Patency of anterior circulation branch vessels after Pipeline embolization: longer-term results from 82 aneurysm cases

OBJECTIVE The Pipeline Embolization Device (PED) has become increasingly used for the treatment of intracranial aneurysms. Given its high metal surface area coverage, there is concern for the patency of branch vessels that become covered by the device. Limited data exist regarding the patency of branch vessels adjacent to aneurysms that are covered by PEDs. The authors assessed the rate of intracranial internal carotid artery, anterior circulation branch vessel patency following PED placement at their institution. METHODS The authors retrospectively reviewed the records of 82 patients who underwent PED treatment between 2009 and 2014 and in whom the PED was identified to cover branch vessels. Patency of the anterior cerebral, posterior communicating, anterior choroidal, and ophthalmic arteries was evaluated using digital subtraction angiography preoperatively and postoperatively after PED deployment and at longer-term follow-up. RESULTS Of the 127 arterial branches covered by PEDs, there were no immediate postoperative occlusions. At angiographic follow-up (mean 10 months, range 3–34.7 months), arterial side branches were occluded in 13 (15.8%) of 82 aneurysm cases and included 2 anterior cerebral arteries, 8 ophthalmic arteries, and 3 posterior communicating arteries. No cases of anterior choroidal artery occlusion were observed. Patients with branch occlusion did not experience any neurological symptoms. CONCLUSIONS In this large series, the longer-term rate of radiographic side branch arterial occlusion after coverage by a flow diverter was 15.8%. Terminal branch vessels, such as the anterior choroidal artery, remained patent in this series. The authors' series suggests that branch vessel occlusions are clinically silent and should not deter aneurysm treatment with flow diversion.

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Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy

Stroke ◽

10.1161/str.46.suppl_1.tp18 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Deepak Gulati ◽

Amin Aghaebrahim, ◽

Amer Malik ◽

Andrew Ducruet ◽

Brian Jankowitz ◽

...

Keyword(s):

Acute Stroke ◽

Posterior Circulation ◽

Preventive Strategies ◽

Anterior Choroidal Artery ◽

Balloon Inflation ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Intracranial Stenting ◽

Anterior Choroidal ◽

Choroidal Artery

BACKGROUND: Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation. METHODS: Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%). RESULTS: A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient. CONCLUSION: Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control.

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Embolization of the choroidal artery in the treatment of cerebral arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/2016.2.jns152370 ◽

2017 ◽

Vol 126 (4) ◽

pp. 1114-1122 ◽

Cited By ~ 7

Author(s):

Alaa Elkordy ◽

Hidenori Endo ◽

Kenichi Sato ◽

Yasushi Matsumoto ◽

Ryushi Kondo ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Open Surgery ◽

Gamma Knife Radiosurgery ◽

Internal Capsule ◽

Endovascular Embolization ◽

Anterior Choroidal Artery ◽

Cerebral Avms ◽

Anterior Choroidal ◽

Choroidal Artery

OBJECTIVE The anterior and posterior choroidal arteries are often recruited to supply arteriovenous malformations (AVMs) involving important paraventricular structures, such as the basal ganglia, internal capsule, optic radiation, lateral geniculate body, and medial temporal lobe. Endovascular embolization through these arteries is theoretically dangerous because they supply eloquent territories, are of small caliber, and lack collaterals. This study aimed to investigate the safety and efficacy of embolization through these arteries. METHODS This study retrospectively reviewed 13 patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between 2006 and 2014. Embolization was performed as a palliative procedure before open surgery or Gamma Knife radiosurgery. Computed tomography and MRI were performed the day after embolization to assess any surgical complications. The incidence and type of complications and their association with clinical outcomes were analyzed. RESULTS Decreased blood flow was achieved in all patients after embolization. Postoperative CT detected no hemorrhagic complications. In contrast, postoperative MRI detected that 4 of the 13 patients (30.7%) developed infarctions: 3 patients after embolization through the anterior choroidal artery, and 1 patient after embolization through the lateral posterior choroidal artery. Two of the 4 patients in whom embolization was from the cisternal segment of the anterior choroidal artery (proximal to the plexal point) developed symptomatic infarction of the posterior limb of the internal capsule, 1 of whom developed morbidity (7.7%). The treatment-related mortality rate was 0%. Additional treatment was performed in 12 patients: open surgery in 9 and Gamma Knife radiosurgery in 3 patients. Complete obliteration was confirmed by angiography at the last follow-up in 10 patients. Recurrent bleeding from the AVMs did not occur in any of the cases during the follow-up period. CONCLUSIONS Ischemic complications are possible following the embolization of cerebral AVMs through the choroidal artery, even with modern neurointerventional devices and techniques. Although further study is needed, embolization through the choroidal artery may be an appropriate treatment option when the risk of surgery or radiosurgery is considered to outweigh the risk of embolization.

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Patency of the anterior choroidal artery covered with a flow-diverter stent

Journal of Neurosurgery ◽

10.3171/2014.11.jns141603 ◽

2015 ◽

Vol 123 (6) ◽

pp. 1540-1545 ◽

Cited By ~ 27

Author(s):

Hiroaki Neki ◽

Jildaz Caroff ◽

Pakrit Jittapiromsak ◽

Nidhal Benachour ◽

Cristian Mihalea ◽

...

Keyword(s):

Choroid Plexus ◽

Clinical Symptoms ◽

Flow Diverter ◽

Anterior Choroidal Artery ◽

Parent Vessel ◽

Flow Diverter Stent ◽

Anterior Choroidal ◽

Long Course ◽

Choroidal Artery

OBJECT The concept of the flow-diverter stent (FDS) is to induce aneurysmal thrombosis while preserving the patency of the parent vessel and any covered branches. In some circumstances, it is impossible to avoid dangerously covering small branches, such as the anterior choroidal artery (AChA), with the stent. In this paper, the authors describe the clinical and angiographic effects of covering the AChA with an FDS. METHODS Between April 2011 and July 2013, 92 patients with intracranial aneurysms were treated with the use of FDSs in the authors’ institution. For 20 consecutive patients (21.7%) retrospectively included in this study, this involved the unavoidable covering of the AChA with a single FDS during endovascular therapy. AChAs feeding the choroid plexus were classified as the long-course group (14 cases), and those not feeding the choroid plexus were classified as the short-course group (6 cases). Clinical symptoms and the angiographic aspect of the AChA were evaluated immediately after stent delivery and during follow-up. Neurological examinations were performed to rule out hemiparesis, hemihypesthesia, hemianopsia, and other cortical signs. RESULTS FDS placement had no immediate effect on AChA blood flow. Data were obtained from 1-month clinical follow-up in all patients and from midterm angiographic follow-up in 17 patients (85.0%), with a mean length of 9.8 ± 5.4 months. No patient in either group complained of transient or permanent symptoms related to an AChA occlusion. In all cases, the AChA remained patent without any flow changes. CONCLUSIONS The results of this study suggest that when impossible to avoid, the AChA may be safely covered with a single FDS during intracranial aneurysm treatment, irrespective of anatomy and anastomoses.

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Flow diversion for anterior choroidal artery (AChA) aneurysms: a multi-institutional experience

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013466 ◽

2017 ◽

Vol 10 (7) ◽

pp. 634-637 ◽

Cited By ~ 5

Author(s):

Visish M Srinivasan ◽

Michael George Zaki Ghali ◽

Jacob Cherian ◽

Maxim Mokin ◽

Ajit S Puri ◽

...

Keyword(s):

Cerebral Arteries ◽

Cerebral Aneurysms ◽

Flow Diversion ◽

Small Subset ◽

Collateral Flow ◽

Anterior Choroidal Artery ◽

Vessel Patency ◽

Anterior Choroidal ◽

Choroidal Artery

BackgroundAnterior choroidal artery (AChA) aneurysms represent a small subset of cerebral aneurysms. The Pipeline Embolization Device (PED) has been successfully applied to various aneurysms of the supraclinoid internal carotid artery (ICA). The treatment of these aneurysms requires special attention due to the eloquent territory supplied by the AChA. We report the largest and first dedicated series of flow diversion treatment of AChA aneurysms.MethodsFour institutional neurointerventional databases were reviewed for cases of intracranial aneurysms treated with PED. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases of AChA aneurysms treated with PED. AChA aneurysms were defined as aneurysms distal to the AChA and proximal to the ICA terminus, with or without the incorporation of the AChA.ResultsEighteen AChA aneurysms were treated during the study period. All aneurysms were successfully treated with a mean follow-up of 19.1 months. The large majority of aneurysms (15/18, 83.3%) were completely obliterated. No patients suffered from intra- or post-procedural complications. A1 stenosis was a common occurrence, seen in 10 of 16 (62.5%) covered anterior cerebral arteries (ACAs), although all were asymptomatic. All AChAs remained patent at last follow-up.ConclusionsThe PED can be used successfully in AChA aneurysms with a good safety and efficacy profile. All AChAs remained patent. Collateral flow networks, especially for the ACA, affect long-term branch vessel patency. Treatment with PED for AChA aneurysms appears to be a reasonable option to consider and should be evaluated in a larger cohort.

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Endovascular coil embolization of anterior choroidal artery aneurysms

Journal of Neurosurgery ◽

10.3171/2009.4.jns08934 ◽

2009 ◽

Vol 111 (5) ◽

pp. 963-969 ◽

Cited By ~ 18

Author(s):

Hyun-Seung Kang ◽

Bae Ju Kwon ◽

O-Ki Kwon ◽

Cheolkyu Jung ◽

Jeong Eun Kim ◽

...

Keyword(s):

Coil Embolization ◽

Nerve Palsy ◽

Oculomotor Nerve ◽

Oculomotor Nerve Palsy ◽

Thromboembolic Events ◽

Anterior Choroidal Artery ◽

Endovascular Coil Embolization ◽

Anterior Choroidal ◽

Choroidal Artery

Object Anterior choroidal artery (AChA) aneurysms are difficult to treat, and the clinical outcome of patients is occasionally compromised by ischemic complications after clipping operations. The purpose of this study was to document the outcome and follow-up results of endovascular coil embolization in patients with AChA aneurysms. Methods Between July 1999 and March 2008, 88 patients with 90 AChA aneurysms (31 ruptured and 59 unruptured aneurysms) were treated with endovascular coil embolization in 91 sessions. There were 87 small aneurysms (< 10 mm) and 3 large aneurysms, with a mean aneurysm volume of 60.9 ± 83.3 mm3. Preprocedural oculomotor nerve palsy associated with AChA aneurysms was noted in 8 patients. Efficacy and safety were evaluated based on the degree of initial occlusion, procedure-related complications, patient outcome based on the Glasgow Outcome Scale score, and follow-up results. Results The degree of angiographic occlusion of the aneurysms was complete for 15 aneurysms (17%), near complete for 69 aneurysms (77%) and partial for 6 aneurysms (7%). There were 4 (4.4%) symptomatic procedure-related complications (3 thromboembolic events and 1 procedural hemorrhage). The procedural hemorrhage resulted in death; however, the thromboembolic events only caused transient deficits. A favorable outcome (Glasgow Outcome Scale score of 5 or 4) was achieved in 90% (79 of 88) of the patients at the time of discharge. No patient showed signs of bleeding or rebleeding during the follow-up period (mean 25 months). Major aneurysm recanalization occurred in 2 cases. The AChA aneurysm–associated oculomotor nerve palsy tended to become aggravated transiently after coil embolization and then completely recovered over the course of 2–9 months. Conclusions Coil embolization is a safe and effective treatment modality in cases of AChA aneurysms. Coil embolization enables procedural recognition of arterial compromise and immediate reestablishment of flow, thus contributing to a favorable outcome.

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Open-cell stent and use of cone-beam CT enables a safe and effective coil embolization of true ophthalmic artery and anterior choroidal artery aneurysms with preservation of parent vessel: Clinical and angiographic results

Interventional Neuroradiology ◽

10.1177/1591019917747246 ◽

2017 ◽

Vol 24 (2) ◽

pp. 135-139 ◽

Cited By ~ 2

Author(s):

Samuel Y Hou ◽

Anna Luisa Kühn ◽

Ajit S Puri ◽

Ajay K Wakhloo

Keyword(s):

Coil Embolization ◽

Ophthalmic Artery ◽

Intraoperative Imaging ◽

Cone Beam ◽

Anterior Choroidal Artery ◽

Parent Vessel ◽

Open Cell ◽

Anterior Choroidal ◽

Choroidal Artery

Background Treatment of true ophthalmic artery (OA) or anterior choroidal artery (AChA) aneurysms with preservation of the parent vessel may be challenging. Flow diverters have limitations when dealing with branch vessels arising from the aneurysm sac. Visual loss or AChA territory infarcts have been reported both for surgical and endovascular treatment. Methods We evaluated the safety and efficacy of an open-cell design, laser-cut, self-expanding Nitinol stent, and use of cone-beam computed tomography (CBCT) for stent-assisted coil embolization. Results A total of seven patients with unruptured OA or AChA aneurysms were enrolled in this prospective small case study and the data were analyzed retrospectively. A complete obliteration was achieved in all aneurysms immediately post-intervention or at six-month follow-up without any evidence for recanalization at up to three-year follow-up. All patients tolerated the procedure well and there was no change in baseline modified Rankin Scale. Conclusions Our study suggests that specific features of an open-cell stent allow a safe and effective treatment of OA or AChA aneurysms with a high technical success rate and excellent mid-term angiographic and clinical outcome. CBCT is a useful intraoperative imaging tool.

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Anterior Choroidal Artery Patency and Clinical Follow-Up after Coverage with the Pipeline Embolization Device

American Journal of Neuroradiology ◽

10.3174/ajnr.a4217 ◽

2015 ◽

Vol 36 (5) ◽

pp. 937-942 ◽

Cited By ~ 41

Author(s):

E. Raz ◽

M. Shapiro ◽

T. Becske ◽

D.W. Zumofen ◽

O. Tanweer ◽

...

Keyword(s):

Anterior Choroidal Artery ◽

Pipeline Embolization Device ◽

Anterior Choroidal ◽

Choroidal Artery

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Incidence and Clinical Implications of Carotid Branch Occlusion Following Treatment of Internal Carotid Artery Aneurysms With the Pipeline Embolization Device

Neurosurgery ◽

10.1227/neu.0000000000000595 ◽

2014 ◽

Vol 76 (2) ◽

pp. 173-178 ◽

Cited By ~ 37

Author(s):

Aditya Vedantam ◽

Vikas Y. Rao ◽

Hashem M. Shaltoni ◽

Michel E. Mawad

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Side Branch ◽

Neurological Deficits ◽

Pipeline Embolization Device ◽

Anterior Choroidal ◽

Choroidal Artery ◽

Flow Diverters

ABSTRACT BACKGROUND: The use of flow diverters such as the pipeline embolization device (PED) for treatment of intracranial aneurysms carries the risk of side branch occlusion. OBJECTIVE: To determine the incidence and clinical outcomes associated with supraclinoid internal carotid artery (ICA) branch occlusion after deployment of PEDs for ICA aneurysms. METHODS: We reviewed patients who underwent endovascular treatment with PEDs for ICA aneurysms between June 2011 and March 2013. Forty-nine patients (43 women, mean age 56.3 ± 1.8 years, 68 aneurysms) in whom PEDs traversed the origin of supraclinoid ICA branches (ophthalmic [OA], posterior communicating [PcommA], and anterior choroidal artery [AChA]) were selected for this study. Follow-up angiograms (mean follow-up, 12.8 ± 0.8 months) were studied to determine the location of PEDs and the patency of ICA branches. RESULTS: PEDs were placed across the ostia of 49 OAs, 14 PcommAs, and 11 AChAs. Multiple PEDs were deployed in 16 patients. Rate of branch occlusion was 4% (2/49) for the OA, 7.1% (1/14) for the PcommA, and 0% for the AChA. Patients with branch occlusion did not endure new neurological deficits. ICA branch occlusion was not associated with the number of PEDs covering the ostia (P = .76) or the origin of ICA branches from the aneurysm (P = .24). CONCLUSION: The incidence of major supraclinoid ICA branch occlusion after treatment with PEDs was low. These events were not associated with new neurological deficits nor were they related to the number of PEDs deployed or the origin of ICA branches from the aneurysm.

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“Two-coil technique” for embolization of small internal carotid artery aneurysms incorporating the origin of the anterior choroidal artery

Interventional Neuroradiology ◽

10.1177/1591019916632368 ◽

2016 ◽

Vol 22 (4) ◽

pp. 396-401 ◽

Cited By ~ 3

Author(s):

Young Jin Heo ◽

Ku Hyun Yang ◽

Sung Chul Jung ◽

Jung Cheol Park ◽

Deok Hee Lee

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Artery Aneurysm ◽

Anterior Choroidal Artery ◽

Single Center Experience ◽

Internal Carotid Artery Aneurysm ◽

Anterior Choroidal ◽

Choroidal Artery

Purpose The purpose of this article is to evaluate the efficacy, safety and stability of the “two-coil technique.” Materials and methods We evaluated a single-center experience by using a two-coil technique, which is a variation of the multiple-microcatheter technique in the treatment of a small internal carotid artery aneurysm with its sac incorporated with the origin of the anterior choroidal artery. Six consecutive patients with small ICA aneurysms with its sac incorporated with origin of the anterior choroidal artery and treated with the two-coil technique were included in this study. We finished the embolization with only two coils introduced via two different microcatheters without any other device assistance in all cases. Embolization status was determined at immediate postoperative and follow-up angiography after six months. Results The two-coil technique was technically successful in five of six cases; one case was converted to surgical clipping because of persistent occlusion of the anterior choroidal artery after several attempts. On follow-up study, all five cases showed stable occlusion status without recanalization or residual aneurysm. Conclusions The two-coil technique has potential to be used for coiling small aneurysms, particularly where there is an important branch incorporated into the sac or neck of the aneurysm.

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Curative and adjunctive AVM Onyx embolization of AVMs through the choroidal arteries

Interventional Neuroradiology ◽

10.1177/1591019917706052 ◽

2017 ◽

Vol 23 (4) ◽

pp. 392-398 ◽

Cited By ~ 3

Author(s):

Xianli Lv ◽

Xiulan Hu ◽

Wei Li ◽

Hongwei He ◽

Chuhan Jiang ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Endovascular Embolization ◽

Anterior Choroidal Artery ◽

Complete Obliteration ◽

Lateral Posterior ◽

Cerebral Avms ◽

Anterior Choroidal ◽

Choroidal Artery ◽

Deep Location

Objective The anterior or posterior choroidal artery is often recruited to supply deep location arteriovenous malformations (AVMs). This study is to report curative and adjunctive AVM Onyx embolization through these arteries. Methods This study retrospectively reviewed six patients with cerebral AVMs who underwent endovascular embolization through the choroidal arteries between October 2015 and October 2016. Embolization was performed as a curative procedure in five patients and adjunctive procedure in one patient. Results Four patients underwent embolization through the anterior choroidal artery (AchA), and two patients underwent embolization through the lateral posterior choroidal artery (LPchA). One of the four patients in whom embolization was from the AchA (distal to the plexal point) developed transient hemiparesis. Complete obliteration was confirmed by angiography at the last follow-up in five patients. Conclusions Onyx embolization of cerebral AVMs through the choroidal arteries is possible as a curative or adjunctive procedure.

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