Comparison of clinical and radiologic outcomes among stent-assisted, double-catheter, and balloon-assisted coil embolization of wide neck aneurysms

Evaluating the Balloon-Assisted Rapid Intermittent Sequential Coiling Technique for the Treatment of Wide-Neck Cerebral Aneurysms

BACKGROUND

 Balloon-assisted coiling (BAC) is acknowledged as an auxiliary method for the endovascular treatment of difficult wide-necked cerebral aneurysms (WNCAs). An intracranial stent may be necessary as a supportive scaffold when the anatomical conditions are unfavorable, as BAC alone may be inadequate to avoid coil protrusion into the parent artery. We aimed to evaluate the safety of the balloon-assisted rapid intermittent sequential coiling technique (BARISCT) and the effectiveness of BARISCT in reducing the risk of coil prolapse in the primary artery during the coiling of WNCA.

METHODOLOGY

 From March 2021 to April 2023, a quasi-experimental investigation was conducted on more than 19 patients with WNCA who visited the Neurointervention Unit at Suez Canal University Hospital and fulfilled the inclusion criteria of WNCA, specifically defined by an unfavorable dome-to-neck ratio of less than 2 or a neck length exceeding 4 mm.

RESULTS

 BARISCT has proven to be a safe and successful tool for occluding ruptured and unruptured WNCA, with a full occlusion rate of roughly 73% with minimum sequelae and no major complications.

CONCLUSION

 BARISCT seems to be a method that is both safe and successful for the endovascular treatment of wide-neck intracranial aneurysms (WNCA), with no concern regarding the potential for an increase in the likelihood of complications.

Stent-assistant versus non-stent-assistant coiling for ruptured and unruptured intracranial aneurysms: A meta-analysis and systematic review

Background

Several different endovascular and non-invasive treatment methods are suggested for the various types of intracranial aneurysms including simple, balloon-assisted, and stent-assisted coiling (SAC). Previous studies investigated the safety and efficacy of SAC versus non-stent-assisted coiling (non-SAC) but the results were controversial. We aim to perform a systematic review and meta-analysis to compare the efficacy and safety of SAC with non-SAC technique in stratifying by the ruptured and unruptured aneurysms.

Methods

PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were searched in April 2022 for studies investigated the efficacy and safety of SAC versus non-SAC.

Results

Overall, 26 studies entered into our qualitative and quantitative synthesis. We found that there was overall lower recurrence rate in SAC versus non-SAC significant (RR: 0.43, 95%CI: 0.33, 0.53). Furthermore, the comparisons were significant in unruptured (RR: 0.63, 95%CI: 0.40, 0.86), ruptured (RR: 0.29, 95%CI), and combination aneurysms (RR: 0.42, 95%CI: 0.30, 0.54). Also, we found higher risk of intraprocedural rupture for SAC versus non-SAC in unruptured aneurysms (RR: 1.40, 95%CI: 1.31, 1.50). Investigating hemorrhagic events risk showed that there was significant difference in ruptured (RR: 1.73, 95%CI: 1.12, 2.34) and combination aneurysms (RR: 0.60, 95%CI: 0.37, 0.82). There was no significant difference in immediate occlusion rate, complete occlusion, and risk of ischemic events in our analysis.

Conclusion

Overall, our findings demonstrated that SAC may have higher efficacy in term of recurrence rate, but also may have a higher risk of complications in the treatment of intracranial aneurysms. As there are several factors affecting the outcomes and safety of these interventions, further RCTs controlled for multiple factors are required better guide the neurointerventionists choose the best strategy.

Treatment of Ruptured Wide-Necked Aneurysms using a Microcatheter Injectable Biomaterial

Ruptured wide-neck aneurysms (WNAs), especially in a setting of coagulopathy, are associated with significant morbidity and mortality. It is shown that by trapping a sub-millimeter clinical catheter inside the aneurysm sac using a flow diverter stent (FDS), instant hemostasis can be achieved by filling the aneurysm sac using a novel biomaterial, rescuing catastrophic bleeding in large-animal models. Multiple formulations of a biomaterial comprising gelatin, nanoclay (NC), and iohexol are developed, optimized, and extensively tested in vitro to select the lead candidate for further testing in vivo in murine, porcine, and canine models of WNAs, including in a subset with aneurysm rupture. The catheter-injectable and X-ray visible versions of the gel embolic agent (GEA) with the optimized mechanical properties outperform control groups, including a subset that receive a clinically used liquid embolic (Onyx, Medtronic), with and without aneurysm rupture. A combinatorial approach to ruptured WNAs with GEA and FDS may change the standard of medical practice and save lives.

Stent-Assisted Coiling in the Treatment of Unruptured Intracranial Aneurysms: A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Stent-assisted coiling may improve angiographic results of endovascular treatment of unruptured intracranial aneurysms compared with coiling alone, but this has never been shown in a randomized trial.

MATERIALS AND METHODS

The Stenting in the Treatment of Aneurysm Trial was an investigator-led, parallel, randomized (1:1) trial conducted in 4 university hospitals. Patients with intracranial aneurysms at risk of recurrence, defined as large aneurysms (≥10 mm), postcoiling recurrent aneurysms, or small aneurysms with a wide neck (≥4 mm), were randomly allocated to stent-assisted coiling or coiling alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS > 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that stent-assisted coiling would decrease treatment failures from 33% to 15%, requiring 200 patients. Primary analyses were intent to treat.

RESULTS

Of 205 patients recruited between 2011 and 2021, ninety-four were allocated to stent-assisted coiling and 111 to coiling alone. The primary outcome, ascertainable in 203 patients, was reached in 28/93 patients allocated to stent-assisted coiling (30.1%; 95% CI, 21.2%-40.6%) compared with 30/110 (27.3%; 95% CI, 19.4%-36.7%) allocated to coiling alone (relative risk = 1.10; 95% CI, 0.7-1.7; P  = .66). Poor clinical outcomes (mRS >2) occurred in 8/94 patients allocated to stent-assisted coiling (8.5%; 95% CI, 4.0%-16.6%) compared with 6/111 (5.4%; 95% CI, 2.2%-11.9%) allocated to coiling alone (relative risk = 1.6; 95% CI, 0.6%-4.4%; P  = .38).

CONCLUSIONS

The STAT trial did not show stent-assisted coiling to be superior to coiling alone for wide-neck, large, or recurrent unruptured aneurysms.

Effect of Stent Porosity, Platelet Function Test Usage, and Dual Antiplatelet Therapy Duration on Clinical and Radiographic Outcomes After Stenting for Cerebral Aneurysms: A Meta-Analysis

BACKGROUND

The use of stents with various porosities for treating cerebral aneurysms requires dual antiplatelet therapy (DAPT) without clear guidelines on the utility of platelet function tests (PFTs) and the duration of DAPT. We sought to determine the effects of stent porosity, PFT usage, and DAPT duration on the radiographic and clinical outcomes after stenting of cerebral aneurysms.

METHODS

PubMed was searched on March 29, 2021 for studies of cerebral aneurysm stenting that had specified the stent type and DAPT duration. A random effects meta-analysis was used to measure the prevalence of nonprocedural thrombotic and hemorrhagic events, clinical outcomes, aneurysm occlusion, and in-stent stenosis stratified by stent porosity, PFT usage, and DAPT duration.

RESULTS

The review yielded 105 studies (89 retrospective and 16 prospective) with 117 stenting cohorts (50 high porosity, 17 intermediate porosity, and 50 low porosity). In the high-, intermediate-, and low-porosity stenting cohorts, PFT usage was 26.0%, 47.1%, and 62.0% and the mean DAPT duration was 3.51 ± 2.33, 3.97 ± 1.92, and 5.18 ± 2.27 months, respectively. The intermediate-porosity stents showed a reduced incidence of hemorrhagic events (π = 0.32%) compared with low-porosity stents (π = 1.36%; P = 0.01) and improved aneurysm occlusion (π = 6.18%) compared with high-porosity stents (π = 14.42%; P = 0.001) and low-porosity stents (π = 11.71%; P = 0.04). The prevalence of in-stent stenosis was lower for the intermediate-porosity (π = 0.57%) and high-porosity (π = 1.51%) stents than for the low-porosity stents (π = 3.30%; P < 0.05). PFT use had resulted in fewer poor clinical outcomes (π = 3.54%) compared with those without PFT use (π = 5.94%; P = 0.04). The DAPT duration had no effect on the outcomes.

CONCLUSIONS

In the present meta-analysis, which had selected for studies of cerebral aneurysm stenting that had reported the DAPT duration, intermediate-porosity stents and PFT use had resulted significantly improved outcomes. No effect of DAPT duration could be detected.

Safety and effectiveness of double microcatheter technique in the treatment of ruptured aneurysms of anterior cerebral circulation

Objective

To evaluate the safety and effectiveness of the double microcatheter technique in the treatment of ruptured aneurysms of the anterior cerebral circulation.

Methods

Between 2012 and 2019, 113 patients with ruptured aneurysms of the anterior cerebral circulation were treated using the double microcatheter technique. Clinical records, angiographic results, and procedure-related complications were reviewed. Clinical and angiographic follow-up was performed.

Results

Complete occlusion, neck remnant, and partial occlusion were, respectively, recorded in 56.6, 38.9, and 4.4% of the total cases. For all patients, the incidence of intraoperative complications was 5.3% (6/113), and the overall rate of morbidity was 10.6% (12/113). Before discharge, three patients (2.7%) died. There was no procedure-related mortality. At discharge, favorable outcomes were observed in 79.6% (90/113) of the patients. High Hunt-Hess grades and receiving a craniotomy or external ventricular drainage were risk factors for clinical outcomes at discharge. Clinical follow-up was performed in 91 patients at a mean interval of 14.07 ± 11.68 months. At follow-up, favorable outcomes were observed in 92.3% (84/91) of the patients. Angiographic follow-up was performed in 66 patients at an average of 11.53 ± 11.13 months. The recurrence rate was 37.9%. Of these patients, 13 (19.7%) received retreatment.

Conclusion

The double microcatheter technique can be performed in ruptured aneurysms with high technical success and low morbidity/mortality. However, recurrence remains a problem, and patients should be followed up regularly.

Intracranial wide neck aneurysms: clinical and angiographic outcomes of endovascular management

Background

The treatment of intracranial wide neck aneurysms (WNAs) is usually difficult, hence several endovascular techniques were developed. This study aims to assess the clinical and angiographic imaging outcome of endovascular management of intracranial wide neck aneurysm. Forty patients were referred to the neuro-endovascular unit, at our hospital, each with a wide neck aneurysm. They were assessed regarding clinical presentation, aneurysm size, the character of the aneurysm, and the age and sex of the patient. Post-procedural, clinical, and angiographic outcomes of the patients who underwent endovascular intervention were reviewed.

Results

In this study, the mean aneurysmal neck was 5.4 ± 1.6 mm (mm). Endovascular intervention was carried out in all 40 patients in the form of simple coiling in 3 patients, double-catheter technique in 5 patients, balloon-assisted coiling (BAC) in 16 patients, stent-assisted coiling (SAC) in 13 patients, and flow diverter (FD) in 3 patients. Regarding clinical outcome, 4 patients had unfavorable outcome (the modified Rankin Scale, mRS > 2) at presentation and 3 patients at discharge. There was no unfavorable clinical outcome at 6- and 12-month follow-ups. Overall angiographic outcome at 1-year follow-up, 37/40 aneurysms (92.5%) had complete occlusion while two aneurysms had neck recurrence and one aneurysm had neck recanalization.

Conclusion

The current endovascular techniques in the treatment of WNAs are considered effective, feasible, and safe.

Intrasaccular flow disruption for brain aneurysms: a systematic review of long-term outcomes

OBJECTIVE

The long-term safety and efficacy of intrasaccular flow disruption (IFD) for the treatment of brain aneurysms remain unclear. With accumulating experience and increasing use of IFD devices, recent studies have provided additional data regarding their outcomes. This review summarizes the long-term outcomes of IFD-treated brain aneurysms.

METHODS

A systematic literature review was performed on May 23, 2021, in PubMed, Web of Science, and Ovid MEDLINE for aneurysm treatment outcomes with IFD devices. Procedural details, including use of adjunctive devices and complications, were collected. The quality of studies was assessed using the Downs and Black checklist. Angiographic outcomes were classified as complete occlusion, residual neck, and residual aneurysm. Other outcomes included need for retreatment, permanent neurological deficit, and mortality. Pooled analyses were performed.

RESULTS

The final analysis comprised 1217 patients with 1249 aneurysms from 22 studies. The mean aneurysm diameter and neck width were 6.9 and 4.5 mm, respectively, and 27.6% of aneurysms were ruptured. The complete occlusion rates at 12 months and final follow-up (pooled mean duration 15.7 months) were 50.1% and 58.2%, respectively. Adjunctive devices were used in 6.4% of cases. The rates of hemorrhage, symptomatic infarction, permanent neurological deficit, and mortality were 1.2%, 2.8%, 1.0%, and 2.6%, respectively.

CONCLUSIONS

IFD is a very safe treatment for appropriately selected brain aneurysms with low complication and neurological deterioration rates. However, complete occlusion is achieved in only half of IFD-treated aneurysms at 1 year with a modest increase beyond this time point. As the majority of the studies were single arm, the pooled data are subject to selection and reporting biases. Future device developments, increased operator experience, and direct comparisons with alternative endovascular strategies and surgical clipping may clarify the role of IFD in aneurysm management.

Rabbit Elastase Aneurysm Model Mimics the Recurrence Rate of Human Intracranial Aneurysms following Platinum Coil Embolization

BACKGROUND AND PURPOSE

Intracranial aneurysms treated with coils have been associated with incomplete occlusion, particularly in large or wide-neck aneurysms. This study aimed to validate the accuracy of the rabbit elastase model in predicting aneurysm recurrence in humans treated with platinum coils.

MATERIALS AND METHODS

Elastase-induced saccular aneurysms were induced in rabbits and embolized with conventional platinum coils. The recurrence rates of aneurysms were retrospectively analyzed. Morphologic characteristics of aneurysms, angiographic outcomes, and histologic healing were evaluated.

RESULTS

A total of 28 (15.3%) of 183 aneurysms recurred. The aneurysm recurrence rate observed in this study (15.3%) is similar to those reported in multiple analyses of aneurysm recurrence rates in humans (7%-27%). The rate of recurrence was higher in aneurysms treated without balloon assistance (19/66, 28.8%) compared with those treated with balloon assistance (9/117, 7.7%). Aneurysms treated with balloon-assisted coiling had a lower recurrence rate (OR = 0.17; 95% CI, 0.05-0.47; P = .001) and higher occlusion rate (OR = 6.88; 95% CI, 2.58-20.37; P < .001) compared with those treated without balloon-assisted coiling. In this rabbit elastase-induced aneurysm model, packing density and aneurysm volume were weak predictors of aneurysm recurrence; however, the packing density was a good predictor of the occlusion rate (OR = 1.05; 95% CI, 1.02-1.10; P = .008).

CONCLUSIONS

The rabbit elastase aneurysm model may mimic aneurysm recurrence rates observed in humans after platinum coil embolization. Moreover, balloon assistance and high packing densities were significant predictors of aneurysm recurrence and occlusion.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling

Objective

Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups.

Methods

Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with singlemicrocatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively.

Results

Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01).

Conclusion

Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Microsurgical and endovascular treatment of un-ruptured cerebral aneurysms by European hybrid neurosurgeons to balance surgical skills and medical staff management

Background

In Europe, aneurysm treatment performed by dually trained neurosurgeons is extremely scarce. We provide outcome data for un-ruptured aneurysm patients treated at a European hybrid center to prove that hybrid neurosurgeons achieve clinical and angiographical results allowing to integrate hybrid neurosurgery into routine aneurysm treatment. This will not only help to maintain neurovascular microsurgical skills but will influence staff costs in related hospitals.

Methods

We retrospectively analyzed all consecutively treated un-ruptured aneurysm patients between 2000 and 2016. The decision-making took into account the pros and cons of both modalities and considered patient and aneurysm characteristics. Clinical outcome was assessed by the modified Rankin scale (mRS). Occlusion rates were stratified into grade I for 100%, grade II for 99–90%, and grade III for <90% occlusion. To account for the introduction of stents, two treatment periods (p1, 2000 to 2008; p2, 2009 to 2016) were defined.

Results

The study population consisted of 274 patients (median age 55 years) harboring 338 un-ruptured aneurysms. Microsurgery (MS) was performed in 51.8% and endovascular therapy (EVT) in 43.1%; 5.1% required combined treatment. Overall, 93% showed a favorable clinical outcome (mRS 0–2), 94.3% after MS and 91.5% after EVT. Grade I aneurysm occlusion was achieved in 82.6% patients, 91.9% after MS and 72.9% after EVT. Procedure-related complications occurred after MS in 5.6% and after EVT in 4.4% patients. Mortality was recorded for five (1.8%) patients, one patient after MS and four after EVT. For the EVT cohort, significant improvement from p1 to p2 was seen with clinical outcomes (P=0.030, RR = 0.905, CI: 0.8351–0.9802) and occlusion rates (P=0.039, RR = 0.6790, CI: 0.499–0.923).

Conclusion

Hybrid neurosurgeons achieve qualified clinical and angiographic results. Dual training will allow to maintain neurovascular caseloads and preserve future aneurysm treatment within neurosurgery. Furthermore economic benefits could be observed in hospital management.

Comparison of Treatment Results by Coil Embolization Procedures for Ruptured Cerebral Aneurysms

Objective

In coil embolization of ruptured cerebral aneurysms, intraoperative cerebral aneurysm re-rupture and thromboembolism are of concern. A good embolic condition can be expected by adjunctive techniques, but there is an increased risk of complications. We investigated the treatment results by coil embolization procedures for ruptured cerebral aneurysms.

Methods

Between January 2016 and December 2019, 75 ruptured saccular cerebral aneurysms were treated by coil embolization at our hospital. The background factors, results of aneurysm embolization, intraoperative re-rupture, symptomatic cerebral embolism, and other factors were investigated retrospectively. We compared and examined these factors based on the procedure.

Results

The mean age was 62.8 and there were 57 female patients (76.0%). The single catheter technique (SCT) was used in 44 cases (58.7%) and the adjunctive technique was used in 31 cases (41.3%). Complete obliteration (CO) was achieved in 24 cases (32.0%), there was a neck remnant (NR) in 23 (30.7%), body filling (BF) was observed in 28 (37.3%), intraoperative re-rupture occurred in 7 (9.3%), and symptomatic cerebral embolism developed in 6 (8.0%), but no postoperative re-rupture was observed. Retreatment was required in only three cases of SCT. On comparison by procedure, the incidence of symptomatic cerebral embolism was significantly lower in SCT group than in the adjunctive technique group (2.3% vs 16.1%, p = 0.04).

Conclusion

Among the cases of coil embolization for ruptured cerebral aneurysms at our hospital, SCT resulted in a lower incidence of symptomatic cerebral embolism than adjunctive techniques. It is essential to select an appropriate procedure in each case by understanding the characteristics of each procedure.

Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: A systematic literature review and meta-analysis of prevalence

BACKGROUND

Stent-assisted coil embolization of ruptured wide-necked aneurysms is a controversial treatment modality due to concerns on the peri-procedural safety of anti-platelet therapy in the setting of acute subarachnoid hemorrhage. Our aim was to systematically review the literature on stent-assisted coil embolization of acutely ruptured wide-neck aneurysms to calculate the pooled prevalence of clinical outcome, thromboembolic and hemorrhagic complication rates and overall mortality.

METHODS

We searched PubMed and Google Scholar for articles published between 2009 and 2019 and stratified selected articles based on risk of publication bias. Data on thromboembolic and hemorrhagic complications, clinical outcomes and mortality rates were analyzed using quality-effects model and double arcsine transformation.

RESULTS

24 articles were included featuring a total of 1582 patients. Thromboembolic and hemorrhagic complication rates were witnessed in 9.1% [95% CI: 6.0% - 12.7%; I² = 72.8%] and 8.7% [95% CI: 5.4 - 12.6%; I² = 77.2%] of patients, respectively. 245 patients received external ventricular drains, of which 33 (13.5%) had EVD-related hemorrhages. Total complication rate was 20.8% [95% CI: 14.2 - 28.1%; I² = 87.0%]. 57% of aneurysms were completely occluded and a favorable clinical outcome was reported in 74.7% [95% CI: 66.4 - 82.2%; I² = 86.0] of patients. Overall mortality rate came at 7.8% [95% CI: 4.8 - 11.6%; I² = 76.9%].

CONCLUSION

Stent-assisted coiling of ruptured intracranial aneurysm is a technically feasible procedure with controlled thromboembolic complication rate but may be associated with higher hemorrhagic and total complication rates compared to coiling alone. While stent-assisted coiling of ruptured wide-necked aneurysm seems to yield a lower rate of favorable clinical outcome, overall mortality is comparable to that of endovascular coiling alone.

Factors related to adverse events during endovascular coil embolization for ruptured cerebral aneurysms

BACKGROUND AND PURPOSE

The risk factors for adverse events for example, intraprocedural rupture (IPR), ischemic complication within 24 hours, and rebleeding after endovascular coil embolization for a ruptured cerebral aneurysm remain unclear. The aim of this study was to identify significant associated risk factors.

METHODS

We retrospectively evaluated data from 5358 patients listed on the Japanese Registry of Neuroendovascular Therapy 3 during 2010-2014.

RESULTS

IPR, ischemic complications, and rebleeding occurred during or after 221 (4.1%), 226 (4.2%), and 63 (1.2%) treatments, respectively. All of the adverse events were significantly associated with the patients' poor outcomes at 30 days. Multivariate analysis revealed the factors independently related to these adverse events as follows: (1) for IPR: female sex, bifurcation type, <5 mm aneurysm, emergent surgery, local anesthesia, a balloon-assisted technique; (2) for an ischemic complication: poor World Federation World Federation of Neurological Societies (WFNS) grade, wide neck, and stent-assisted technique; (3) for rebleeding: poor WFNS grade, bifurcation type, wide neck, and body filling as the initial result.

CONCLUSIONS

Knowledge of the risk factors of endovascular coil embolization and paying attention to them are essential for patients' safe treatment and good outcomes.

Combination of the double-microcatheter technique and triaxial system in coil packing for visceral and renal artery aneurysms

Background

In coil packing for visceral artery aneurysms (VAAs), difficulties are sometimes associated with preserving the patency of the parent artery, particularly for wide-neck aneurysms. However, the double-microcatheter technique effectively prevents coil migration, while the triple-coaxial (triaxial) system is useful for reducing microcatheter kick-back.

Purpose

To assess the feasibility of combining these two techniques in coil packing for VAAs.

Material and Methods

Coil packing using the double-microcatheter technique and triaxial system was attempted for seven VAAs in six patients between August 2015 and January 2018. The technical success rate, packing density of aneurysms, complications related to the procedure, and occlusion status were evaluated. Technical success was defined as the completion of coil packing by immediate post-embolic angiography. The occlusion status was evaluated using time-resolved magnetic resonance angiography.

Results

There were three renal, three splenic, and one anterior superior pancreaticoduodenal aneurysms. The median size of VAAs was 13 mm (range = 8–21 mm), with five being classified as wide-neck aneurysms. The completion of coil packing was confirmed for all VAAs and the technical success rate was 100%. The median packing density was 28% (range = 22–40%). There were no complications related to the procedure. The median follow-up period was 14 months (range = 8–24 months). In six VAAs that were followed up, there were three complete occlusions, three neck remnants, and no body filling; re-treatment was not required in any patient.

Conclusion

The combination of the double-microcatheter technique and triaxial system is a feasible method of coil packing for VAAs.

Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms

Background: Wide-necked cerebral aneurysms at a bifurcation can be difficult to treat with endovascular techniques despite recent advancements.

Objective: We describe a new technique of micro-scaffold remodeling of the aneurysm neck of wide-necked bifurcation aneurysms by placing one or more microcatheters and/or wires in the efferent vessels. We hypothesize that this technique would be a better choice to change the branch angulation, allowing for an improved configuration to stably deploy coils. We present a retrospective case series to illustrate this technique.

Methods: 17 wide-necked bifurcation aneurysms in 17 patients were coil embolized using this technique during a 3 year study period. Branch-vessel microcatheters and/or microwires were used to remodel the aneurysm neck and support the coil mass. Statistical analysis of the branch angulation and neck-width changes were performed during treatment. Long-term clinical outcome and follow-up angiography was obtained in 8 patients.

Results: Eleven patients had complete occlusion of their aneurysm (Raymond-Roy Class I), and 6 patients had Raymond-Roy Class 2 immediately after treatment. Efferent vessels demonstrated a statistically significant change in angulation with insertion of microcatheters or microwires, while neck width did not change significantly. There were four intraoperative complications and no neurological morbidity in the immediate post-operative period. Complete occlusion was documented for all 10 subjects with long-term follow-up.

Conclusions: The micro-scaffold endosurgical remodeling technique is a useful adjunct in treating wide-necked bifurcation aneurysms. By elevating branch vessels away from the aneurysm neck, this technique allows for dense coil packing while decreasing the need for balloon or stent assistance.

Analysis of Wide-Neck Aneurysms in the Barrow Ruptured Aneurysm Trial

BACKGROUND

Ruptured wide-neck aneurysms (WNAs) are difficult to treat and few publications have compared clipping to coiling.

OBJECTIVE

To determine, using Barrow Ruptured Aneurysm Trial (BRAT) data: (1) How many aneurysms had a wide neck? (2) Did wide-neck status influence treatment? (3) How did clipping compare to coiling for WNAs?

METHODS

A post hoc analysis was conducted of saccular WNAs in the BRAT. A WNA was defined as maximum neck width ≥ 4 mm or maximum aneurysm dome-diameter–to–neck-width ratio < 2. Both intent-to-treat and as-treated analyses were performed.

RESULTS

Of the 327 patients analyzed, 177 (54.1%) had a WNA. WNAs were more likely to occur in older patients (P = .03) with worse presenting clinical grade (P = .02), were more likely to arise from the middle cerebral artery, basilar tip, or internal carotid artery other than the junction with the posterior communicating artery (P = .001) and were associated with worse clinical outcomes at all time points (P ≤ .01). WNAs were equally distributed in assigned treatment groups (clip 56.6% vs coil 51.8%; P = .38), but were overrepresented in the actual clipping group (clip 62.4% vs coil 37.6%, P < .001). Most patients (76.7%) in the coil-to-clip crossover group had a WNA. Comparing clipping to coiling, there was no difference in clinical outcomes at any time point in either analysis (P ≥ .33). The aneurysm obliteration rate was lower (P < .001) and the retreatment rate higher (P < .001) in the actual coiling group.

CONCLUSION

Wide-neck status significantly impacted treatment strategy in the BRAT, favoring clipping. Clipping and coiling of ruptured WNAs resulted in statistically similar long-term clinical outcomes.

10.1093/neuros/nyy439 Video Abstract 10.1093.neuros.nyy439 5850292551001

Angiographic and clinical outcomes of balloon remodeling versus unassisted coil embolization in the ruptured aneurysm cohort of the GEL THE NEC study

BACKGROUND AND PURPOSE

GEL THE NEC (GTN) was a multicenter prospective registry developed to assess the safety and efficacy of HydroSoft coils in treating intracranial aneurysms. We compared the angiographic and clinical outcomes of aneurysms treated with balloon assisted coil embolization (BACE) versus unassisted coil embolization (CE) in the ruptured aneurysm cohort.

MATERIALS AND METHODS

GTN was performed at 27 centers in five countries. Patients aged 21-90 years with a ruptured aneurysm 3-15 mm in size were eligible for enrollment. We analyzed demographics/comorbidities, aneurysm location, and geometry, including maximum diameter, neck size, and dome to neck ratio, immediate and long term angiographic outcomes (graded by an independent core laboratory using the modified Raymond Scale), and procedure related adverse events. Angiographic and clinical outcomes were studied using χ²and t tests.

RESULTS

Of the 599 patients in the GTN, 194 met the inclusion criteria. 84 were treated with BACE and 110 with CE. There were more prior smokers in the BACE group (p=0.01). The BACE group also had more vertebrobasilar aneurysms (p=0.006) and a larger mean neck size (p=0.02). More aneurysms were immediately completely occluded in the BACE group (p=0.02) Procedure- related major morbidity and mortality were no different between the techniques (p=0.4 and p=1, respectively).

CONCLUSIONS

In this prospective ruptured aneurysm cohort from the GTN, BACE resulted in greater occlusion rates compared with unassisted CE with similar morbi-mortality.

Coiling of wide-necked carotid artery aneurysms assisted by a temporary bridging device (Comaneci): preliminary experience

Background

Endovascular treatment of wide-necked aneurysms remains challenging without the use of adjunctive devices to preserve the parent artery.

Objective

To present our initial experience with a temporary bridging device, the Comaneci (Rapid Medical, Israel). The compliant remodeling mesh protects the parent artery during coil occlusion without flow arrest in the distal vasculature. Permanent dual antiplatelet therapy is not required since the device is fully removed at the end of the procedure.

Methods

All intracranial aneurysms treated by coil occlusion with the Comaneci device between December 2014 and November 2015 were included. Angiographic and clinical results were retrospectively analysed, including follow-up examinations. All aneurysms were unruptured.

Results

18 aneurysms of the internal carotid artery were included. Successful coil occlusion assisted by the Comaneci device as intended was possible in 14 cases (77.8%). Insufficient coverage of the aneurysmal neck was observed in four cases (22.2%), with modification of the treatment to stent-assisted coiling or remodeling. One clinically relevant complication occurred (5.6%).

Conclusions

Our initial experience shows that use of the Comaneci device is straightforward for the treatment of selected wide-necked aneurysms. Further studies with long-term follow-up data are needed to identify the significance of the presented technique in the neurointerventional armamentarium.

Comparison of Stent-Assisted Coiling and Balloon-Assisted Coiling in the Treatment of Ruptured Wide-Necked Intracranial Aneurysms in the Acute Period

OBJECTIVE

The purpose of this study was to compare the efficacy, stability, and safety of stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) in the treatment of ruptured wide-necked aneurysms in the acute period.

METHODS

Consecutive patients including 65 cases treated with SAC and 32 with BAC were reviewed at the authors' institution between November 2011 and December 2014. The efficacy of these 2 approaches and the incidence of periprocedural complications were retrospectively evaluated.

RESULTS

Morphologic analysis showed a lower fundus/neck ratio (1.2 vs. 1.6) in the aneurysms treated with SAC versus BAC (P < 0.001). The mean neck width of aneurysms was 4.0 mm in the patients treated with SAC versus 3.4 mm in those treated with BAC (P < 0.04). Coil protrusion into the parent vessels during embolization was an independent risk factor for cerebral ischemic events (odds ratio [OR], 4.08; 95% confidence interval [CI], 1.03-16.2). Neck width (OR, 0.65; 95% CI, 0.44-0.97) and aneurysm perforation during procedure (OR, 6.24; 95% CI, 1.21-32.3) were independent predictors of complete occlusion (Raymond 1) by immediate postembolization angiography. There was no statistical difference between the 2 techniques regarding the rate of aneurysm occlusion at the end of procedure, periprocedural complications, and favorable outcome at discharge and follow-up.

CONCLUSIONS

These findings suggested that SAC was more appropriate than BAC for ruptured wide-necked aneurysms with lower fundus/neck ratio or wider neck size. However, periprocedural complications, occlusion rates, and favorable outcomes did not differ between the 2 techniques.

Stent-assisted coiling and balloon-assisted coiling in the management of intracranial aneurysms: A systematic review & meta-analysis

BACKGROUND

Stent-assisted coiling and balloon-assisted coiling are well-established minimally invasive techniques for treatment of intracranial aneurysms. The aim of this study was to use meta-analysis methods to compare clinical outcomes of aneurysms treated with stent-assisted coiling versus balloon-assisted coiling.

METHODS

We searched for two-arm prospective studies and retrospective studies that compared the clinical outcomes in patients that received stent-assisted or balloon-assisted aneurysm treatment. Database search was performed through May 2015. Odds ratios (OR) with 95% confidence intervals (CI) were used to compare the clinical outcomes in patients that underwent either stent-assisted or balloon-assisted coiling for intracranial aneurysms management.

RESULTS

Complete occlusion rates at the end of the coiling procedure were similar between patients that received stent-assisted and balloon-assisted aneurysm treatment (OR=0.763, 95% CI=0.47 to 1.23, P=0.270). However, complete occlusion rates were higher with stent-assisted coiling at 6months or later after the procedure (OR=1.82, 95% CI=1.21 to 2.74). The overall complication rates and retreatment rates in patients with recurrence were similar between stent-assisted and balloon-assisted aneurysm treatments.

CONCLUSION

Stent-assisted coiling achieved better complete occlusion rates of aneurysms at 6months or later after the procedure compared to balloon-assisted coiling, without being associated with a higher risk of intraprocedural complications and retreatment.

Endovascular and surgical treatment of internal carotid bifurcation aneurysms: comparison of results, outcome, and mid-term follow-up

BACKGROUND

Aneurysms of the internal carotid artery (ICA) bifurcation are rare, and no studies have compared patient outcomes after endovascular vs surgical treatment.

OBJECTIVE

To report the safety, efficacy, and follow-up outcome of these 2 treatment options for patients with ICA bifurcation aneurysms.

METHODS

Patient and aneurysm characteristics, treatment results, and follow-up outcomes (at 30 months) were analyzed from patient records and review of imaging findings.

RESULTS

A total of 58 patients with ICA bifurcation aneurysms were treated. By interdisciplinary consensus, 30 aneurysms were assigned for coiling and 28 for clipping. Patients who underwent surgical clipping were younger and had larger aneurysms. More patients were assigned to coiling if their aneurysms originated only from the ICA bifurcation or projected superiorly. For the combined angiographic endpoint, complete and nearly complete occlusion (Raymond-Roy I + II), similar rates of 96% (coiling) or 100% (clipping) could be achieved. Raymond-Roy I occlusion occurred more often after clipping (79% vs 41% coiling). Follow-up of the endovascular group showed minor recanalization of the aneurysm neck (Raymond-Roy II) in 42%. One patient (4%) showed a major recanalization (Raymond-Roy III) and needed re-treatment. For incidental findings, no bleeding complications or new persistent neurological deficits occurred during follow-up.

CONCLUSION

Treatment of ICA bifurcation aneurysms after interdisciplinary assignment to clipping or coiling is effective and safe. Despite significantly more minor recanalizations after coiling, the re-treatment rate was very low, and no bleeding was observed during follow-up. Multivariate analysis revealed that origin only from the ICA bifurcation was an independent predictor of aneurysm recanalization after endovascular treatment.

Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms

BACKGROUND AND PURPOSE

Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms.

MATERIALS AND METHODS

All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. "Complex aneurysm" was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed.

RESULTS

Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent (n = 42, 3 ruptured) or balloon (n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6-72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% (n = 50) (mean, 21 months; range, 6-65 months). There were 4 minor and 3 major recurrences (14.0%).

CONCLUSIONS

In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.

HydroCoils Are Associated with Lower Angiographic Recurrence Rates Than Are Bare Platinum Coils in Treatment of "Difficult-to-Treat" Aneurysms: A Post Hoc Subgroup Analysis of the HELPS Trial

BACKGROUND AND PURPOSE

The HydroCoil Endovascular Aneurysm Occlusion and Packing Study was a randomized controlled trial that compared HydroCoils to bare platinum coils. Using data from this trial, we performed a subgroup analysis of angiographic and clinical outcomes of patients with "difficult-to-treat" aneurysms, defined as irregularly shaped and/or having a dome-to-neck ratio of <1.5.

MATERIALS AND METHODS

Separate subgroup analyses comparing outcomes of treatment with HydroCoils to that of bare platinum coils were performed for the following: 1) irregularly shaped aneurysms, 2) regularly shaped aneurysms, 3) aneurysms with a dome-to-neck ratio of <1.5, and 4) aneurysms with a dome-to-neck ratio of ≥1.5. For each subgroup analysis, the following outcomes were studied at the last follow-up (3-18 months): 1) any recurrence, 2) major recurrence, 3) re-treatment, and 4) an mRS score of ≤2. Multivariate logistic regression analysis was performed to determine if the HydroCoil was independently associated with improved outcomes in these subgroups.

RESULTS

Among the patients with an irregularly shaped aneurysm, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (17 of 66 [26%] vs 30 of 69 [44%], respectively; P = .046). Among the patients with an aneurysm with a small dome-to-neck ratio, the HydroCoil was associated with lower major recurrence rates than the bare platinum coils (18 of 73 [24.7%] vs 32 of 76 [42.1%], respectively; P = .02). No difference in major recurrence was seen between HydroCoils and bare platinum coils for regularly shaped aneurysms (42 of 152 [27.6%] vs 52 of 162 [32.1%], respectively; P = .39) or aneurysms with a large dome-to-neck ratio (41 of 145 [28.3%] vs 50 of 155 [32.3%], respectively; P = .53).

CONCLUSIONS

This unplanned post hoc subgroup analysis found that HydroCoils are associated with improved angiographic outcomes in the treatment of irregularly shaped aneurysms and aneurysms with a dome-to-neck ratio of <1.5. Because this was a post hoc analysis, these results are not reliable and absolutely should not alter clinical practice but, rather, may inform the design of future randomized controlled trials.

Arterial occlusion to treat basilar artery dissecting aneurysm

OBJECT

To explore the clinical feasibility of employing occlusion to treat basilar artery dissecting aneurysm.

METHODS

One patient, male and 46 years old, suffered transient numbness and weakness on the right limbs. Cerebral angiography indicated basilar artery dissecting aneurysm. The patient underwent the stent-assisted coil embolization of aneurysm and the result is satisfactory. Digital subtraction angiography (DSA) reviews were performed at 1 month and 4.5 months, respectively after the operation and indicate that the basilar artery is unobstructed and there was no recurrence of the aneurysm. DSA review 1 year after the first treatment indicates the aneurysm recurrence, stent-assisted coils dense embolization of aneurysm was performed again and the result was satisfactory. Ten months after the second operation, DSA review found the basilar artery aneurysm recurrence again and occlusion of the basilar artery was performed.

RESULTS

The basilar artery occlusion was effective. The bilateral posterior inferior cerebellar arteries and the bilateral posterior cerebral arteries are unobstructed. Five months of follow-up found that the patient recovered well. DSA reviews performed 5 months after occlusion indicate no recurrence of the aneurysm.

CONCLUSIONS

Occlusion to treat basilar artery dissecting aneurysm is clinically feasible, but surgical indications should be considered strictly.