Current Trends and Results of Endovascular Treatment of Unruptured Intracranial Aneurysms at a Single Institution in the Flow-Diverter Era

Petr, Ondra; Brinjikji, Waleed; Cloft, Harry J.; Kallmes, David F.; Lanzino, Giuseppe

doi:10.3174/ajnr.a4699

Cited by 53 publications

(27 citation statements)

References 37 publications

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“…With the development of flow-diverting stents, such as the Pipeline embolization device (PED), many of these aneurysms can now be treated endovascularly. 8,24 Estimates suggest that nearly 50% of all aneurysms can be treated with flow diversion-a statistic that highly varies based on aneurysm location within the cerebral circulation. 7 Despite FDA approval of the PED in 2011, there is no corresponding inflection point in trends of bypass utilization.…”

Section: Discussionmentioning

confidence: 99%

National trends in cerebral bypass surgery in the United States, 2002–2014

Winkler

Yue

Deng

et al. 2019

Neurosurgical Focus

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OBJECTIVECerebral bypass procedures are microsurgical techniques to augment or restore cerebral blood flow when treating a number of brain vascular diseases including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. With advances in endovascular therapy and evolving evidence-based guidelines, it has been suggested that cerebral bypass procedures are in a state of decline. Here, the authors characterize the national trends in cerebral bypass surgery in the United States from 2002 to 2014.METHODSUsing the National (Nationwide) Inpatient Sample, the authors extracted for analysis the data on all adult patients who had undergone cerebral bypass as indicated by ICD-9-CM procedure code 34.28. Indications for bypass procedures, patient demographics, healthcare costs, and regional variations are described. Results were stratified by indication for cerebral bypass including moyamoya disease, occlusive vascular disease, and cerebral aneurysms. Predictors of inpatient complications and death were evaluated using multivariable logistic regression analysis.RESULTSFrom 2002 to 2014, there was an increase in the annual number of cerebral bypass surgeries performed in the United States. This increase reflected a growth in the number of cerebral bypass procedures performed for adult moyamoya disease, whereas cases performed for occlusive vascular disease or cerebral aneurysms declined. Inpatient complication rates for cerebral bypass performed for moyamoya disease, vascular occlusive disease, and cerebral aneurysm were 13.2%, 25.1%, and 56.3%, respectively. Rates of iatrogenic stroke ranged from 3.8% to 20.4%, and mortality rates were 0.3%, 1.4%, and 7.8% for moyamoya disease, occlusive vascular disease, and cerebral aneurysms, respectively. Multivariate logistic regression confirmed that cerebral bypass for vascular occlusive disease or cerebral aneurysm is a statistically significant predictor of inpatient complications and death. Mean healthcare costs of cerebral bypass remained unchanged from 2002 to 20014 and varied with treatment indication: moyamoya disease $38,406 ± $483, vascular occlusive disease $46,618 ± $774, and aneurysm $111,753 ± $2381.CONCLUSIONSThe number of cerebral bypass surgeries performed for adult revascularization has increased in the United States from 2002 to 2014. Rising rates of surgical bypass reflect a greater proportion of surgeries performed for moyamoya disease, whereas bypasses performed for vascular occlusive disease and aneurysms are decreasing. Despite evolving indications, cerebral bypass remains an important surgical tool in the modern endovascular era and may be increasing in use. Stagnant complication rates highlight the need for continued interest in advancing available bypass techniques or technologies to improve patient outcomes.

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Section: Discussionmentioning

confidence: 99%

National trends in cerebral bypass surgery in the United States, 2002–2014

Winkler

Yue

Deng

et al. 2019

Neurosurgical Focus

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“…With the expansion of FDS use beyond the large and giant wide-necked aneurysms of the ICA not amenable to coil em-bolization, a comparison can now be made between traditional coil embolization and FDS for treatment of cerebral aneurysms. Petr et al 91) reported their institutional series of endovascular treatment of 310 patients with aneurysms of varied size and locations. Treatment modalities included both coil embolization and FDS.…”

Section: Coil Embolization Vs Fdsmentioning

confidence: 99%

The Evolution of Flow-Diverting Stents for Cerebral Aneurysms; Historical Review, Modern Application, Complications, and Future Direction

Shin

Carroll

Elghareeb

et al. 2020

J Korean Neurosurg Soc

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In spite of the developing endovascular era, large (15-25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.

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“…FDs are a reconstructive treatment in which altered flow within an aneurysm induces gradual remodeling and eventual thrombosis of the aneurysm. Several studies have demonstrated good safety and efficacy of FDs for the treatment of unruptured intracranial aneurysms, [8][9][10][11][12][13][14][15][16][17] though the safe use of these devices requires the use of dual antiplatelet therapy. [18][19][20] Understandably, the need for antiplatelet medications and the delayed nature of aneurysm thrombosis have tempered en-thusiasm for using FDs for ruptured aneurysms.…”

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confidence: 99%