Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

Beaty, Narlin; Campos, Jessica K.; Colby, Geoffrey P.; Lin, Li-Mei; Bender, Matthew T.; Xu, Risheng; Coon, Alexander L.

doi:10.1159/000484986

Cited by 7 publications

(8 citation statements)

References 30 publications

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“…Some investigators have treated AVM-associated feeding artery aneurysms with flow-diverting stents56–58 or stent-assisted coiling 59. These small case studies have advocated use of a standard dual antiplatelet medication regimen to prevent stent thrombosis.…”

Section: Disease-specific Considerationsmentioning

confidence: 99%

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Schirmer

Bulsara

Al‐Mufti

et al. 2023

J NeuroIntervent Surg

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BackgroundAntiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline ‘Platelet function inhibitor and platelet function testing in neurointerventional procedures’, providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.MethodsWe performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6–12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual’s ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient’s risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).ConclusionsAlthough the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

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Section: Disease-specific Considerationsmentioning

confidence: 99%

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Schirmer

Bulsara

Al‐Mufti

et al. 2023

J NeuroIntervent Surg

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“…Complete occlusion of the aneurysm was achieved in 56.3% of cases with coiling and 99% with parent vessel sacrifice. Recent techniques such as flow diversion remain possible in this context and are described in case-studies (27,28). Symptomatic or ruptured venous aneurysms can also be selectively treated using a transvenous method (29).…”

Section: Acute Hemorrhagic Presentationmentioning

confidence: 99%

“…Recent techniques such as flow diversion remain possible in this context and are described in case studies. 38 39 Symptomatic or ruptured venous aneurysms can also be selectively treated using a transvenous method. 40 41…”

Section: General Strategies For the Selection Of Evt For Bavm Treatmentmentioning

confidence: 99%

“…Recent techniques such as flow diversion remain possible in this context and are described in case studies. 38,39 Symptomatic or ruptured venous aneurysms can also be selectively treated using a transvenous method. 40,41 Nidal compression or global angioarchitecture distortion brought on by the mass effect of an adjacent hematoma may potentially lead to the misinterpretation of the actual nidus size and morphology.…”

Section: Acute Management Of Ruptured Bavmsmentioning

confidence: 99%

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Endovascular Management of Brain Arteriovenous Malformations

et al. 2023

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Due to the risk of cerebral hemorrhage, and its related morbidity-mortality, brain arteriovenous malformations (bAVM) are a rare and threatening disease. Concerning bAVM management, only one randomized control trial -the ARUBA trial -has been published so far. The results of the ARUBA trial favor a non-interventional approach in the case of an unruptured bAVM, however implementation of these findings is challenging in daily practice.Instead, management relies on multidisciplinary discussions that lead to patient-specific strategies based on local expertise and experience in reference centers. Given the wide patterns of presentation and multiple treatment modalities recommendations are also difficult to follow. Endovascular treatment (EVT) is a widely used modality which can be used for curative treatment, or prior to surgery or radiosurgery ("pre-EVT"). EVT practice is in constant evolution (i.e. venous approach, combination with surgery during the same anesthesia, etc.). Liquid embolic agents (LEA) such as ethylene vinyl alcohol (EVOH) copolymer and cyanoacrylates (CYA), and their method of injection to increase bAVM occlusion, have also benefited from technical evolutions such as the use of adjunctive flow arrest techniques (mini balloons, pressure cooker technique and multiple catheters). Further research is necessary to evaluate the advantages and disadvantages of EVT.

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“…The treatments reported include gamma knife surgery, endovascular treatment, combined modality staging, and hybrid surgical treatment. However, flow diverters (FDs) have shown limited effectiveness in treating flow-related cerebral aneurysms associated with AVMs (1)(2)(3).…”

Section: Introductionmentioning

confidence: 99%

Utilizing the Trans-Cell Approach as a Salvage Treatment for an Unopened Flow Redirection Endoluminal Device in a Flow-Related Aneurysm Associated with Arteriovenous Malformation: A Case Report

Yen,

Lai

2024

I J Radiol

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Introduction: We report the first case demonstrating the viability of the trans-cell approach as a salvage strategy in situations where Flow Redirection Endoluminal Devices (FREDs) fail to open. Case Presentation: A 64-year-old woman was admitted to our facility after a motorcycle accident. During her examination, an arteriovenous malformation (AVM) in the right temporal lobe was incidentally discovered. The AVM was associated with large flow-related aneurysms in the bilateral supraclinoid internal carotid artery (ICA), as revealed by computed tomography and magnetic resonance imaging. The AVM was surgically removed, and the aneurysm was treated endovascularly using a FRED. However, the middle section of the FRED failed to open post-deployment. We successfully carried out a salvage therapy using the stent strut technique with a Headway Duo microcatheter for coiling. Conclusion: The trans-cell technique utilizing a Headway Duo 156 microcatheter can be an effective salvage treatment for unopened FRED stents used in brain aneurysm cases.

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Pipeline Flex Embolization of Flow-Related Aneurysms Associated with Arteriovenous Malformations: A Case Report

Cited by 7 publications

References 30 publications

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Endovascular Management of Brain Arteriovenous Malformations

Utilizing the Trans-Cell Approach as a Salvage Treatment for an Unopened Flow Redirection Endoluminal Device in a Flow-Related Aneurysm Associated with Arteriovenous Malformation: A Case Report

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