Limitations of Flow Diverters in Posterior Communicating Artery Aneurysms

Background: Treatment of intracranial aneurysms with flow diverters (FDs) showed promising results. However, a subset of patients treated for posterior communicating artery (PComA) aneurysms has variable occlusion rates. Especially the fetal type-associated PComA aneurysms seemed to respond differently to treatment. We analyze our series of fetal type PComA aneurysms treated with a FD. The literature on this subject is reviewed. Methods: Data from patients treated with FD for all PComA aneurysms at the RadboudUMC Nijmegen were retrospectively analysed. Primary end-point was complete aneurysm occlusion at six months. Secondary end-points were clinical outcome, treatment safety, and results of secondary treatment after non-closure. The results for the fetal PComA aneurysms were compared to the literature. Results: Nineteen consecutive patients harboring 21 PComA aneurysms were treated. Three aneurysms had ipsilateral fetal type PCA (14.3%). Overall, none of the fetal type PcomA aneurysm showed complete occlusion versus 77.8% of the others (p = 0.03). Mortality and permanent morbidity rates were respectively 5.3% and 0%. Conclusions: FD treatment for PComA aneurysm with fetal type circulation seemed to be less effective compared to other types of PComA aneurysms. Flow characteristics at the PComA bifurcation are thought to be causative Alternative strategies should be considered as first line treatment.

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Relationship between haemodynamic changes and outcomes of intracranial aneurysms after implantation of the pipeline embolisation device: a single centre study

Interventional Neuroradiology ◽

10.1177/1591019919849673 ◽

2019 ◽

Vol 25 (6) ◽

pp. 671-680 ◽

Cited By ~ 1

Author(s):

Junfan Chen ◽

Yisen Zhang ◽

Zhongbin Tian ◽

Wenqiang Li ◽

Qianqian Zhang ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Factors Affecting ◽

Single Centre Study ◽

Haemodynamic Changes ◽

Device Placement ◽

Aneurysm Occlusion ◽

Independent Risk Factors ◽

Incomplete Occlusion ◽

Inflow Jet ◽

Flow Diverters

Background Intracranial aneurysms are increasingly being treated by the placement of flow diverters; however, the factors affecting the outcome of aneurysms treated using flow diverters remain unclarified. Methods The present study investigated 94 aneurysms treated with pipeline embolisation device placement, and used a computational fluid dynamics method to explore the factors influencing the outcome of aneurysms. Results Seventy-six completely occluded aneurysms and 18 incompletely occluded aneurysms were analysed. Before treatment, inflow jets were found in 13 (72.2%) aneurysms in the incompletely occluded group and 34 (44.7%) in the completely occluded group ( P = 0.292). After deployment of the pipeline embolisation device, inflow jets remained in nine (50%) aneurysms in the incompletely occluded group and nine (11.8%) in the completely occluded group ( P = 0.001). In the incompletely occluded group, regions with inflow jets after treatment corresponded with the patent areas shown on follow-up digital subtraction angiography. The mean reduction ratios of velocity in the whole aneurysm and on the neck plane were lower in the incompletely occluded than in the completely occluded group ( P = 0.003; P = 0.017). Multivariate analysis revealed that the only independent risk factors for incomplete aneurysm occlusion were the reduction ratios of velocity (in the whole aneurysm, threshold 0.362, P = 0.005; on the neck plane, threshold 0.273, P = 0.015). Conclusions After pipeline embolisation device placement, reduction ratios of velocity in the whole aneurysm of less than 0.362 and on the neck plane of less than 0.273 are significantly associated with a greater risk of aneurysm incomplete occlusion. In addition, the persistence of inflow jets in aneurysms is associated with incomplete occlusion in the inflow jet area.

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Stenting as Monotherapy for Uncoilable Intracranial Aneurysms

Operative Neurosurgery ◽

10.1227/neu.0b013e31827fcaba ◽

2012 ◽

Vol 73 (suppl_1) ◽

pp. ons80-ons85 ◽

Cited By ~ 2

Author(s):

Ketan R. Bulsara ◽

Gregory A. Kuzmik ◽

Ryan Hebert ◽

Vincent Cheung ◽

Charles C. Matouk ◽

...

Keyword(s):

Clinical Condition ◽

Intracranial Aneurysms ◽

Senior Author ◽

Radiographic Outcomes ◽

Effective Option ◽

Good Clinical Condition ◽

Aneurysm Occlusion ◽

Flow Diverters

Abstract BACKGROUND: Small, blister-like aneurysms (BLAs), by virtue of their unique morphology, are difficult to treat with conventional modalities. The use of oversized self-expanding stents as monotherapy for BLAs is a relatively new and promising concept that warrants further investigation. OBJECTIVE: To clarify the role of oversized self-expanding stents as monotherapy for BLAs. METHODS: Five consecutive patients were treated for BLAs with oversized self-expanding stents alone by the senior author (K.R.B.). We report on their clinical and radiographic outcomes. RESULTS: All 5 patients in our series were discharged in good clinical condition. Complete aneurysm occlusion was observed in all patients at the time of most recent radiographic follow-up. Mean follow-up time was 13.6 months (range, 1 month to 4.5 years). CONCLUSION: The use of oversized self-expanding stents to redirect flow away from aneurysms is an effective option for patients with BLAs. This approach represents an alternative to the use of flow diverters.

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Hemodynamic Environment and Occlusion Time of Tandem Intracranial Aneurysms Treated With Flow Diverters

ASME 2012 Summer Bioengineering Conference, Parts A and B ◽

10.1115/sbc2012-80172 ◽

2012 ◽

Author(s):

Fernando Mut ◽

Esteban Scrivano ◽

Pedro Lylyk ◽

Juan R. Cebral

Keyword(s):

Intracranial Aneurysms ◽

Occlusion Time ◽

Aneurysm Occlusion ◽

Flow Diverters ◽

Occlusion Period

The use of flow diverting devices to treat complex intracranial aneurysms difficult to treat with coils and clips has recently received substantial attention. Initial experiences with increasing numbers of patients have been carried out with promising results [1]. However, it is still difficult to predict the outcome and/or the aneurysm occlusion time after treatment with flow diverters. The purpose of this work was to relate the hemodynamic environment created immediately after treatment and the occlusion period of a pair of tandem aneurysms.

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p64 flow diverter: Results in 108 patients from a single center

Interventional Neuroradiology ◽

10.1177/1591019920932048 ◽

2020 ◽

pp. 159101992093204 ◽

Cited By ~ 1

Author(s):

Tom De Beule ◽

T Boulanger ◽

S Heye ◽

WJ van Rooij ◽

WH van Zwam ◽

...

Keyword(s):

Intracranial Aneurysms ◽

Flow Diverter ◽

Neurological Deficits ◽

Stent Occlusion ◽

Hemorrhagic Complications ◽

Previously Treated ◽

Aneurysm Occlusion ◽

Permanent Morbidity ◽

Stent Stenosis

Background and purpose Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. Materials and methods We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. Results Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1–6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. Conclusion The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

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Remodeling of the Posterior Cerebral Artery P1-Segment after Pipeline Flow Diverter Treatment of Posterior Communicating Artery Aneurysms

Neurology International ◽

10.3390/neurolint13020020 ◽

2021 ◽

Vol 13 (2) ◽

pp. 195-201

Author(s):

Miguel S. Litao ◽

Jan-Karl Burkhardt ◽

Omar Tanweer ◽

Eytan Raz ◽

Paul Huang ◽

...

Keyword(s):

Cerebral Artery ◽

Posterior Cerebral Artery ◽

Flow Diverter ◽

Posterior Communicating Artery ◽

Vessel Remodeling ◽

Before And After ◽

Aneurysm Occlusion ◽

Account Due ◽

Flow Diverters

Introduction: Flow diverters such as the pipeline embolization device (PED) cause hemodynamic changes of the treated vessel segment. In posterior communicating artery (PcomA), aneurysms’ unique anatomic consideration have to be taken in account due to the connection between the anterior and posterior circulation. We hypothesize that in conjunction with PcomA remodeling, there will also be remodeling of the ipsilateral P1 segment of the posterior cerebral artery (PCA) after PED treatment for PcomA aneurysms. Methods: We retrospectively collected radiological as well as clinical data of PcomA aneurysm patients treated with PED including PcomA and P1 vessel diameters before and after treatment as well as patient and aneurysm characteristics. Results: Overall, 14 PcomA aneurysm patients were included for analysis and PED treatment was performed without complications in all patients. In 10 out of 14 patients (71%), a decrease in PcomA diameter was observed and there was a significant mean decrease of 0.78 mm in PcomA diameter on angiographic last follow-up (LFU) (p = 0.003). In the same patient population (10 out of 14 patients), there was meanwhile a significant mean increase of 0.43 mm in the ipsilateral P1 segment diameter observed (p = 0.015). These vessel remodeling effects were in direct correlation with aneurysm occlusion since all of these patients showed aneurysm occlusion at LFU while 29% showed only partial occlusion without vessel remodeling effects. A decrease in PcomA diameter was directly associated with aneurysm occlusion (p = 0.042). There were no neurologic complications on LFU. Conclusion: In the treatment of PcomA aneurysms with PED, the P1 segment of the PCA increases in diameter while the PcomA diameter decreases. Our results suggest that this remodeling effect is associated with aneurysm occlusion and decrease of PcomA is hemodynamically compensated for by an increase in the ipsilateral P1 diameter.

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Predictors of incomplete aneurysm occlusion after treatment with the Pipeline Embolization Device: PREMIER trial 1 year analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-018054 ◽

2021 ◽

pp. neurintsurg-2021-018054

Author(s):

Ricardo A Hanel ◽

Andre Monteiro ◽

Peter K Nelson ◽

Demetrius K Lopes ◽

David F Kallmes

Keyword(s):

Treatment Failure ◽

Intracranial Aneurysms ◽

Side Branch ◽

Maximum Diameter ◽

Complete Occlusion ◽

Unruptured Aneurysms ◽

Aneurysm Occlusion ◽

Incomplete Occlusion ◽

Flow Diverters

BackgroundFlow diverters have revolutionized the treatment of intracranial aneurysms. Nevertheless, some aneurysms fail to occlude with flow diversion. The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device (PREMIER) was a prospective, multicenter and single-arm trial of small and medium wide-necked unruptured aneurysms. In the current study, we evaluate the predictors of treatment failure in the PREMIER cohort.MethodsWe analyzed PREMIER patients who had incomplete occlusion (Raymond-Roy >1) at 1 year angiographic follow-up and compared them with those who achieved Raymond-Roy 1, aiming to identify predictors of treatment failure.Results25 aneurysms demonstrated incomplete occlusion at 1 year. There was a median reduction of 0.9 mm (IQR 0.41–2.43) in maximum diameter between pre-procedure and 1 year measurements, with no aneurysmal hemorrhage. Patients with incomplete occlusion were significantly older than those with complete occlusion (p=0.011). Smoking (p=0.045) and C6 segment location (p=0.005) were significantly associated with complete occlusion, while location at V4 (p=0.01) and C7 (p=0.007) and involvement of a side branch (p<0.001) were significantly associated with incomplete occlusion. In multivariable logistic regression, significant predictors of incomplete occlusion were non-smoker status (adjusted OR 4.49, 95% CI 1.11 to 18.09; p=0.03) and side branch involvement (adjusted OR 11.68, 95% CI 3.84 to 35.50; p<0.0001), while C6 location had reduced odds of incomplete occlusion (adjusted OR 0.29, 95% CI 0.10 to 0.84; p=0.02).ConclusionsThe results of our study are consistent with previous retrospective series and warrant consideration for technique adaptations to achieve higher occlusion rates. Further follow-up is needed to assess progression of aneurysm occlusion and clinical behavior in these cases.

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