The pCONus Device in Treatment of Wide-necked Aneurysms : Technical and Midterm Clinical and Angiographic Results

Efficacy of pCONUS Devices in the Management of Intracranial Aneurysms: Outcomes of 190 Patients

Intracranial aneurysms (IAs) pose a significant health concern, necessitating effective treatment modalities. The pCONUS device has emerged as a promising option for managing complex IAs, particularly wide-necked bifurcation aneurysms. Evaluating its efficacy across multiple studies is essential for establishing therapeutic guidelines. A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies assessing the efficacy of pCONUS devices in treating cerebral aneurysms. PubMed, Google Scholar, and Scopus were searched for relevant articles published from January 1, 2000, to December 31, 2021. Inclusion criteria encompassed clinical trials examining pCONUS device benefits for ruptured or unruptured cerebral aneurysms. Data extraction and quality assessment were performed independently by two reviewers. Out of 390 initially identified articles, eight studies met the inclusion criteria. These studies collectively involved 190 participants with intracranial aneurysms. The sample sizes ranged from seven to 40 patients, predominantly in retrospective designs. Complete occlusion rates varied from 46.8% to 100%, with a mean diameter of treated aneurysms ranging from 2.5 mm to 8.83 mm. This systematic review suggests that pCONUS devices are feasible and effective for treating complex bifurcation cerebral aneurysms, with acceptable complication rates. Despite limitations such as retrospective study designs and limited follow-up durations, the findings support the beneficial role of pCONUS devices in managing challenging intracranial aneurysms. Larger collaborative efforts with longer follow-up durations are warranted to validate these findings and establish wider therapeutic guidelines.

Endovascular treatment of middle cerebral artery aneurysms: current status and future prospects

Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.

Results of the pToWin Study: Using the pCONUS Device for the Treatment of Wide-Neck Intracranial Aneurysms

Coil embolization has become a well-established option for the treatment of intracranial aneurysms. Yet, wide-neck bifurcation aneurysms (WNBAs) remain a challenge. The pCONUS is the first generation of a stent-like implant for the bridging of WNBAs to enable coiling. The pToWin study was a prospective, single-arm, multicenter study conducted to analyze the safety and efficacy of the pCONUS in the treatment of WNBAs. The primary effectiveness endpoint was the rate of adequate occlusion of the aneurysm at 3–6 and 7–12 months. The primary safety endpoint was the occurrence of major ipsilateral stroke or neurological death during the follow-up. A total of 115 patients were included. Aneurysm locations were the middle cerebral artery in 52 (45.2%), the anterior communicating artery in 35 (30.4%), the basilar artery in 23 (20%), the internal carotid artery terminus in three (2.6%), and the pericallosal artery in two (1.7%) patients. Treatment was successfully performed in all but one patient. The morbi-mortality rate was 1.9% and 2.3% at 3–6 and 7–12 months, respectively. Of the aneurysms, 75.0% and 65.6% showed adequate occlusion at 3–6 and 7–12 months, respectively. pCONUS offers a safe and reasonably effective treatment of WNBAs, demonstrated by acceptable adequate aneurysm occlusion and low rates of adverse neurologic events.

Long-term follow-up of the pCONus device for the treatment of wide-neck bifurcation aneurysms

PURPOSE

Wide-neck bifurcation aneurysms remain challenging for the neurointerventionist and/or neurosurgeon despite many recent advances. The pCONus (Phenox, Bochum, Germany) is an emerging device for endovascular neck protection, we report the first long-term results of this device.

METHODS

We performed a retrospective analysis of all consecutive intracranial wide-neck bifurcation aneurysms treated with the pCONus. Patients' characteristics were reviewed, procedural complications, angiographic (Roy-Raymond scale) and clinical outcomes were documented.

RESULTS

Between January 2016 and September 2019, 43 patients (74% female, median age 56 [49-66] years) with 43 wide-neck bifurcation aneurysms (mean width of 6.8 ± 2.1 mm, dome/neck ratio of 1.3 ± 0.2 and neck of 5.2 ± 1.3 mm) were included. A procedural angiographic complication was reported in five patients (12%), no patient presented a post-operative neurological deficit or long-term complication, mortality rate was 0%. At last follow-up (median of 46.5 months [38.3-51.7]), an adequate occlusion (complete and neck remnant) was observed in 37/43 patients (86%) and an aneurysm remnant in 6/43 (14%). Four patients (9%) needed retreatment. No in-stent stenosis or branch occlusion was depicted.

CONCLUSION

pCONus device provides a safe and efficient alternative for endovascular wide-neck bifurcation aneurysms management, with long-term stability.

"Shelf" Technique Using a Novel Braided Self-Expandable Stent for the Treatment of Wide-Necked Bifurcation Aneurysms

Background

Different endovascular techniques exist for treatment of cerebral wide-necked bifurcation aneurysms (WNBA). We present the “shelf” technique with the novel woven LVIS EVO stent, which enables forming a buttress at the level of the aneurysm neck to prevent coil prolapse and additional stenting.

Methods

Single-center retrospective analysis of patients treated with the “shelf” technique by using LVIS EVO stent in incidental WNBAs between January 2020 and March 2021. Inclusion criteria were saccular aneurysms with neck width ≥4 mm or a dome/neck ratio ≤2. Primary endpoint was a favorable navigation to the target vessel and successful deployment of the LVIS EVO stent with forming a buttress that enables aneurysm occlusion by subsequent coiling. Secondary endpoints were aneurysm occlusion on follow-up, procedure-related complications and clinical outcome.

Results

A total of 15 patients were included. The primary end point was reached in 100% of cases. A complete aneurysm occlusion at the end of the procedure was achieved in 14/15 patients (93%). No intraprocedural complications occurred. All patients except one were discharged with an modified Rankin Scale (mRS) of 0. Procedure-related morbidity was 7%. Median follow-up imaging was 115 days (7–419 days) and available for 11/15 (73%) of the patients. Of those, 10 (91%) individuals had a complete aneurysm occlusion and 1 showed a residual neck. In all patients, the covered branch was patent and no ischemic complications occurred during follow-up.

Conclusion

This study demonstrates the “shelf” technique with LVIS EVO stents as a feasible and safe treatment option for WNBAs with very good short-term occlusion rates.

Endovascular embolization of wide-necked bifurcation aneurysms with the use of pCONus device: A systematic review and meta-analysis

BACKGROUND

The following study aimed to summarize the overall safety and efficacy of the pCONus device in the treatment of wide-necked bifurcation aneurysms.

MATERIAL AND METHODS

Major electronic medical databases were thoroughly searched to identify relevant studies. Data regarding the type of included studies, type of aneurysm and its location, treatment results measured in Raymond-Roy Occlusion Class (RROC) and its complications, as well as patients' neurological outcome at the discharge were extracted from the eligible studies and included in the meta-analysis. The subgroup analyses dependent on the aneurysm rupture status were also conducted.

RESULTS

A total of 8 studies (198 patients with 200 aneurysms) were included in this meta-analysis. The most common localization of the treated aneurysms was the middle cerebral artery with its pooled prevalence estimate (PPE) of 44.5%. Immediately after the procedure, RROC I (complete obliteration of the aneurysm) was observed in 46.8%, RROC II in 32.9%, while RROC III (residual aneurysm) in 20.3% of the patients. In a short-term follow-up, PPE of RROC I was 55.0%, RROC II 29.0%, and RROC III 16.1%. The PPE of intraprocedural complications was 17.3%, the most frequent were thromboembolic events, which were observed in 12.1% of all procedures. Poor neurological outcome at the discharge was noted with PPE of 9.6%.

CONCLUSIONS

The effectiveness and safety of wide-necked bifurcation aneurysm treatment utilizing the pCONus device is moderate. There is still a need for a consensus regarding the effective antiplatelet regimen in furtherance of diminishing the rate of thromboembolic events.

Novel Noncrossing Y-Stent Technique Using Tapered Proximal End of a Solitaire AB Stent for Coil Embolization of Wide-Neck Bifurcation Aneurysms

The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.

The pCONUS bifurcation aneurysm implants for endovascular treatment of adults with intracranial aneurysms: A systematic review and meta-analysis

Background

The authors sought to assess the safety and early efficacy of the pCONUS Bifurcation Aneurysm Implants in a meaningful number of patients; we performed a systematic review and meta-analysis for the treatment of 203 intracranial aneurysms.

Methods

A literature search was performed by a reference librarian, and after screening nine case series were included in this analysis. We estimated from each study the cumulative incidence (event rate) and 95% confidence interval (CI) for each outcome. Event rates were pooled in a meta-analysis across studies using the random-effects model; descriptive statistics were reported when relevant.

Results

The pCONUS devices can be used with a technical success rate of 100% (95% CI: 0.98-1.00) and a technical complication rate of 0% (95% CI: 0.00-0.02). Perioperative morbidity and mortality rates were 7% (95% CI: 0.03-0.11) and 0% (95% CI: 0.00-0.01), respectively. Perioperative hemorrhage rate was 0% (95% CI: 0.00-0.02); rate of treatment-related long-term neurological deficit was 2% (95% CI: 0.00-0.06). The long-term complete occlusion rate was 60% (95% CI: 0.52-0.69) and retreatment rate was 14% (95% CI: 0.06-0.22).

Conclusions

The pCONUS devices are an additional tool for the treatment of wide-necked intracranial aneurysms with high rates of technical success and sufficiently low rates of morbidity and mortality. Comparative studies with longer-term follow-up are needed to clarify the role of this device in the management of challenging aneurysms.

Repeating enlargement, recanalisations, and subarachnoid haemorrhages after middle cerebral artery aneurysm embolisation using pCONus stent and coils - a case report

Purpose

Large and wide-necked bifurcation aneurysms remain technically challenging to treat by the endovascular approach. Several endovascular strategies have been established in recent years for treating wide-necked bifurcation aneurysms, such as balloon-assisted coiling, stent-assisted coiling, waffle cone technique (WCT), and intrasaccular flow disruptors.

Case report

A 64-year-old woman was diagnosed with three intracranial aneurysms of the right and left middle cerebral artery and right internal carotid artery. She was qualified for endovascular treatment of the left middle cerebral artery (LMCA) aneurysm because it posed the greatest risk of rupture. Due to complicated morphology, a pCONus stent and coils were chosen for treatment. Three months later the right middle cerebral artery aneurysm was embolised and the woman was scheduled for second-stage treatment of the LMCA aneurysm. One week before the planned admission the woman was diagnosed with subarachnoid haemorrhage (SAH) in the region of the previously treated LMCA aneurysm, and the second-stage treatment was conducted with a good result. The woman was discharged in improved condition. Three months later the woman was once again admitted with SAH – an enlarged LMCA aneurysm was observed and immediate third-stage embolisation was performed, but due to complications of SAH the woman eventually died.

Conclusions

On the basis of the presented case we would like to emphasise the importance of sufficient initial coil packing and frequent control of neck region of the aneurysm for the long-term stability and safety after pCONus-assisted coiling of intracranial aneurysms.

Re-treatment of an unruptured anterior communicating artery aneurysm using the new pCONus 2 device: Description of a case

Endovascular approach represents today the first option in treatment of ruptured and unruptured cerebral aneurysms. Nevertheless, wide-neck bifurcation aneurysms still represent a technical challenge for endovascular treatment due to the need to protect vessels arising next to the aneurysmal neck. A variety of devices have been implemented to ensure adequate assistance for coiling of these lesions. Among these devices, the new pCONus 2 represents an evolution of the well-known pCONus; compared to the previous one in fact, it allows a degree of articulation and flexibility between the shaft and the distal part (crown), making it more suitable for treatment of aneurysms presenting an angle between the longitudinal axis of the dome and parent vessel. We report our first case using pCONus 2 in the re-treatment of an unruptured anterior communicating artery aneurysm in a 57-year-old man, showing evident recanalization two years after coiling.

Current Status of the PulseRider in the Treatment of Bifurcation Aneurysms: A Systematic Review

BACKGROUND

The PulseRider is an innovative stent-like device designed for the treatment of intracranial bifurcation aneurysms. The aim of this study was to assess the current evidence on safety and effectiveness of the PulseRider.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Ovid MEDLINE, and Scopus. The search strategy consisted of "pulserider," "bifurcation aneurysm," and "endovascular" in both AND and OR combinations. Studies included were original research articles in peer-reviewed journals. The manuscripts were thoroughly examined for study design, outcomes, and results.

RESULTS

Three studies were identified describing use of the PulseRider device in the treatment of 63 patients with 63 bifurcation aneurysms. We identified 2 multicenter case series and 1 single-arm clinical trial. The majority of aneurysms treated were located at the basilar tip (37, 58.7%). All devices were successfully deployed, and there were 5 intraoperative complications (7.9%), including 2 intraoperative aneurysm ruptures, 1 vessel dissection, and 2 thrombus formations. Immediate complete aneurysm occlusion was achieved in 61.9% (39/63) of cases and at the 6-month imaging follow-up, 66.7% (42/63) achieved complete aneurysm occlusion. One recanalization was reported in 1 of the multicenter case series within the 6-month follow-up.

CONCLUSIONS

The PulseRider is safe and probably effective for the treatment of intracranial bifurcation aneurysms, sometimes not amenable for stent-assisted coiling. However, current evidence is limited to a small sample and short follow-up. In addition, the device has not been compared with other treatment modalities.

Treatment of Wide-Necked Bifurcation Aneurysms : Initial Results with the pCANvas Neck Bridging Device

Background

Recently, numerous devices dedicated to the treatment of wide-necked aneurysms have become available. We present our initial experience with the pCANvas device and present the technical success rate, clinical outcome and immediate angiographic occlusion rates.

Objective

We sought to determine the efficacy of flow with the pCANvas for the treatment of unruptured intracranial aneurysms.

Methods

We performed a retrospective review of our prospectively collected data to identify patients treated with the pCANvas device between February 2015 and February 2017. The patient demographics, aneurysm characteristics, immediate and delayed clinical and radiographic follow-up data were recorded.

Results

We identified 17 patients (13 female) treated only with the pCANvas device. The average age of the patients was 60.5 ± 13.3 years (range 25–75 years). The average dome width was 7.6 ± 3.2 mm (range 3–15.8 mm), dome height 7.1 ± 3.2 mm (range 3–12.9 mm) and neck width 5.4 ± 3.2 (range 3–16.3 mm). The average aspect ratio was 1.5 ± 0.8 (range 0.6–3.7). At the end of the procedure 15 aneurysms continued complete filling of the aneurysm (Raymond Roy Classification[RRC] 3) with 2 aneurysms showing only filling of the neck of the aneurysm (RRC 2). Early follow-up angiography was available for 16 patients and at this stage 11 aneurysms showed persistent and complete filling of the aneurysm (RRC 3), 5 aneurysms showed complete occlusion of the aneurysm (RRC 1) and 7 aneurysms underwent repeat treatment with coiling.

Conclusion

The early results on the use of the pCANvas are promising; however, longer term follow-up and larger studies are required.

Endovascular Treatment of Unruptured Intracranial Aneurysms by the Woven EndoBridge Device (WEB): Are There Any Aspects Influencing Aneurysm Occlusion?

BACKGROUND

The experience with Woven EndoBridge (WEB) device is still limited. The aim of this study is to discuss the efficacy of this new device, focusing on any anatomical and procedural factors influencing aneurysm occlusion.

METHODS

Between October 2011 and November 2016, 24 patients (10 female, 14 male) harboring 24 cerebral aneurysms treated with WEB in a single center were retrospectively reviewed. Patients underwent 6-month and 12- to 24-month (median 18 months) clinical and neuroradiologic follow-up. We evaluated whether any procedural or anatomical aspect influenced the occlusion rate.

RESULTS

Adequate occlusion (AO) was achieved in 68% of cases at 6 months' and in 87% at 18 months' follow-up respectively. Technical difficulties occurred in 3 procedures (12.5%). No postprocedural morbidity was reported. One patient (4%) died after 1 month for reasons unrelated to the procedure. Neck size and dome-to-neck ratio were significantly associated with aneurysm occlusion (P < 0.05). AO was not associated with postoperative dual antiplatelet therapy (P > 0.99) or device compression at both first and second follow-up (P > 0.99). Immediate contrast agent stagnation was more common in aneurysms that were occluded at first (P = 0.37) and second follow-up (P = 0.24), but statistical significance was not reached.

CONCLUSIONS

Endovascular treatment with WEB is a safe treatment for unruptured cerebral aneurysms, also resulting in a good AO rate in aneurysms that would otherwise require complex assisted coiling techniques. However, results are less favorable in cases of very large aneurysmal neck. Nevertheless, further series with larger patient populations and longer follow-up will define the role of WEB in the treatment of aneurysms.