Progressive Deconstruction: A Novel Aneurysm Treatment Using the Pipeline Embolization Device for Competitive Flow Diversion: Case Report

2013 ◽  
Vol 10 (1) ◽  
pp. E161-E166 ◽  
Author(s):  
Eduardo Wajnberg ◽  
Thiago S. Silva ◽  
Andrew K. Johnson ◽  
Demetrius K. Lopes
Keyword(s):  
Giant Aneurysm ◽  
Flow Diverter ◽  
Balloon Occlusion ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Pipeline Embolization Device ◽  
Aneurysm Treatment ◽  
Neurologically Intact

Abstract BACKGROUND AND IMPORTANCE: A variety of deconstructive and reconstructive therapies have been used to treat intracranial aneurysms. The Pipeline embolization device (PED) has become a quite successful option to treat aneurysms, while reconstructing and remodeling the parent vessel. We report a case of off-label PED use, where a flow diverter was placed across the parent vessel of a giant intracranial aneurysm in a novel deconstructive strategy. CLINICAL PRESENTATION: A 40-year-old man with a giant, slow-flow aneurysm of the distal middle cerebral artery (MCA) was treated with the placement of a PED across the vessel containing the aneurysm after superselective test balloon occlusion of that vessel failed. PED was successfully deployed in a competing MCA branch across the origin of the MCA branch supplying the giant aneurysm. The patient continued dual-antiplatelet therapy for 5 months and aspirin monotherapy thereafter. Follow-up angiography, performed 6 months after treatment, demonstrated complete and asymptomatic thrombosis of the aneurysm and its parent MCA branch. A collateral pial and leptomeningeal network developed, reconstructing the distal branches of the occluded MCA branch. After 18 months, the patient remains neurologically intact. CONCLUSION: This appears to be the first description of progressive deconstruction for aneurysm treatment by using PED. Despite not tolerating acute vessel occlusion with superselective test balloon occlusion, the patient was asymptomatic following long-term occlusion with PED secondary to the growth of pial and leptomeningeal collateral networks.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

Treatment of a Basilar Trunk Perforator Aneurysm With the Pipeline Embolization Device

Neurosurgery ◽  
2014 ◽  
Vol 74 (6) ◽  
pp. E697-E701 ◽  
Author(s):  
Nohra Chalouhi ◽  
Pascal Jabbour ◽  
Robert M. Starke ◽  
Mario Zanaty ◽  
Stavropoula Tjoumakaris ◽  
...  
Keyword(s):  
Clinical Presentation ◽  
Endovascular Coiling ◽  
Complete Disappearance ◽  
Parent Vessel ◽  
Pipeline Embolization Device ◽  
Microsurgical Clipping ◽  
First Case ◽  
Flow Through ◽  
Neurologically Intact

ABSTRACT BACKGROUND AND IMPORTANCE: Basilar trunk perforator (BTP) aneurysms are rare lesions that pose significant challenges to microsurgical clipping and endovascular coiling. We present the intriguing case of a ruptured BTP aneurysm that was successfully treated with the Pipeline Embolization Device (PED). CLINICAL PRESENTATION: An elderly woman presenting with subarachnoid hemorrhage was found to have a 1.5-mm aneurysm arising from the proximal portion of a thin midbasilar perforator. The decision was made to treat this aneurysm with flow diversion in an attempt to preserve the patency of the perforator and to avoid the hazards associated with parent vessel trapping. A 3 × 12-mm PED was successfully deployed in the basilar trunk across the neck of the aneurysm, causing stasis in the aneurysm, with continuous flow through the parent vessel. The procedure and postoperative course were uneventful. A follow-up angiogram 2 weeks later showed complete disappearance of the aneurysm with preservation of the patency of the perforator. At the 6-month follow-up, the patient was asymptomatic and remained neurologically intact. CONCLUSION: We present the first case of a BTP aneurysm treated with the PED. The aneurysm was successfully occluded, and the patency of the feeding vessel was preserved. In light of the limitations of coiling and the hazards associated with microsurgery and parent vessel trapping, the PED may be a valuable option for BTP aneurysms.

scholarly journals Pipeline Embolization Device for Pericallosal Artery Aneurysms: A Retrospective Single Center Safety and Efficacy Study

2017 ◽  
Vol 14 (4) ◽  
pp. 351-358 ◽  
Author(s):  
Katyucia De Macedo Rodrigues ◽  
Anna Luisa Kühn ◽  
Takamitsu Tamura ◽  
Guilherme Dabus ◽  
Peter Kan ◽  
...  
Keyword(s):  
Artery Aneurysm ◽  
Flow Diverter ◽  
Pipeline Embolization Device ◽  
Pericallosal Artery ◽  
Flow Diverter Stent ◽  
Procedural Complication ◽  
Aneurysm Occlusion ◽  
Flow Diverters

Abstract BACKGROUND Pericallosal artery aneurysm treatment may be challenging using traditional endovascular techniques. OBJECTIVE To demonstrate the feasibility, efficacy, and safety of endovascular treatment of pericallosal artery aneurysm using flow diverters. METHODS We performed a retrospective review of our institutional database from July 2013 through July 2016 and identified 7 subjects with a pericallosal artery aneurysm treated with the Pipeline embolization device (ev3 Neurovascular, Medtronic, Dublin, Ireland) and at least 1 follow-up angiogram. Technical feasibility, procedural complication, angiographic results, and clinical outcome were evaluated. RESULTS Placement of the Pipeline embolization device was successful in all cases without evidence of procedural complication. Five out of 7 subjects showed a complete aneurysm occlusion at 6- to 12-mo follow-up angiogram. The 2 subjects with persistent aneurysm filling showed decreased aneurysm sac volume on follow-up angiograms (96% and 60%). There was no evidence of in-implant stenosis or intimal hyperplasia. No thromboembolic or hemorrhagic complications were seen during the follow-up period. Only 1 patient had a transient change in Modified Rankin scale score from baseline as a result of different unrelated procedure. CONCLUSION Our preliminary results demonstrate feasibility of the use of flow diverter stent for treatment of aneurysms of the pericallosal artery with rate of aneurysm occlusion comparable to literature and without evidence of increased procedural or short-term morbidity. A long-term and larger cohort study is needed to validate our findings.

scholarly journals Sole Stenting with Large Cell Stents for Very Small Ruptured Intracranial Aneurysms

2014 ◽  
Vol 20 (1) ◽  
pp. 45-53 ◽  
Author(s):  
Young-Joon Kim ◽  
Jung HO Ko
Keyword(s):  
Intracranial Aneurysms ◽  
Large Cell ◽  
Bleeding Complications ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Ruptured Intracranial Aneurysms ◽  
Small Aneurysms ◽  
Flow Diverting Stent

A flow-diverting stent such as the Pipeline embolization device (PED, ev3 Endovascular, Plymouth, MN, USA) and Silk flow-diverting stent (Balt Extrusion, Montmorency, France) offers an acceptable alternative for the treatment of difficult aneurysms according to their morphologies, including giant, wide-necked, fusiform, and blister types. However, complications arising from the use of these stents have frequently been reported including several cases of branch artery occlusion and delayed occlusion of the stented parent vessel shortly after antiplatelet medications were discontinued, highlighting the potential need for long-term antiplatelet therapy, and disastrous bleeding complications in unruptured aneurysm. In addition, these microcell stents are difficult to use in distal aneurysms located over the ICA bifurcation and basilar tip because of the stiffness of the device, and perforating vessel occlusion is more likely to occur due to the characteristics of the stent. Before the era of flow-diverting microcell stents, large cell intracranial stents like the Neuroform stent (Boston Scientific/Target Therapeutic, Fremont, CA, USA) and Enterprise stent (Cordis Neurovascular, Miami, FL, USA) without coiling were used to provide flow-diverting effects for complex intracranial aneurysms. Sole stenting has been used even in cases of ruptured aneurysm, with patients on different antiplatelet medications. However, no single endovascular institute has embraced sole stenting using large cell intracranial stents as a systemized treatment for ruptured intracranial aneurysms. Here we designed this study to evaluate the possibility of safely treating very small aneurysms using one or two stents without coiling during the period of subarachnoid hemorrhage (SAH). This retrospective study was conducted with eight patients who had rupture of very small intracranial aneurysms (less than 3 mm in size). All were treated using the Neuroform and the Enterprise stents; there was single stenting in five, in-stent telescopic stenting in two, and Y-configured stenting in one. The angiographic results with clinical outcomes were collected and analyzed. Complete aneurysm obliteration was observed in three cases, and size reduction or stable angiographic findings was found in five cases on the last follow-up angiography. No growing aneurysm or rebleeding was found on any follow-up angiography. Thromboembolic complications were found in one patient. It is difficult to make conclusions on the long-term efficacy of this technique with such a small number of cases, however sole stenting with a large cell intracranial stent for the treatment of very small aneurysms may be used safely as an alternative treatment even during an episode of SAH.

Giant Aneurysm Clipping Under Protection of an Excimer Laser–Assisted Non-occlusive Anastomosis Bypass

Neurosurgery ◽  
2010 ◽  
Vol 66 (3) ◽  
pp. 439-447 ◽  
Author(s):  
Tristan P. C. van Doormaal ◽  
Albert van der Zwan ◽  
Bon H. Verweij ◽  
Luca Regli ◽  
Cornelis A. F. Tulleken
Keyword(s):  
Excimer Laser ◽  
Giant Aneurysm ◽  
Aneurysm Rupture ◽  
Hemorrhagic Complication ◽  
Clinical Value ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Recipient Artery ◽  
Aneurysm Clipping

Abstract OBJECTIVE To define the safety and clinical value of giant aneurysm clipping under protection of an excimer laser–assisted non-occlusive anastomosis (ELANA) bypass. METHODS We report 32 patients with an uncoilable intracerebral giant aneurysm, operated on with the aid of an ELANA protective bypass between January 1, 1994, and January 1, 2008. We retrospectively collected data from patient records. Follow-up data were updated by telephone interview. We defined a favorable outcome as a successfully treated aneurysm and a better or equal postoperative modified Rankin scale (mRS) score compared with the preoperative mRS. RESULTS In total 33 bypasses were constructed, of which 31 (94%) were patent during the rest of the procedure. The first failed bypass was salvaged during a second procedure. Of the second failed bypass, the ELANA anastomosis could be reused during second bypass surgery. All 32 aneurysms could be treated. The bypasses served as protection during temporary parent vessel occlusion (n = 24, 75%), control during aneurysm rupture (n = 3, 9%), and in all patients as an indicator for recipient artery narrowing during clip placement. Four bypasses (12%) eventually had to partially (n = 3) or fully (n = 1) replace recipient artery flow at the end of surgery. Postoperatively, 3 patients (9%) had a hemorrhagic complication and 2 patients (6%) had an ischemic complication. At long-term follow-up (mean, 6.1 ± 3.4 y), 28 patients (88%) had a favorable functional outcome. CONCLUSION The ELANA protective bypass is a safe and useful instrument for the treatment of these difficult aneurysms.

scholarly journals Microsurgical Treatment of Pediatric Intracranial Aneurysms

Neurosurgery ◽  
2010 ◽  
Vol 67 (2) ◽  
pp. 237-250 ◽  
Author(s):  
Udaya K. Kakarla ◽  
Elisa J. Beres ◽  
Francisco A. Ponce ◽  
Steven W. Chang ◽  
Vivek R. Deshmukh ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Intracranial Aneurysms ◽  
De Novo ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Circulatory Arrest ◽  
Morbidity Rate ◽  
Parent Vessel ◽  
Vessel Occlusion

Abstract BACKGROUND Pediatric aneurysms are rare and complex to treat. Long-term angiographic and clinical data after microsurgical or endovascular therapies are lacking. OBJECTIVE To study the clinical and radiographic outcomes in aneurysms in pediatric patients treated with microsurgery. METHODS Between 1989 and 2005, 48 patients ≤ 18 years of age (28 boys, 20 girls; mean age, 12.3 years) were treated for intracranial aneurysms. Patient charts were reviewed retrospectively for age, presentation, type and location of aneurysm(s), surgical approach, complications, and clinical and angiographic outcomes. Rates of aneurysm recurrence and de novo formation were calculated. RESULTS Seventy-two aneurysms were treated. Presentations included incidental aneurysm (35%), aneurysmal subarachnoid hemorrhage (17%), stroke (13%), and traumatic subarachnoid hemorrhage (10%). Location was anterior circulation in 76% and posterior circulation in 24%. Twenty-eight (39%) were fusiform/dissecting, and 16 (23%) were giant. Most aneurysms were clipped directly. A vascular bypass with parent-vessel occlusion was used to treat 13 aneurysms (18%). Hypothermic circulatory arrest was used to treat 10 aneurysms (14%), all involving the basilar artery. The perioperative morbidity rate was 25%. There were no deaths. The long-term morbidity rate was 14%, and the mortality rate was 3%. Clinical outcome was favorable in 92% and 94% at discharge and follow-up, respectively (mean, 59 months; median, 32 months). At angiographic follow-up (mean, 53 months; median, 32 months), the annual recurrence rate was 2.6%, and the annual rate of de novo formation or growth was 7.8%. CONCLUSION Pediatric aneurysms require complex microsurgical techniques to achieve favorable outcomes. They leave higher rates of recurrence and de novo formation or growth than their adult counterparts, which mandates lifelong follow-up.

The ARTISSE intrasaccular device for intracranial aneurysm treatment: short-term, mid-term and long-term clinical and angiographic results

2021 ◽  
pp. neurintsurg-2021-017806
Author(s):  
Michel Piotin ◽  
Robert Fahed ◽  
Hocine Redjem ◽  
Stanislas Smajda ◽  
Jean Philippe Desilles ◽  
...  
Keyword(s):  
Hemorrhagic Stroke ◽  
New Paradigm ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Parent Vessel Occlusion ◽  
Aneurysm Occlusion ◽  
Permanent Neurological Deficit ◽  
Major Stroke

BackgroundThe concept of intra-aneurysmal flow disruption has emerged as a new paradigm for the treatment of primarily bifurcation aneurysms. The purpose of this study was to determine the clinical and angiographic outcomes of patients treated with the new ARTISSE intrasaccular device (ISD).MethodsSelected patients with bifurcation aneurysms that matched the indications of the ARTISSE ISD defined by the manufacturer were treated in a single center. Clinical and angiographic follow-up was conducted at 6 and 36 months. Aneurysm occlusion was assessed using the Raymond–Roy classification scale.ResultsNine subjects with nine unruptured bifurcation aneurysms were enrolled. Mean aneurysm size was 7.2±1.2 mm (range 5.5–9.7 mm). An adequate aneurysm occlusion (defined as a complete occlusion or a neck remnant) was achieved in 6/9 patients (66.7%) at 6 months and 4/7 patients (57.1%) at 36 months follow-up. Two of the nine subjects experienced a major stroke (22.2%), including one on postoperative day 1 due to a procedure-related parent vessel occlusion and subsequent ischemic stroke. The other major stroke occurred within the 36-month follow-up period during treatment of a separate aneurysm with coils, leading to perforation with hemorrhagic stroke causing a permanent neurological deficit.ConclusionThe ARTISSE ISD was successfully deployed in all nine cases. There were, however, several procedure-related complications and results in terms of angiographic aneurysm occlusion were modest.

Middle cerebral artery aneurysms in children: case series and review

2011 ◽  
Vol 8 (1) ◽  
pp. 79-89 ◽  
Author(s):  
Daniel H. Fulkerson ◽  
Jason M. Voorhies ◽  
Troy D. Payner ◽  
Thomas J. Leipzig ◽  
Terry G. Horner ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Case Series ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Initial Surgery ◽  
Operative Notes ◽  
Middle Cerebral Artery Aneurysms

Object Pediatric intracranial aneurysms are rare lesions that differ from their adult counterparts. Aneurysms involving the middle cerebral artery (MCA) are particularly challenging to treat in children, as they are often fusiform and cannot undergo direct clipping alone. The authors recently treated a patient with a heavily calcified, dysplastic, left-sided MCA aneurysm. The present study was performed to evaluate the authors' previous operative and follow-up experience with these difficult lesions. Methods The authors performed a review of a prospectively maintained database of all aneurysms treated at Methodist Hospital in Indianapolis, Indiana, from January 1990 through November 2010. Relevant operative notes, clinical charts, and radiological reports were reviewed for all patients 18 years of age or younger. Results A total of 2949 patients with aneurysms were treated over the study period, including 28 children (0.95%). Seven children harbored MCA aneurysms. Five of these 7 aneurysms (71.4%) were fusiform. Two patients were treated with direct clipping, 2 underwent parent vessel occlusion without bypass, and 3 underwent aneurysm trapping with extracranial-intracranial vessel bypass. Long-term follow-up data were available in 6 cases. All 6 patients had a 1-year follow-up Glasgow Outcome Scale score of 5. Long-term radiological follow-up was available in 4 patients. One patient required a reoperation for a recurrent aneurysm 4 years after the initial surgery. Conclusions Middle cerebral artery aneurysms in children are often fusiform, giant, and incorporate the origins of proximal artery branches. Direct clipping may not be possible; trapping of the lesion may be required. Children seem to tolerate surgical trapping with or without bypass extremely well. Aggressive therapy of these rare lesions in children is warranted, as even patients presenting with a poor clinical grade may have excellent outcomes. Long-term surveillance imaging is necessary because of the risk of aneurysm recurrence.

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