Flow diverter stents for unruptured saccular anterior circulation perforating artery aneurysms: safety, efficacy, and short-term follow-up

Kühn, Anna Luisa; Hou, Samuel Y; Perras, M; Brooks, Christopher; Gounis, Matthew J.; Wakhloo, Ajay K.; Puri, Ajit S

doi:10.1136/neurintsurg-2014-011237

Cited by 31 publications

(18 citation statements)

References 41 publications

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“…4,6,24,37,40,46 These promising results led to increasing off-label use of the PED for aneurysms that are not large and not wide necked, and several groups have found similarly strong results after treating small aneurysms 11,17,26 and other off-label applications. 2,10,13,28,32,36 Still, the number of studies on use of the PED to treat small aneurysms has been limited, and very few have directly compared patient outcomes with those of patients after coiling or clipping. 30 The mean aneurysm size in this study was 8.2 mm, which is smaller than the minimum size (10 mm) for which the PED is approved.…”

Section: Discussionmentioning

confidence: 99%

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Silva

See

Khandelwal

et al. 2019

Journal of Neurosurgery

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OBJECTIVE Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling. METHODS The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention. RESULTS A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03). CONCLUSIONS In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

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Section: Discussionmentioning

confidence: 99%

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Silva

See

Khandelwal

et al. 2019

Journal of Neurosurgery

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“…A recent clinical study on intracranial perforators has shown results that further support our observations. 23 Additionally, in a recent CFD study in small-caliber human arteries, 17 a relatively low flow rate reduction of 8% was found after FDS jailing. In a recent animal study dealing with telescopic stenting, Dai et al 8 found patency of the jailed branches while at the same time acknowledging limitations regarding perforators.…”

Section: Study Limitationsmentioning

confidence: 96%

“…In a few human case series involving intracranial arterial perforators, 15,23 rare symptomatic occlusions in jailed branches were reported. Perforators are by definition terminal arteries and, according to our observations, are expected to remain patent after stenting.…”

Section: Study Limitationsmentioning

confidence: 99%

Role of terminal and anastomotic circulation in the patency of arteries jailed by flow-diverting stents: from hemodynamic changes to ostia surface modifications

Iosif

Berg

Ponsonnard

et al. 2017

Journal of Neurosurgery

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OBJECTIVE The outcome for jailing arterial branches that emerge near intracranial aneurysms during flow-diverting stent (FDS) deployment remains controversial. In this animal study, the authors aimed to elucidate the role of collateral supply with regard to the hemodynamic changes and neointimal modifications that occur from jailing arteries with FDSs. To serve this purpose, the authors sought to quantify 1) the hemodynamic changes that occur at the jailed arterial branches immediately after stent placement and 2) the ostia surface values at 3 months after stenting; both parameters were investigated in the presence or absence of collateral arterial flow. METHODS After an a priori power analysis, 2 groups (Group A and Group B) were created according to an animal flow model for terminal and anastomotic arterial circulation; each group contained 7 Large White swine. Group A animals possessed an anastomotic-type arterial configuration to supply the territory of the right ascending pharyngeal artery (APhA), while Group B animals possessed a terminal-type arterial configuration to supply the right APhA territory. Subsequently, all animals underwent FDS placement, thereby jailing the right APhAs. Mean flow rates and velocities inside the jailed branches were quantified using time-resolved 3D phase-contrast MR angiography before and after stenting. Three months after stent placement, the jailed ostia surface values were quantified on scanning electron micrographs. The data were analyzed using descriptive statistics and group comparisons with parametric and nonparametric tests. RESULTS The endovascular procedures were feasible, and there were no findings of in situ thrombus formation on postprocedural optical coherence tomography or ischemia on postprocedural diffusion-weighted imaging. In Group A, the mean flow rate values at the jailed right APhAs were reduced immediately following stent placement as compared with values obtained before stent placement (p = 0.02, power: 0.8). In contrast, the mean poststenting flow rates for Group B remained similar to those obtained before stent placement. Three months after stent placement, the mean ostia surface values were significantly higher for Group B (527,911 ± 306,229 μm) than for Group A (89,329 ± 59,762 μm; p < 0.01, power: 1.00), even though the initial dimensions of the jailed ostia were similar between groups. A statistically significant correlation was found between groups (A or B), mean flow rates after stent placement, and ostia surface values at 3 months. CONCLUSIONS When an important collateral supply was present, the jailing of side arteries with flow diverters resulted in an immediate and significant reduction in the flow rate inside these arteries as compared with the prestenting values. In contrast, when competitive flow was absent, jailing did not result in significant flow rate reductions inside the jailed arteries. Ostium surface values at 3 months after stent placement were significantly higher in the terminal group of jailed arteries (Group B) than in the an...

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“…2 Numerous studies have since demonstrated the safety and efficacy of the PED in treating aneurysms with varying morphologies in different anatomic locations. [3][4][5][6][7][8] As the clinical indications for PED placement expand, predictors of radiographic outcomes have become a topic of ongoing investigation. Although 1 study found that fusiform aneurysm morphology and shorter follow-up length were independent predictors of incomplete occlusion, this study was limited by a small sample size and a mean follow-up of 6.1 months.…”

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confidence: 99%

Predictors of Incomplete Occlusion following Pipeline Embolization of Intracranial Aneurysms: Is It Less Effective in Older Patients?

Adeeb

Moore

Wirtz

et al. 2017

AJNR Am J Neuroradiol

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Complete occlusion following PED treatment of intracranial aneurysms can be influenced by several factors related to the patient, aneurysm, and treatment. Of these factors, older age (older than 70 years) and nonsmoking status were independent predictors of incomplete occlusion. While the physiologic explanation for these findings remains unknown, identification of factors predictive of incomplete aneurysm occlusion following PED placement can assist in patient selection and counseling and might provide insight into the biologic factors affecting endothelialization.

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Flow diverter stents for unruptured saccular anterior circulation perforating artery aneurysms: safety, efficacy, and short-term follow-up

Abstract: Our preliminary results show that flow diversion technology is an effective and safe therapy for complex, hard-to-treat aneurysms in perforating arteries. Larger studies with long-term follow-up are needed to validate our promising results.

Cited by 31 publications

References 41 publications

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

Role of terminal and anastomotic circulation in the patency of arteries jailed by flow-diverting stents: from hemodynamic changes to ostia surface modifications

Predictors of Incomplete Occlusion following Pipeline Embolization of Intracranial Aneurysms: Is It Less Effective in Older Patients?

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