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

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.

scholarly journals Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

2018 ◽  
Vol 15 (6) ◽  
pp. 624-633 ◽  
Author(s):  
Fawaz Al-Mufti ◽  
Krishna Amuluru ◽  
Eric R Cohen ◽  
Vikas Patel ◽  
Mohammad El-Ghanem ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Significant Risk ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Side Branch ◽  
Parent Vessel ◽  
Vessel Injury ◽  
Procedural Complications ◽  
Background Material ◽  
Device Deployment

Abstract Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary. Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.” A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.

scholarly journals First Experience of Three Neurovascular Centers With the p64MW-HPC, a Low-Profile Flow Diverter Designed for Proximal Cerebral Vessels With Antithrombotic Coating

2021 ◽  
Vol 12 ◽  
Author(s):  
Helge Winters ◽  
Marie-Sophie Schüngel ◽  
Cordula Scherlach ◽  
Dirk Mucha ◽  
Jörg Thalwitzer ◽  
...  
Keyword(s):  
Cerebral Arteries ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Low Profile ◽  
Procedural Complications ◽  
Caroticocavernous Fistula ◽  
Treatment For Cerebral Aneurysms

Background: In the last decade, flow diversion (FD) has been established as hemodynamic treatment for cerebral aneurysms arising from proximal and distal cerebral arteries. However, two significant limitations remain—the need for 0.027” microcatheters required for delivery of most flow diverting stents (FDS), and long-term dual anti-platelet therapy (DAPT) in order to prevent FDS-associated thromboembolism, at the cost of increasing the risk for hemorrhage. This study reports the experience of three neurovascular centers with the p64MW-HPC, a FDS with anti-thrombotic coating that is implantable via a 0.021” microcatheter.Materials and methods: Three neurovascular centers contributed to this retrospective analysis of patients that had been treated with the p64MW-HPC between March 2020 and March 2021. Clinical data, aneurysm characteristics, and follow-up results, including procedural and post-procedural complications, were recorded. The hemodynamic effect was assessed using the O'Kelly–Marotta Scale (OKM).Results: Thirty-two patients (22 female, mean age 57.1 years) with 33 aneurysms (27 anterior circulation and six posterior circulation) were successfully treated with the p64MW-HPC. In 30/32 patients (93.75%), aneurysmal perfusion was significantly reduced immediately post implantation. Follow-up imaging was available for 23 aneurysms. Delayed aneurysm perfusion (OKM A3: 8.7%), reduction in aneurysm size (OKM B1-3: 26.1%), or sufficient separation from the parent vessel (OKM C1-3 and D1: 65.2%) was demonstrated at the last available follow-up after a mean of 5.9 months. In two cases, device thrombosis after early discontinuation of DAPT occurred. One delayed rupture caused a caroticocavernous fistula. The complications were treated sufficiently and all patients recovered without permanent significant morbidity.Conclusion: Treatment with the p64MW-HPC is safe and feasible and achieves good early aneurysm occlusion rates in the proximal intracranial circulation, which are comparable to those of well-established FDS. Sudden interruption of DAPT in the early post-interventional phase can cause in-stent thrombosis despite the HPC surface modification. Deliverability via the 0.021” microcatheter facilitates treatment in challenging vascular anatomies.

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 Quantitative assessment of parent vessel and distal intracranial hemodynamics following pipeline flow diversion

2016 ◽  
Vol 23 (1) ◽  
pp. 34-40 ◽  
Author(s):  
Sophia F Shakur ◽  
Victor A Aletich ◽  
Sepideh Amin-Hanjani ◽  
Ahmed E Hussein ◽  
Fady T Charbel ◽  
...  
Keyword(s):  
Internal Carotid ◽  
Cerebral Aneurysms ◽  
Flow Diversion ◽  
Flow Volume ◽  
Intraparenchymal Hemorrhage ◽  
Parent Vessel ◽  
Volume Rate ◽  
Significant Difference ◽  
The Impact ◽  
Flow Velocities

Background Pipeline embolization devices (PEDs) are commonly used for endovascular treatment of cerebral aneurysms but can be associated with delayed ipsilateral intraparenchymal hemorrhage. Although intra-aneurysmal hemodynamic changes have been studied, parent vessel and intracranial hemodynamics after PED use are unknown. We examine the impact of flow diversion on parent artery and distal intracranial hemodynamics. Method Patients with internal carotid cerebral aneurysms treated with PED who had flow volume rate, flow velocities, pulsatility index, resistance index, Lindegaard ratio, and wall shear stress (WSS) obtained after treatment using quantitative magnetic resonance angiography were reviewed. Means were compared between ipsilateral and contralateral internal carotid artery (ICA) and middle cerebral artery (MCA) using paired t tests. Results A total of 18 patients were included. Mean flow volume rate was lower in the ipsilateral versus contralateral ICA ( p = 0.04) but tended to be higher in the ipsilateral versus contralateral MCA ( p = 0.08). Lindegaard ratio was higher ipsilateral to the PED in diastole ( p = 0.05). Although there was no significant difference in flow velocities, pulsatility or resistance indices, and WSS, the two cases in our cohort with hemorrhagic complications did display significant changes in MCA flows and MCA WSS. Conclusion PED placement appears to alter the elasticity of the stented ICA segment, with lower flows in the ipsilateral versus contralateral ICA. Conversely, MCA flows and MCA WSS are higher in the ipsilateral MCA among patients with hemorrhage after PED placement, suggesting the role of disrupted distal hemodynamics in delayed ipsilateral intraparenchymal hemorrhage.

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.

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.

Giant Cavernous-Segment Internal Carotid Artery Aneurysm Presenting with Cranial Neuropathy

2019 ◽  
pp. 129-136
Author(s):  
Jacob F. Baranoski ◽  
Tyler S. Cole ◽  
Colin J. Przybylowski ◽  
Rami O. Almefty ◽  
Dale Ding ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Artery Aneurysm ◽  
Flow Diversion ◽  
Cranial Neuropathy ◽  
Parent Vessel ◽  
Carotid Artery Aneurysm ◽  
Internal Carotid Artery Aneurysm ◽  
Procedural Complications ◽  
Technical Details ◽  
Cavernous Carotid Artery

Abstract: This chapter discusses issues surrounding the management of giant cavernous carotid artery aneurysms. These aneurysms most commonly present with symptoms of cranial neuropathy. They present a unique treatment challenge given their location and often large size. Endovascular flow diversion has emerged as the mainstay of treatment, although parent vessel sacrifice, high-flow bypass, and surgical trapping are important alternatives. Evaluation of the nature of collateral circulation and the tolerance of the intracranial circulation to carotid artery sacrifice should also be part of the work-up. The technical details of endovascular flow diversion strategy are described, as well as the management of known post-procedural complications.

Flow Modification of Cerebral Aneurysm by Flow Diverter (Pipeline) With Different Packing Densities

2012 ◽  
Author(s):  
Jianping Xiang ◽  
Ding Ma ◽  
Adnan Siddiqui ◽  
Hui Meng
Keyword(s):  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
High Recurrence Rate ◽  
Parent Vessel ◽  
Novel Device ◽  
Flow Modification ◽  
Fine Mesh ◽  
High Flexibility ◽  
Vessel Reconstruction ◽  
Packing Densities

Flow diverter, a braided fine mesh stent, is emerging as a novel device to treat wide-necked, fusiform, and giant cerebral aneurysms since these types of aneurysms are either untreatable otherwise or have high recurrence rate treated by endovascular coils. Flow diverter devices represent a major paradigm shift in the endovascular treatment of aneurysms from filling the aneurysm cavity to diverting blood flow away from aneurysm sac with parent vessel reconstruction. Due to its high flexibility, a flow diverter can be manipulated during deployment process to achieve better results; for example, an experienced neuro-interventionalist can manipulate the stent’s local metal coverage through coordinated movement of catheter pull-back, pusher advancement, and distal coil release to pack higher density for the aneurysm orifice region to divert more flow away from aneurysm, making aneurismal thrombosis quicker and easier. Pipeline embolization device is the first flow diverter approved by FDA. In this study, we investigate the flow modification of a wide-necked aneurysm by Pipeline with different packing densities.

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