were discharged home in 48 hours with NIHSS 0 and achieved baseline mRS. Patients were continued full antiplatelets for six months followed by an 81 mg baby aspirin and 75 mg of clopidogrel. Follow‐up MR angiogram demonstrate complete obligations of the aneurysms without stenosis. Conclusions : Our case series demonstrate that DCAC for the FD of the intracranial aneurysm is feasible and safe when performed carefully and in coordination with a multidisciplinary team. Further studies are required.

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Transradial approach for flow diversion treatment of cerebral aneurysms: a multicenter study

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014620 ◽

2019 ◽

Vol 11 (8) ◽

pp. 796-800 ◽

Cited By ~ 29

Author(s):

Stephanie H Chen ◽

Brian M Snelling ◽

Sumedh Subodh Shah ◽

Samir Sur ◽

Marie Christine Brunet ◽

...

Keyword(s):

Carotid Artery ◽

Cerebral Aneurysms ◽

High Volume ◽

Flow Diverter ◽

Acute Angle ◽

Flow Diversion ◽

Left Internal Carotid Artery ◽

Access Site ◽

Transradial Approach ◽

Aneurysm Treatment

BackgroundThe transradial approach (TRA) to endovascular procedures decreases access site morbidity and mortality in comparison with the traditional transfemoral technique (TFA). Despite its improved safety profile, there is a concern that TRA is less favorable for neurointerventional procedures that require large coaxial systems to manage the small tortuous cerebral vessels.ObjectiveTo report our experience with TRA for flow diverter placement for treatment of unruptured cerebral aneurysms.MethodsWe performed a retrospective review of prospective institutional databases at two high-volume centers to identify 49 patients who underwent flow diversion for aneurysm treatment via primary TRA between November 2016 and November 2018. Patient demographics, procedural techniques, and clinical data were recorded.ResultsOf the 49 patients, 39 underwent successful flow diversion placement by TRA. Ten patients were converted to TFA after attempted TRA. There were no procedural complications. Reasons for failure included tortuosity in eight patients and severe radial artery spasm in two.ConclusionsIn the largest reported series to date of flow diverter deployment via TRA for aneurysm treatment, we demonstrate the technical feasibility and safety of the method. The most common reason for failure of TRA was an acute angle of left common carotid artery origin or left internal carotid artery tortuosity. Overall, our data suggest that increasing adoption of TRA is merited given its apparent equivalence to the current TFA technique and its documented reduction in access site complications.

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Angiographic assessment of the efficacy of flow diverter treatment for cerebral aneurysms

Interventional Neuroradiology ◽

10.1177/1591019919860829 ◽

2019 ◽

Vol 25 (6) ◽

pp. 655-663 ◽

Cited By ~ 4

Author(s):

Chander Sadasivan ◽

Ronak Dholakia ◽

Lissa Peeling ◽

Philipp Gölitz ◽

Arnd Doerfler ◽

...

Keyword(s):

Cerebral Aneurysms ◽

Flow Diverter ◽

Post Treatment ◽

Flow Diversion ◽

Data Set ◽

Predictive Values ◽

Density Curve ◽

Aneurysm Occlusion ◽

Time Density ◽

Flow Diverters

Background The recent growth of neuro-endovascular treatment has rekindled interest in the use of angiographic techniques for flow assessment. Aneurysm treatment with flow diverters is particularly amenable to such analysis. We analyze contrast time–density curves — recorded within aneurysms before (pre) and immediately after (post) flow diverter implantation to estimate six-month treatment outcomes. Methods Fifty-six patients with 65 aneurysms were treated with flow diverters at two institutions. A region of interest was drawn around the aneurysm perimeter in image sequences taken both pre and post angiography, and the temporal variation in grayscale intensity within the aneurysm (time–density curve) was recorded. Eleven parameters were quantified from each time–density curve. Aneurysm occlusion status was recorded six months post treatment. The change in parameters from pre to post treatment was statistically evaluated between aneurysm occluded and non-occluded groups. Results Of the 11 parameters, eight were significantly different before and immediately after flow diversion. Considering the entire data set, none of the parameters was statistically different between the occluded and non-occluded groups. However, subgroup analyses showed that four variables were significantly different between the aneurysm occluded and non-occluded groups. The sensitivity of these variables to predict aneurysm occlusion at six months ranged from 60% to 89%, while the specificity ranged from 55% to 70%. Conclusions Device-induced intra-aneurysmal flow alterations quantified by simple aneurysmal time–density curves can potentially be used to predict long-term outcomes of flow diversion. Large multi-center studies will be required to confirm these findings. Patient-to-patient variability in coagulation may need to be incorporated for clinically relevant predictive values.

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Indirect Flow Diversion for Off-Centered Bifurcation Aneurysms and Distant Small-Vessel Aneurysms, a Retrospective Proof of Concept Study From Five Neurovascular Centers

Frontiers in Neurology ◽

10.3389/fneur.2021.801470 ◽

2022 ◽

Vol 12 ◽

Author(s):

Stefan Schob ◽

Richard Brill ◽

Eberhard Siebert ◽

Massimo Sponza ◽

Marie-Sophie Schüngel ◽

...

Keyword(s):

Average Distance ◽

Cerebral Aneurysms ◽

Flow Diverter ◽

Flow Diversion ◽

Small Vessel ◽

Parent Vessel ◽

Therapeutic Success ◽

Subsequent Formation ◽

Procedural Complications

Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms–off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels–oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion–a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm–can be a viable treatment strategy, but clinical evidence is lacking in this regard.Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded.Results: Seventeen patients (mean age: 60.5 years, range: 35–77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4–2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case.Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted.

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An autopsy report of basilar artery aneurysm flow diversion complicated by postoperative day 3 hemorrhage from vessel rupture

BMJ Case Reports ◽

10.1136/bcr-2018-014511 ◽

2018 ◽

Vol 11 (1) ◽

pp. e014511 ◽

Cited By ~ 2

Author(s):

Azeem A Rehman ◽

Ryan C Turner ◽

Stephanie Wright ◽

SoHyun Boo ◽

Ansaar T Rai

Keyword(s):

Subarachnoid Hemorrhage ◽

Basilar Artery ◽

Artery Aneurysm ◽

Symptomatic Improvement ◽

Aneurysm Rupture ◽

Flow Diversion ◽

Atheromatous Plaque ◽

Parent Artery ◽

Autopsy Report ◽

Complete Procedure

A middle-aged patient presented with posterior circulation symptoms attributable to a large eccentric basilar trunk aneurysm. The planned treatment was flow diversion with loose coil packing which was successfully performed using a Pipeline Flex device deployed from the basilar to the left posterior cerebral artery. The complete procedure including live biplane fluoroscopy was digitally recorded. The patient had symptomatic improvement postoperatively and was discharged on day 1. The patient suffered a cardiac arrest on postoperative day 3 secondary to massive intraventricular and subarachnoid hemorrhage. An aneurysm rupture was suspected; however, postmortem examination showed an intact aneurysm sac. The hemorrhage was attributed to a small focal rent in the distal basilar artery next to an atheromatous plaque. The Pipeline device was visible through the rent. This is an autopsy report documenting an injury to the parent artery and not the aneurysm as a source of fatal delayed subarachnoid hemorrhage following flow diversion.

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Comparison of the In Vitro Hemodynamic Performance of New Flow Diverters for Bypass of Brain Aneurysms

Journal of Biomechanical Engineering ◽

10.1115/1.4006454 ◽

2012 ◽

Vol 134 (8) ◽

Cited By ~ 5

Author(s):

Asher L. Trager ◽

Chander Sadasivan ◽

Baruch B. Lieber

Keyword(s):

Cerebral Aneurysms ◽

Flow Diverter ◽

Parent Artery ◽

New Device ◽

Design Changes ◽

Hemodynamic Performance ◽

Braiding Angle ◽

Treatment For Cerebral Aneurysms

One possible treatment for cerebral aneurysms is a porous tubular structure, similar to a stent, called a flow diverter. A flow diverter can be placed across the neck of a cerebral aneurysm to induce the cessation of flow and initiate the formation of an intra-aneurysmal thrombus. This excludes the aneurysm from the parent artery and returns the flow of blood to normal. Previous flow diverting devices have been analyzed to determine optimal characteristics, such as braiding angle and wire diameter. From this information, a new optimized device was designed to achieve equivalent hemodynamic performance to the previous best device, but with better longitudinal flexibility to preserve physiological arterial configuration. The new device was tested in vitro in an elastomeric replica of the rabbit elastase induced aneurysm model and is now in the process of being tested in vivo. Particle image velocimetry was utilized to determine the velocity field in the plane of symmetry of the model under pulsatile flow conditions. Device hemodynamic performance indices such as the hydrodynamic circulation were evaluated from the velocity fields. Comparison of these indices with the previous best device and a control shows that the significant design changes of the device did not change its hemodynamic attributes (p > 0.05).

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Analysis of cerebrovascular aneurysm treatment cost: retrospective cohort comparison of clipping, coiling, and flow diversion

Neurosurgical FOCUS ◽

10.3171/2018.1.focus17775 ◽

2018 ◽

Vol 44 (5) ◽

pp. E3 ◽

Cited By ~ 12

Author(s):

Spencer Twitchell ◽

Hussam Abou-Al-Shaar ◽

Jared Reese ◽

Michael Karsy ◽

Ilyas M. Eli ◽

...

Keyword(s):

Health Care ◽

Intracranial Aneurysms ◽

Flow Diverter ◽

Flow Diversion ◽

High Quality ◽

Total Cost ◽

Cost Drivers ◽

Discharge Disposition ◽

Unruptured Intracranial Aneurysms ◽

Care Costs

OBJECTIVEWith the continuous rise of health care costs, hospitals and health care providers must find ways to reduce costs while maintaining high-quality care. Comparing surgical and endovascular treatment of intracranial aneurysms may offer direction in reducing health care costs. The Value-Driven Outcomes (VDO) database at the University of Utah identifies cost drivers and tracks changes over time. In this study, the authors evaluate specific cost drivers for surgical clipping and endovascular management (i.e., coil embolization and flow diversion) of both ruptured and unruptured intracranial aneurysms using the VDO system.METHODSThe authors retrospectively reviewed surgical and endovascular treatment of ruptured and unruptured intracranial aneurysms from July 2011 to January 2017. Total cost (as a percentage of each patient’s cost to the system), subcategory costs, and potential cost drivers were evaluated and analyzed.RESULTSA total of 514 aneurysms in 469 patients were treated; 273 aneurysms were surgically clipped, 102 were repaired with coiling, and 139 were addressed with flow diverter placements. Middle cerebral artery aneurysms accounted for the largest portion of cases in the clipping group (29.7%), whereas anterior communicating artery aneurysms were most frequently involved in the coiling group (30.4%) and internal carotid artery aneurysms were the majority in the flow diverter group (63.3%). Coiling (mean total cost 0.25% ± 0.20%) had a higher cost than flow diversion (mean 0.20% ± 0.16%) and clipping (mean 0.17 ± 0.14%; p = 0.0001, 1-way ANOVA). Coiling cases cost 1.5 times as much as clipping and flow diversion costs 1.2 times as much as clipping. Facility costs were the most significant contributor to intracranial clipping costs (60.2%), followed by supplies (18.3%). Supplies were the greatest cost contributor to coiling costs (43.2%), followed by facility (40.0%); similarly, supplies were the greatest portion of costs in flow diversion (57.5%), followed by facility (28.5%). Cost differences for aneurysm location, rupture status, American Society of Anesthesiologists (ASA) grade, and discharge disposition could be identified, with variability depending on surgical procedure. A multivariate analysis showed that rupture status, surgical procedure type, ASA status, discharge disposition, and year of surgery all significantly affected cost (p < 0.0001).CONCLUSIONSFacility utilization and supplies constitute the majority of total costs in aneurysm treatment strategies, but significant variation exists depending on surgical approach, rupture status, and patient discharge disposition. Developing and implementing approaches and protocols to improve resource utilization are important in reducing costs while maintaining high-quality patient care.

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Re-treatment of residual aneurysms after flow diversion: An experimental study

The Neuroradiology Journal ◽

10.1177/1971400918763198 ◽

2018 ◽

Vol 31 (3) ◽

pp. 270-279 ◽

Cited By ~ 1

Author(s):

Robert Fahed ◽

Tim E Darsaut ◽

Marc Kotowski ◽

Igor Salazkin ◽

Jean Raymond

Keyword(s):

Flow Diverter ◽

Artery Occlusion ◽

Flow Diversion ◽

Embolic Agent ◽

Parent Artery ◽

Arterial Lumen ◽

Parent Artery Occlusion ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Flow Diverters

Aim Flow diverters are increasingly used to treat aneurysms, but treatment is not always effective. The management of aneurysms that fail to occlude following flow diversion is problematic. We aimed to reproduce failures in an animal model and study re-treatment with additional flow diverters alone or with flow diverters and liquid embolic agent. Material and methods Twenty wide-necked aneurysms were created at the carotid-lingual bifurcation in 10 dogs, and were treated with flow diverters 4–6 weeks later. Follow-up angiography was performed at three months. Suitable residual aneurysms were randomly allocated: re-treatment with flow diverters alone ( n = 6), or with the injection of liquid embolic between two layers of flow diverters ( n = 4) or no re-treatment ( n = 2). Angiography was repeated three months later, followed by euthanasia, photography and pathology. Results Patent wide-necked aneurysms were produced in 17/20 attempts (85%); three months after flow diversion there were 15/17 (88%) residual aneurysms. In three cases, re-treatment was not possible because the flow diverter had prolapsed into the aneurysm, leaving 12 aneurysms to study. Re-treated aneurysms showed improved angiographic results at six months (median score of 2; P = 0.03), but residual aneurysms were present in all cases. Parent artery occlusion occurred in two aneurysms treated with flow diverter plus liquid embolic. At pathology, aneurysms were only partially filled with thrombus; leaks through the flow diverters were found in the neointima connecting the arterial lumen to residual aneurysms. Conclusion Re-treatment of residual flow-diverted experimental aneurysms with additional flow diverters did not lead to aneurysm occlusion.

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

Interventional Neurology ◽

10.1159/000486458 ◽

2018 ◽

Vol 7 (5) ◽

pp. 218-232 ◽

Cited By ~ 5

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.

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