COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience

Abstract

BackgroundWe report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.MethodsConsecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020–2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.ResultsA total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3–4) to post-treatment (0–2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0–2) was noted in 51.5% of patients (median follow-up 6 months).ConclusionsThe Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage

“…Instead, a mechanical radial force is gradually exerted on the spastic vascular wall by means of self-expansion after release of the stent retriever without the need for temporary occlusion. In addition, different novel non-occlusive stents are currently used for treating spasms [71][72][73]. In our institution we have had positive experiences with the Comaneci instrument with an adjustable and easy-to-control radial force for the endovascular treatment of CVS.…”

“…Anders als bei der BA ist dabei keine direkte Intimaschädigung zu erwarten, viel mehr wir nach Freisetzen des Stentretrievers durch Selbstexpansion schrittweise eine mechanische Radialkraft auf die spastische Gefäßwand ausgeübt, ohne dass eine passagere Okklusion erfolgen muss. Zusätzlich werden aktuell auch unterschiedliche neuartige, nicht-okklusive Stents zur Spasmusbehandlung genutzt 71 72 73 . Wir selbst haben in unserer Institution mit dem Comaneci-Instrument unter Nutzung einer verstellbaren und dabei gut steuerbaren Radialkraft positive Erfahrungen bei der endovaskulären Behandlung von ZVS gesammelt.…”

Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018–2021: an overview of the current care situation

“…Im Rahmen der Bewertung dieser Methode ist im Januar dieses Jahres vor einer abschließenden Entscheidung über eine Richtlinie zur Erprobung des Materials vom Gemeinsamen Bundesausschuss (GBA) ein Stellungnahmeverfahren eingeleitet worden [26]. Darüber hinaus finden auch andere nicht okklusive Stents Anwendung [15]. Interessant erscheint auch die Häufigkeit des Stentings in 176 Fällen aller EST (2,3 %).…”

“…Die BA wird ganz überwiegend zusätzlich zur medikamentösen EST durchgeführt, mit sowohl Non-Compliant-als auch Compliant-Ballonkathetern [12]. Außerdem kommen lokale medikamentöse Dauertherapien unter Verwendung von Mikrokathetern sowie Gefäßdilatationen mit Stentretrievern oder anderen nicht okklusiven Stents zur Anwendung [13][14][15]. Ferner sind bei rekurrenten ZVS auch Fallserien zur dauerhaften Stentangioplastie zu finden [16].…”

“…Balloon angioplasty is predominantly performed in addition to EVT with medication, with both non-compliant and compliant balloon catheters [12]. In addition, topical long-term drug therapies using microcatheters and vascular dilatation with stent retrievers or other non-occlusive stents are used [13][14][15]. Furthermore, in the case of recurrent CVS, case series on long-term stent angioplasty can also be found [16].…”