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.

Short – term outcomes of flow diverter stent (Pipeline) for treatment intracranial aneurysms

2022 ◽  
Vol 35 ◽  
pp. 205-211
Author(s):  
Hoang Van
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
High Rate ◽  
Consecutive Series ◽  
Parent Vessel ◽  
Stent Patency ◽  
Surgical Clip ◽  
Flow Diverter Stent

Background: With the approval of detachable coils in 1995, endovascular treatment of intracranial aneurysms has become an alternative to surgical clip ligation. Despite the introduction of “modified” coils and advanced techniques such as stent-assisted and balloon-assisted coiling, coil embolization has major limitations because of inability to completely and permanently occlude all aneurysms. As stents were being developed for intracranial use, it was hypothesized that stents could be utilized to divert flow “away” from the aneurysm “back” into the parent vessel, and the concept of “endovascular flow diversion” was proposed. This study aims to report our experience with cerebral aneurysms, which may improve in the treatment with the flow-diverter stent and follow up (1). Methods: This study was conducted in consecutive series of 23 patients. 23 procedures were performed for treating these patients in Ha Noi heart hospital from January 2019 to January 2020. 23 flow diverter stents (Pipeline) were used. Aneurysms morphology, stent patency and cerebral parenchyma before and after intervention were analyzed on images of digital subtraction angiography (DSA), computed tomography (CT) and magnetic resonance (MR). The follow-up data after 3–6 months and 12 months were recorded. Results: In 23 patients (8 men, 15 women), aneurysms of internal carotid artery were mostly common (95.7%), especially in cavernous segments. 13 cases (74%) had saccular aneurysms, and 2 cases (9%) had multiple aneurysms, and only 3 cases (13%) had fusiform aneurysms. Endovascular treatment was successfully performed at rate of 100%.. Mortality and morbidity rates were 0% and 0%, respectively. MRI and MSCT follow-up at 3 months showed complete or incomplete occlusions of aneurysms was 26.1% or 34.8%, respectively.  Conclusions: Deployment of flow diverter stent is safe and effective with high rate of successful and low procedural complications

scholarly journals Flow Diversion in Aneurysms Trial: The Design of the FIAT Study

2011 ◽  
Vol 17 (2) ◽  
pp. 147-153 ◽  
Author(s):  
J. Raymond ◽  
T.E. Darsaut ◽  
F. Guilbert ◽  
A. Weill ◽  
D. Roy
Keyword(s):  
Treatment Option ◽  
Conventional Treatment ◽  
Clinical Care ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Parent Vessel Occlusion ◽  
One Year ◽  
Flow Diverters

Intracranial aneurysms, particularly large and giant, fusiform or recurrent aneurysms are increasingly treated with flow diverters (FDs), a recently introduced and approved neurovascular device. While some rare cases may not be treated any other way, in most patients a more conventional, conservative, or validated approach such as coiling, parent vessel occlusion, or surgical clipping exists. Only a randomized clinical trial can answer the question of which treatment option leads to better patient outcomes. We report the design of the FIAT study, a clinical care trial aiming to compare angiographic and clinical outcomes following treatment with a Flow-Diverter or with the best conventional treatment option. The FIAT study will include both a randomized and a registry portion. Patients will be proposed randomization to either FD stenting or best conventional treatment option (observation, coiling, stenting, or clipping) as determined by the treating physician. FIAT will recruit a total of 338 patients, to show that i) FD stenting can be performed with an ‘acceptable’ immediate complication rate of less than 15% morbidity and mortality (defined as mRS > 2); ii) FD stenting can increase from 75 to 90% the proportion of patients with a “good outcome”, defined as complete or near-complete occlusion of the aneurysm AND a good clinical outcome (mRS ≤ 2) at one year, as compared to the best conventional option. The FIAT study provides a scientific and ethical context to care for patients eligible for flow-diversion therapy.

Flow redirection endoluminal device (FRED) for treatment of intracranial aneurysms: A systematic review

2021 ◽  
pp. 159101992110279
Author(s):  
Muhammad Waqas ◽  
Rimal H Dossani ◽  
Modhi Alkhaldi ◽  
Jocelyn Neveu ◽  
Justin M Cappuzzo ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Complication Rates ◽  
Mesh Terms ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Layered Flow ◽  
Comparative Safety

Introduction The Flow Redirection Endoluminal Device (FRED; MicroVention) is a dual-layered flow diverter used for the treatment of intracranial aneurysms. The objective of this systematic review was to compile device-related safety and effectiveness data. Methods The literature from January 1, 2013 to April 30, 2021 was searched for studies describing use of the FRED for intracranial aneurysm treatment irrespective of aneurysm location and morphology. The review included anterior and posterior circulation ruptured and unruptured saccular, fusiform or dissection, and blister aneurysms. MeSH terms related to “flow re-direction endoluminal device” and “FRED for aneurysms” were used. Data related to indication, complications, and rates of aneurysm occlusion were retrieved and analyzed. Results Twenty-two studies with 1729 intracranial aneurysms were included in this review. Overall reported morbidity was 3.9% (range 0–20%). Overall procedure-related mortality was 1.4% (range 0–6%). Complication rates fell into 5 categories: technical (3.6%), ischemic (3.8%), thrombotic or stenotic (6%), hemorrhagic (1.5%), and non-neurological (0.8%). The aneurysm occlusion rate between 0 and 3 months (reported in 11 studies) was 47.8%. The occlusion rate between 4 and 6 months (reported in 14 studies) was 73.8%. Occlusion rates continued to increase to 75.1% at 7–12 months (reported in 10 studies) and 86.6% for follow-up beyond 1 year (reported in 10 studies). Conclusion This review indicated that the FRED is a safe and effective for the treatment of intracranial aneurysms. Future studies should directly compare the FRED with other flow diverters for a better understanding of comparative safety and effectiveness among the different devices.

Overview of Different Flow Diverters and Flow Dynamics

Neurosurgery ◽  
2019 ◽  
Vol 86 (Supplement_1) ◽  
pp. S21-S34 ◽  
Author(s):  
Georgios A Maragkos ◽  
Adam A Dmytriw ◽  
Mohamed M Salem ◽  
Vincent M Tutino ◽  
Hui Meng ◽  
...  
Keyword(s):  
Rapid Evolution ◽  
Evidence Base ◽  
Flow Diverter ◽  
Outcome Data ◽  
Flow Diversion ◽  
Comprehensive Overview ◽  
Flow Diverter Devices ◽  
Technical Specifications ◽  
Flow Diverters

Abstract Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.

A2, M2, P2 aneurysms and beyond: results of treatment with pipeline embolization device in 65 patients

2019 ◽  
Vol 11 (9) ◽  
pp. 903-907 ◽  
Author(s):  
Christopher T Primiani ◽  
Zeguang Ren ◽  
Peter Kan ◽  
Ricardo Hanel ◽  
Vitor Mendes Pereira ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
Vascular Pathology ◽  
Parent Vessel ◽  
Rare Type ◽  
Pipeline Embolization Device ◽  
Aneurysm Size

BackgroundIntracranial aneurysms located in the distal vessels are rare and remain a challenge to treat through surgical or endovascular interventions.ObjectiveTo describe a multicenter approach with flow diversion using the pipeline embolization device (PED) for treatment of distal intracranial aneurysms.MethodsCases of distal intracranial aneurysms defined as starting on or beyond the A2 anterior cerebral artery, M2 middle cerebral artery, and P2 posterior cerebral artery segments were included in the final analysis.Results65 patients with distal aneurysms treated with the PED were analyzed. Median aneurysm size at the largest diameter was 7.0 mm, 60% were of a saccular morphology, and 9/65 (13.8%) patients presented in the setting of acute rupture. Angiographic follow-up data were available for 53 patients, with a median follow-up time of 6 months: 44/53 (83%) aneurysms showed complete obliteration, 7/53 (13.2%) showed reduced filling, and 2/53 (3%) showed persistent filling. There was no association between patient characteristics, including aneurysm size (P=0.36), parent vessel diameter (P=0.27), location (P=0.81), morphology (P=0.63), ruptured status on admission (P=0.57), or evidence of angiographic occlusion at the end of the embolization procedure (P=0.49). Clinical outcome data were available for 60/65 patients: 95% (57/60) had good clinical outcome (modified Rankin Scale score of 0–2) at 3 months.ConclusionsThis large multicenter study of patients with A2, M2, and P2 distal aneurysms treated with the PED showed that flow diversion may be an effective treatment approach for this rare type of vascular pathology. The procedural compilation rate of 7.7% indicates the need for further studies as the flow diversion technology constantly evolves.

Abstract 1122‐000103: FlowDiverter:A Study Safety and Efficacy in a Consecutive Group of 53 Patient and 60 Aneurysm

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Marcelo Bolcato ◽  
ana Carolina Dalmonico ◽  
Leo Ditzel ◽  
Savio Machareti ◽  
Thiago Yoshida ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Consecutive Series ◽  
Safety And Efficacy ◽  
Grading Scale ◽  
Aneurysm Occlusion ◽  
Occlusion Rate ◽  
Flow Diverters

Introduction : Endovascular flow diverters are increasingly used for the treatment of cerebral aneurysms. We assessed the safety and efficacy of the Flow Diverters in a consecutive series of 53 patients and 60 aneurysms. Methods : Inclusion criteria were wide‐neck, blister‐like, or fusiform aneurysms independent of size, treated with the FRED, PIPELINE and SILK between December 2014 and Junho 2021. Assessment criteria were aneurysm occlusion, manifest ischemic stroke, bleeding, or death. The occlusion rate was assessed at 6 months and 1 year with DSA by using the Raymond classification and the O'Kelly‐Marotta grading scale. Results : Fifty three patients (mean age 54.3 years;81.1% female) with 60 aneurysms were treated with 9 Silk, 38 FREDs and 13 Pipeline. Aneurysm size ranged from 2.5 to 30 mm. Deployment of the Flow diverters was successful in 52 aneurysms. Three patient developed mild stroke symptoms that fully receded within days, 4 patients occlusion total carotid because resistant antiagregation and another patient’s development Swelling syndrome. There has been one death. Initial follow‐up at 6 months showed complete occlusion in 90% of the overall study group and 93,33% at 1 year. Conclusions : The flow diverter is a safe device for the treatment of cerebral aneurysms of various types. Our data reveal high occlusion rates at 6 months and 1 year. Long‐term occlusion rates are expected.

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications

2021 ◽  
pp. 1-8
Author(s):  
José E. Cohen ◽  
J. Moshe Gomori ◽  
Samuel Moscovici ◽  
Andrew H. Kaye ◽  
Yigal Shoshan ◽  
...  
Keyword(s):  
Thrombus Formation ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Complication Rates ◽  
Imaging Data ◽  
Total Occlusion ◽  
Early Management ◽  
Ruptured Aneurysms ◽  
Aneurysm Occlusion

OBJECTIVE Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome. METHODS The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed. RESULTS Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0–2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage. CONCLUSIONS Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors’ experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.

scholarly journals Flow Diverters for Intracranial Aneurysms

2014 ◽  
Vol 2014 ◽  
pp. 1-12 ◽  
Author(s):  
Yazan J. Alderazi ◽  
Darshan Shastri ◽  
Tareq Kass-Hout ◽  
Charles J. Prestigiacomo ◽  
Chirag D. Gandhi
Keyword(s):  
Antiplatelet Therapy ◽  
Intracranial Aneurysms ◽  
Evidence Base ◽  
Flow Diverter ◽  
Parent Artery ◽  
Comparative Efficacy ◽  
Parent Vessel ◽  
Wide Neck ◽  
Endovascular Devices ◽  
Flow Diverters

Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies.

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.

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