Comparison of Recanalization and In-Stent Stenosis Between the Low-Profile Visualized Intraluminal Support Stent and Enterprise Stent-Assisted Coiling for 254 Intracranial Aneurysms

Short-term outcome of stenting with Enterprise stents for symptomatic intracranial atherosclerotic disease at a single center

OBJECTIVE

To evaluate the safety and efficacy of stenting for symptomatic intracranial atherosclerotic severe stenosis or occlusion with Enterprise stents.

METHODS

Fifty-three consecutive patients with symptomatic intracranial atherosclerotic severe (70%-99%) stenosis or occlusion who underwent endovascular treatment with Enterprise stents between September 2019 and March 2022 were retrospectively analyzed. Primary outcomes included technical stenting success rates, the incidence of complications within 30 days of the procedure, and the in-stent restenosis rates during the follow-up period. These outcomes were further categorized based on lesion location and operation time.

RESULTS

Fifty-seven lesions in 53 patients aged 61.0 ± 10.0 years were treated with Enterprise stents with a technical success rate of 100%. Seven patients (12.3%) had severe complications within 30 days of the procedure: five had a symptomatic ischemic stroke, one had a symptomatic intracerebral hemorrhage, and one had a subarachnoid hemorrhage related to the procedure. No deaths were observed. The rate of in-stent restenosis was 18.2%, with a mean vascular imaging follow-up period of 6.7 months. The 30-day complication and in-stent restenosis rates did not differ significantly between patients with different lesion locations and operation times (P > 0.05).

CONCLUSION

This retrospective study suggests that percutaneous transluminal angioplasty and stenting with Enterprise stents is an effective treatment for symptomatic intracranial arterial stenosis or occlusion with a high technical success rate. It also indicates that stenting during the early nonacute stage after stroke may not increase the incidence of perioperative complications for symptomatic intracranial atherosclerotic stenosis when following strict inclusion criteria.

Long-term results of wide-necked intracranial bifurcation aneurysms treated with stent-assisted coiling using low-profile acandis acclino stents

PURPOSE

Little data exists on endovascular treatment of complex intracranial aneurysms with the Acandis Acclino low-profile self-expanding closed-cell stent systems and is mainly limited to short- or midterm results. We report our long-term, single-centre experience with three generations of Acclino stents treating complex intracranial aneurysms.

METHODS

62 wide-necked intracranial aneurysms were treated electively using 88 Acclino stent systems. Single stent-assisted coiling was the preferred treatment in 38 cases and the kissing-Y stenting technique in 24 cases. We analysed demographic data and long-term follow-up results.

RESULTS

All stents were successfully deployed with immediate complete (Raymond Roy occlusion classification, RROC I) or near-complete occlusion (RROC II) achieved in 93,5%. Follow-up was available in 55 cases with a mean follow-up of 36 months (range 9-80 months). Long-term RROC I or II was achieved in 49 cases (89,1%). Three cases of stable residual aneurysmal filling were observed (5,5%). Seven aneurysms (12,7%) demonstrated a worsening on follow-up leading either to a neck remnant (4 cases, 7,3%) or to an aneurysm recurrence (3 cases, 5,5%). One recurrent aneurysm was retreated with coilembolization (1,8%). The directly procedural-related complication rate was 4,8%. Seven cases of clinically silent in-stent stenosis (12,7%; morbidity n = 0) were detected on long-term follow-up, six of them using the kissing-Y stenting technique.

CONCLUSION

Endovascular treatment of various intracranial aneurysms using the Acandis Acclino stent systems is safe and efficient with high aneurysm occlusion rates combined with low complication rates on long-term follow-up. Overall, rates of in-stent stenosis are low but may depend on the treatment technique (single stent-assisted coiling versus kissing-Y stenting with coiling).

Treatment of broad-based intracranial aneurysms with the LVIS EVO stent: a retrospective observational study at two centers with short- and medium-term follow-up

The use of stents is well established in the treatment of broad-based intracranial aneurysms. The aim of this study is to report on safety, feasibility and midterm follow-up of the new LVIS EVO braided stent for the treatment of cerebral aneurysms. All consecutive patients with intracranial aneurysms who were treated with the LVIS EVO stent in two high volume neurovascular centers were retrospectively enrolled in this observational study. Clinical and technical complications, angiographic outcome and clinical short-term and midterm results were evaluated. The study included 112 patients with 118 aneurysms. 94 patients presented with incidental aneurysms, 13 patients with acute SAH and 2 patients with acute cranial nerve palsy. For 100 aneurysms a jailing technique was used, re-crossing of the stent was performed in 3 cases. For the residual 15 cases the stent was placed as a bail-out or as a second step. Immediate complete occlusion was observed in 85 aneurysms (72%). Midterm follow-up was available for 84 patients with 86 aneurysms (72.9%). One stent showed asymptomatic complete occlusion on follow-up imaging, in all other cases no in-stent stenosis was observed. The rate of complete occlusion was 79.1% at 6 months and 82.2% at 12-18 months. Midterm follow-up data of this retrospective observational cohort of two neurovascular centers corroborates the safety profile of the LVIS EVO device for treatment of ruptured and unruptured intracranial aneurysms.

Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms

PURPOSES

Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations.

METHODS

Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization.

RESULTS

The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization.

CONCLUSIONS

Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

Utility of low-profile visualized intraluminal support (LVIS™) stent for treatment of acutely ruptured bifurcation aneurysms: A single-center study

Objective

Stent-assisted coiling has been increasingly used in the treatment of intracranial aneurysms. However, its application in ruptured bifurcation aneurysms remains controversial and challenging. This study aimed to present the safety and feasibility of low-profile visualized intraluminal support (LVIS™, LVIS, and LVIS Jr.) stent for acutely ruptured bifurcation aneurysms.

Methods

A total of 41 patients with acutely ruptured intracranial aneurysms arising at the bifurcation were treated with LVIS™ stent-assisted coiling in our hospital between January 2017 and December 2021. The clinical data and angiographic results of the patients were analyzed.

Results

Among these patients, all stents were successfully implanted. According to the immediate angiographic results, 29 aneurysms (70.7%) were completely occluded. Intraoperative thrombosis and hemorrhage occurred in two and one cases, respectively. No post-operative thrombosis or rebleeding events were observed. The clinical follow-up of all patients revealed that 38 (92.7%) cases had favorable outcomes (modified Rankin scale: 0-2). The angiographic results available for the 36 patients during the follow-up period revealed complete occlusion was achieved in 30 patients (83.3%) and residual neck in six patients.

Conclusion

The LVIS™ stent-assistant coiling is a safe and feasible option for acutely ruptured bifurcation aneurysms. Further studies with a prospective design, a larger sample size, and long-term follow-up are needed to validate these findings.

Angiographic Follow-Up for Small Ruptured Intracranial Aneurysm Treated by Endovascular Treatment : Follow-Up Plan and Long-Term Follow-Up Results

Objective

Although endovascular treatment for intracranial aneurysms is considered effective and safe, its durability is still debated. Also, few studies have described angiographic follow-up plan after endovascular treatment of intracranial aneurysm, especially in ruptured cases. Hence, we report the long-term results of follow-up angiography protocol.

Methods

Radiological records of 639 cases of coil embolization with ruptured aneurysms from March 2003 to December 2016 were retrospectively reviewed. Patients who received treatment of a saccular aneurysm less than 7 mm resulted with near complete occlusion were included. Two hundred thirty-eight aneuryms which received the follow-up angiography at least once were enrolled. We classified four periods of follow-up as follows : post-treatment 1 year (defined as the first period), from 1 to 2 years (the second period), 2 to 5 years (the third period), and over 5 years (long-term).

Results

We identified 14 cases (6.4%) of recurrence from 218 aneurysms in follow-up angiography in the first period. Among 143 aneurysms in the second period, five cases (3.5%) of recurrence were identified. There were no findings suspicious of recanalization in 97 patients in the third period. Of the total 238 cases, there were 19 recurrences, for a recurrence rate of 8.0%. Six (31.6%) out of 19 recurrences showed a tendency toward repeat recurrences even after additional treatment. Twenty-eight received long-term follow-up over 5 years and there was no recurrence.

Conclusion

Most of the recurrence were found during the first and the second year. We suggest that at least one digital subtraction angiography examination may be necessary around post-treatment 2 years, especially in ruptured cases. If the angiographic results are favorable at 2 years post-treatment, long-term result should be favorable.

Braided stents assisted coiling for endovascular management of posterior cerebral artery aneurysms: a preliminary mid-term experience

PURPOSE

Posterior cerebral artery (PCA) aneurysms are rare. This study is to evaluate the preliminary experience of braided stents applied in PCA aneurysms treatment.

METHODS

Angiographic and clinical data of 28 PCA patients treated with braided stents from July 2016 and September 2020 were retrospectively analyzed.

RESULTS

A total of 28 PCA aneurysms were enrolled. 22 (78.6%) aneurysms were dissecting aneurysms, while 6 (21.4%) aneurysms were saccular aneurysms. Thirty-five braided stents were implanted with dual stents implanted in 7 cases. Immediate angiographic results show that Raymond class I was obtained in 13 patients (46.4%), Raymond class II was obtained in 4 patients (14.3%), and Raymond class III was obtained in 11 patients (39.3%). Perioperative hemorrhagic events occurred in 1 patient (3.6%). Twenty-four patients (85.7%) received angiographic follow-up, and the mean follow-up time was 11.2 ± 4.9 months. Two patients (8.3%) were confirmed with IA neck recurrence, and 3 patients (12.5%) were confirmed asymptomatic parent artery occlusion (PAO). The other 19 patients were confirmed promoted occlusion with 18 Raymond class I (75%) and 1 Raymond class II (4.2%). Twenty-seven patients (96.4%) received clinical follow-up, and the mean follow-up time was 32.2 ± 13.5 months. One patient (3.7%) confirmed the death event 2 weeks after discharge. The other 27 patients (96.3%) got favorable clinical outcomes with an mRS score of 0-2.

CONCLUSIONS

Braided stent-assisted coiling with a high occlusion rate and relatively low complication rate provides an alternative strategy in treating PCA aneurysms. Long-term outcomes need further randomized study with larger case numbers.

Outcomes following aneurysmal coil embolization with intentionally shortened low-profile visible intraluminal support stent deployment

PURPOSE

Among all stents available for neuroendovascular therapy, the low-profile visible intraluminal support stent bears the highest metal coverage ratio. We deployed a low-profile visible intraluminal support stent with a delivery wire or/and microcatheter system push action to shorten the low-profile visible intraluminal support stent and thus achieve a flow diversion effect. We report our single-institution experience with the use of low-profile visible intraluminal support stents for intentionally shortened deployment (shortening group) and non-shortened deployment (non-shortening group) for unruptured intracranial aneurysms.

METHODS

We retrospectively reviewed the medical records of 130 patients with 131 intracranial aneurysms who were treated with low-profile visible intraluminal support stent-assisted coil embolization from February 2016-January 2019. All perioperative complications were noted. Every 6 months, we re-examined the patients with cerebral angiography or magnetic resonance angiography. The outcomes of aneurysm occlusion were evaluated by the modified Raymond-Roy occlusion classification. We used the finite element method and computational fluid dynamics to investigate the hemodynamics after shortened low-profile visible intraluminal support stent deployment.

RESULTS

Immediately after treatment, the modified Raymond-Roy occlusion classification was significantly better in the shortening group than in the non-shortening group (p<0.05). The latest angiographic outcomes showed the same tendency. Hemodynamic analysis by computational fluid dynamics suggested an adequate flow diversion effect with the use of our intentional shortening method.

CONCLUSIONS

Stent-assisted coil embolization using this technique showed good results of a high complete occlusion rate and low complication rate. These findings suggest that shortened low-profile visible intraluminal support stent deployment yields a flow diversion effect and may lead to early intra-aneurysmal thrombus formation.

Endovascular treatment of symptomatic intracranial atherosclerotic stenosis with low profile visualized intraluminal support stent

OBJECTIVE

Severe intracranial atherosclerotic stenosis has become one of the main causes resulting transient ischemic attack and stroke. This study aimed to evaluate the efficacy and safety of low profile visualized intraluminal support (LVIS) stent in treating symptomatic intracranial atherosclerotic stenosis.

METHODS

Data of 31 patients with at least 70% stenosis treated with LVIS stent in our center were retrospectively collected between July 2017 and November 2020. Further evaluation of lesion characteristics, technical success rate, preoperative complication, clinical and angiographic follow-up outcome, delayed in-stent stenosis were conducted.

RESULTS

Stent delivery and deployment were successfully achieved in all 31 patients (100%). 22 cases (71%) were located in anterior circulation and 9 cases (29%) were located in posterior circulation. The mean degree of stenosis lesion before stent deployment was 85.6 ± 9.4%, while after stenting was 11.2 ± 11.8%. One patient suffered from ischemic complication in stenting procedure, and timely delivery of rt-PA successfully recanalized the artery. Clinical follow-up was available in all 31patients (100%) with mean follow-up time 15.0 ± 12.1(3-45) months. No patients experienced the recurrence of stroke or TIA or death after discharge. Angiographic follow-up was available in 21patients (67.7%) with mean follow-up time 11.43 ± 6.8 (6-36) months. 19 patients (90.5%) were stable while 2 patients (9.5%) developed ISR in their last angiographic follow-up. The 2 patients received balloon angioplasty and reached satisfactory results after retreatment.

CONCLUSION

This preliminary study suggests that LVIS stent deployment was a feasible approach in treating intracranial atherosclerotic stenosis with satisfactory procedure success rate, low complication rate and favorable long-term outcome.

Factors affecting in-stent restenosis after angioplasty with the Enterprise stent for intracranial atherosclerotic diseases

This study investigated factors affecting the safety and in-stent restenosis after intracranial stent angioplasty using the Enterprise stent for symptomatic intracranial atherosclerotic stenosis. Between January 2017 and March 2019, patients with intracranial atherosclerotic stenosis treated with Enterprise stent angioplasty were enrolled, including 400 patients in the modeling group and 89 patients in the validation group. The clinical factors affecting in-stent restenosis after Enterprise stent angioplasty in the modeling group were analyzed, and a logistic regression model of these factors was established and validated in the validation group. The receiver operating characteristic (ROC) curve and the area under the ROC curve (AUC) were analyzed. In the modeling group with 400 patients, there were 410 lesions, including 360 stenotic lesions and 50 occluded lesions, with 176 (42.9%) lesions in the anterior circulation and 234 (57.1%) in the posterior circulation. Successful stenting was performed in 398 patients (99.5%). Stenosis was significantly (P < 0.05) improved after stenting compared with before stenting (27.7% ± 2.9% vs. 77.9% ± 8.0%). Periprocedural complications included ischemic stroke (3.25%), hemorrhagic stroke (0.75%), and death (0.50%), with a total periprocedural complication rate of 4.0%. The first follow-up angiography was performed in 348 (87.0%) patients with 359 lesions 3.5-14 months (mean 5.7 months) after stenting. In-stent restenosis occurred in 62 (17.3%) lesions, while the other 295 (82.7%) had no restenosis. Lesion location, calcification degree, balloon expansion pressure, residual stenosis, intraprocedural dissection, and cerebral blood flow TICI grade were significant (P < 0.05) risk factors for in-stent restenosis. The in-stent restenosis prediction model was established as follows: P = 1/[1 + e^{-(-6.070-1.391 location + 2.745 calcification + 4.117 balloon inflation pressure + 2.195 intraprocedural dissection + 1.163 residual stenosis + 1.174 flow TC grade)}]. In the validation group, the AUC in the ROC curve analysis was 0.902 (95% CI: 0.836-0.969), and when the cutoff value was 0.50, the sensitivity and specificity of this model were shown to be 76.92% and 80.26%, respectively, in predicting in-stent restenosis at angiographic follow-up, with a total coincidence rate of 79.78%. In conclusion, in-stent restenosis after intracranial Enterprise stenting is affected by stenosis location, calcification, balloon inflation pressure, intraprocedural arterial dissection, residual stenosis, and cerebral flow grade, and establishment of a logistic model with these factors can effectively predict in-stent restenosis.

Clinical and Angiographic Outcomes After Stent-Assisted Coiling of Cerebral Aneurysms With Laser-Cut and Braided Stents: A Comparative Analysis of the Literatures

Introduction: Stent-assisted coiling (SAC) plays an important role in endovascular treatment of intracranial aneurysms (IAs). This comparative analysis examines the safety and efficacy of SAC in general and compares clinical and angiographic outcomes between laser-cut stents and braided stents.

Methods: Relevant English-language studies were identified via a PubMed search for published articles regarding outcomes of SAC using laser-cut stents and braided stents published from 2015 to 2020. Data from 56 studies that met our inclusion criteria were pooled and statistically compared.

Results: A total of 4,373 patients harboring with 4,540 IAs were included. Patients were divided into two groups on the basis of stent type: laser-cut stents (2,076 aneurysms in 1991 patients; mean follow-up, 12.99 months) and braided stents (2,464 aneurysms in 2382 patients; mean follow-up, 18.41 months). Overall, the rates of successful stent deployment, thromboembolic events, stent stenosis, periprocedural intracranial hemorrhage, permanent morbidity, mortality, and recanalization were 97.72, 4.72, 2.87, 1.51, 2.14, 1.16, and 6.06%, respectively. Laser-cut stents were associated with a significantly higher rate of successful deployment (p = 0.003) and significantly lower rate of periprocedural intracranial hemorrhage (p = 0.048). Braided stents were associated with a significantly lower rate of permanent morbidity (p = 0.015).

Conclusion: SAC of IAs using laser-cut stents or braided stents was effective and safe. Rates of thromboembolic events, stent stenosis, mortality, and recanalization were comparable between the stent types. Braided stents were associated with lower permanent morbidity while laser-cut stents were associated with more favorable rates of successful deployment and periprocedural intracranial hemorrhage.

Factors related to microcatheter passage through the trans-cell approach using a low-profile visualized intraluminal support device: an in-vitro study

BACKGROUND AND PURPOSE

The trans-cell approach using a low-profile visualized intraluminal support (LVIS) device is sometimes used for aneurysm coil embolization. However, factors related to microcatheter passage remain uninvestigated. We aimed to examine in-vitro factors related to microcatheter passage using the trans-cell approach with an LVIS.

METHODS

Silicone vessel models (inner diameter, 4 mm) were created with different bend segments and a 4-mm hole assuming an aneurysm neck on the side of the greater curvature. The LVIS Blue (4.5 × 32 mm) was deployed at the bend segment, and passability on the trans-cell surface was evaluated by passing the microcatheter along the micro guidewire. A total of 800 passage experiments were performed using two types of microcatheter, ten types of silicone vessel, four cell widths, five cells with the same LVIS device, and two micro guidewire directions in the aneurysm.

RESULTS

The Headway Duo microcatheter (35.5%, 142/400) tended to have better passability compared with the Headway 17 microcatheter (29.3%, 117/400) (p = 0.070). As the cell width and angle between the trans-cell surface and microcatheter direction increased, passability significantly increased (p = 0.027 and p < 0.001, respectively). There was no significant difference in passability when the micro guidewire was directed to the proximal side versus the distal side (p = 0.45).

CONCLUSIONS

A large cell width and an obtuse angle between the trans-cell surface and microcatheter direction facilitated good passability. Although statistically marginal, microcatheters with small ledges and small tips had relatively good passability.

Safety and efficacy of stent-assisted coiling for acutely ruptured wide-necked intracranial aneurysms: comparison of LVIS stents with laser-cut stents

Background

To compare the safety and efficacy of LVIS stent-assisted coiling with those of laser-cut stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms.

Methods

Patients with acutely ruptured wide-necked intracranial aneurysms treated with LVIS stent-assisted coiling (LVIS stent group) and laser-cut stent-assisted coiling (laser-cut stent group) were retrospectively reviewed from January 2014 to December 2017. Propensity score matching was used to adjust for potential differences in age, sex, aneurysm location, aneurysm size, neck width, Hunt-Hess grade, and modified Fisher grade. Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared. Univariate and multivariate analyses were performed to determine the associations between procedure-related complications and potential risk factors.

Results

A total of 142 patients who underwent LVIS stent-assisted coiling and 93 patients who underwent laser-cut stent-assisted coiling were enrolled after 1:2 propensity score matching. The angiographic follow-up outcomes showed that the LVIS stent group had a slightly higher complete occlusion rate and lower recurrence rate than the laser-cut stent group (92.7% vs 80.6%; 3.7% vs 9.7%, P = 0.078). The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences (P = 0.495 and P = 0.875, respectively). The rates of intraprocedural thrombosis, postprocedural thrombosis, postoperative early rebleeding, and procedure-related death were 0.7% (1/142), 1.4% (2/142), 2.8% (4/142), and 2.1% (3/142) in the LVIS stent group, respectively, and 4.3% (4/93), 2.2% (2/93), 1.1% (1/93), and 3.2% (3/93) in the laser-cut stent group, respectively (P = 0.082, 0.649, 0.651, and 0.683). Nevertheless, the rates of overall procedure-related complications and intraprocedural rupture in the LVIS stent group were significantly lower than those in the laser-cut stent group (5.6% vs 14.0%, P = 0.028; 0.7% vs 6.5%, P = 0.016). Multivariate analysis showed that laser-cut stent-assisted coiling was an independent predictor for overall procedure-related complications (OR = 2.727, P = 0.037); a history of diabetes (OR = 7.275, P = 0.027) and other cerebrovascular diseases (OR = 8.083, P = 0.022) were independent predictors for ischemic complications, whereas none of the factors were predictors for hemorrhagic complications.

Conclusions

Compared with laser-cut stent-assisted coiling, LVIS stent-assisted coiling for the treatment of acutely ruptured wide-necked intracranial aneurysms could reduce the rates of overall procedure-related complications and intraprocedural rupture.

Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms With a Low-Profile Visualized Intraluminal Support Device

Objective: Stenting in ruptured middle cerebral artery (MCA) aneurysms was reported with a high perioperative complication rate. However, the treatment devices and physician's experience have continued to evolve. We performed this retrospective study to evaluate the safety and efficacy of LVIS stent-assisted coiling for ruptured MCA aneurysms.

Methods: Patients with acutely ruptured MCA aneurysms treated between November 2014 and October 2019 were retrospectively reviewed. Clinical and angiographic data of those treated with LVIS stents were collected from a prospectively maintained database.

Results: A total of 40 patients with 40 ruptured MCA aneurysms were enrolled, which comprised 26.3% (40/152) of all the ruptured MCA aneurysms at the same time. All stents were successfully deployed except for one (2.5%), which had a poor stent opening. Ischemic procedure-related complications were encountered in three patients (7.5%). One patient died of complications related to high-grade SAH on admission. Follow-up (mean 15.9 months) angiography was performed for 36 patients, which showed 33 (91.7%) aneurysms were completely occluded, 1 (2.8%) was improved, 1 (2.8%) was stable, and 1 (2.8%) was recanalized. Clinical follow-up (mean 29.6 months) was available for all survived patients, which showed 38 (95.0%) patients had favorable neurologic outcomes (mRS score 0–2), and 2 (5.0%) patients had poor neurologic outcomes.

Conclusion: The use of LVIS stents is feasible, safe, and effective with glycoprotein IIb/IIIa inhibitor for the treatment of ruptured MCA aneurysms in the acute setting. Prospective, multicenter studies with larger sample sizes are still required to further evaluate the safety and long-term efficacy.

Pipeline Embolization Device Versus Stent-Assisted Coiling for Intracranial Aneurysm Treatment: A Retrospective Propensity Score-Matched Study

BACKGROUND

Pipeline embolization device (PED; Medtronic) and stent-assisted coiling (SAC) are established modalities for treatment of intracranial aneurysms.

OBJECTIVE

To comparatively assess the efficacy of these techniques.

METHODS

We conducted a retrospective analysis of patients with aneurysms treated at our institution with either PED from 2013 to 2017 or SAC from 2009 to 2015. All large (>10 mm), ruptured, fusiform, anterior communicating artery, posterior circulation aneurysms, and patients with no available follow-up imaging were eliminated before running the propensity score matching (PSM). Patients were matched using nearest neighbor controlling for: age, gender, smoking, exact location, maximal diameter, and presence of multiple aneurysms. Total hospital costs for equipment and implants were calculated from procedure product and hospital billing records, and compared between the propensity-matched pairs.

RESULTS

Out of 165 patients harboring 202 aneurysms; 170 (84.2%) were treated with the PED, and 32 (15.8%) were treated using SAC. PSM resulted in 23 matched pairs; with significantly longer follow up in the SAC group (mean 29.8 vs 14.1 mo; P = .0002). Complete occlusion rates were not different (82.6 vs 87%; P = .68), with no difference between the groups for modified Rankin Scale on last clinical follow-up, procedural complications or retreatment rates. Average total costs calculated from the hospital records, including equipment and implants, were not different between propensity-score matched pairs (P = .48).

CONCLUSION

PED placement and SAC offer equally efficacious occlusion rates, functional outcomes, procedural complication rates, and cost profiles for small unruptured anterior circulation saccular aneurysms which do not involve the anterior communicating artery.

Rescue permanent LVIS stenting with post-stenting angioplasty after failed mechanical thrombectomy for refractory internal carotid artery occlusion at the paraclinoid segment: two-case report

BACKGROUND

Previous studies indicated the effectiveness of permanent stenting when dealing with retriever-failed refractory large vascular occlusion (LVO). Variety types of stents were implanted permanently to achieve recanalization. Low-profile visualized intraluminal support (LVIS) is generally used as a supportive device for embolization of intracranial aneurysm. Its specific structural and functional characteristics contribute to its potential of treating LVO.

CASES PRESENTATION

A 51-year-old male was transferred to our stroke center because of conscious disturbance with the weakness of the left upper limb. The National Institute of Health Stroke Scale (NIHSS) was 24; the Glasgow Coma Scale (GCS) was 10. Digital subtraction angiography (DSA) showed that his paraclinoid segment of R-ICA was occluded due to hard clot embolization. Thrombectomy was performed 6 times, but the occlusion remained. Finally, LVIS was implanted permanently and post-dilation was performed, which successfully recanalized the artery (eTICI 2c). The post-operative NIHSS and GCS were 20 and 11, respectively, which were 10 and 14 when discharged. Another patient was a 71-year-old male who suffered weakness of left limbs. NIHSS was 15; GCS was 11. DSA confirmed that the paraclinoid segment of his R-ICA was occluded due to hard clot embolization. Totally 6 times of mechanical thrombectomy, angioplasty, and tirofiban infusion were performed, which failed to recanalize the artery. In the end, LVIS implantation with post-dilation was performed, and full recanalization was achieved (mTICI 3). The post-operative NIHSS and GCS were 9 and 15, respectively, which were 3 and 15 when discharged.

CONCLUSIONS

These 2 cases invited LVIS into the treatment of refractory occlusion due to hard clot embolization at the paraclinoid segment, and the outcomes were preferable because of the higher visibility, higher flexibility, and lower cell size of LVIS.

Postinterventional Assessment after Stent and Flow-Diverter Implantation Using CT: Influence of Spectral Image Reconstructions and Different Device Types

BACKGROUND AND PURPOSE

CTA provides a noninvasive alternative technique to DSA in the follow-up after endovascular aneurysm treatment to evaluate aneurysm occlusion and exclude intraluminal narrowing after stent or flow-diverter implantation; however, assessability may be impeded by stent material artifacts. The objective of this in vitro study was to compare the visual assessability of different conventional stents and flow diverters as well as different reconstructions of dual-layer CT images.

MATERIALS AND METHODS

Four conventional intracranial stents and 4 flow diverters were implanted in identical aneurysm phantoms. Conventional and monoenergetic images (40, 50, 60, 90, 120, 180 keV) were acquired to evaluate attenuation alteration, visible lumen diameter, and SNR. Image quality was rated subjectively by 2 independent radiologists using a 4-point Likert scale.

RESULTS

Low kiloelectron volt (40-60 keV) monoenergetic reconstructions showed an improved SNR and an improved lumen density ratio compared with high kiloelectron volt reconstructions (90-180 keV) and conventional reconstructions, however without reaching significance compared with the latter. Assessment of the adjacent aneurysm and subjective evaluation was not affected by the imaging technique and stent type. Artifact susceptibility varied with the device used and increased among flow diverters.

CONCLUSIONS

Low kiloelectron volt reconstructions improved the assessment of the stent lumen in comparison with high kiloelectron volt reconstructions. No significant improvement in image quality could be shown compared with conventional images. For some devices, iodine-specific reconstructions led to severe artifacts and are therefore not recommended. There was no relevant improvement in the assessability of the adjacent aneurysm.

Follow-up outcomes of intracranial aneurysms treated using braided or laser-cut stents with closed-cell design: a propensity score-matched case-controlled comparison

BACKGROUND

The impact of various stents on patients with intracranial aneurysms who undergo stent-assisted coiling has been debated. We conducted this study to compare follow-up outcomes of coiling procedures involving braided or laser-cut stents with closed-cell design. A propensity score-matched case-controlled analysis was applied.

METHODS

A total of 413 intracranial aneurysms consecutively coiled using laser-cut (n=245) or braided stents (n=168) in procedures performed between September 2012 and June 2017 were eligible for study. Time-of-flight magnetic resonance angiography, catheter angiography, or both were used to gauge occlusive status after coiling. Recanalization was determined by Raymond classification (complete occlusion vs recanalization). A propensity score-matched analysis was conducted, based on probability of stent type in use.

RESULTS

Ultimately, 93 coiled aneurysms (22.5%) showed some recanalization (minor, 51; major, 42) during the follow-up period (mean 21.7±14.5 months). Patient gender (P=0.042), hyperlipidemia (P=0.015), size of aneurysm (P=0.004), neck size (P<0.001), type of aneurysm (P<0.001), and packing density (P=0.024) differed significantly by group. Midterm and cumulative recanalization incidence rates in the braided-stent group were initially lower than those of the laser-cut stent group (P=0.009 and P=0.037, respectively) but they did not differ significantly after 1:1 propensity score matching (midterm OR=0.88, P=0.724; cumulative HR=0.91, P=0.758).

CONCLUSION

In stent-assisted coiling of intracranial aneurysms, laser-cut and braided stent groups produced similar outcomes in follow-up. Consequently, product selection may hinge on suitability for deployment rather than anticipated results.

Comparison of Low-Profiled Visualized Intraluminal Support Stent-Assisted Coiling and Coiling Only for Acutely Ruptured Intracranial Aneurysms: Safety and Efficacy Based on a Propensity Score-Matched Cohort Study

BACKGROUND

Low-profiled visualized intraluminal support (LVIS) is suggested as a promising stent for complex intracranial aneurysms. However, the safety and efficacy of LVIS-assisted coiling of acutely ruptured wide-necked intracranial aneurysms have not been well reported.

OBJECTIVE

To evaluate the safety and efficacy of LVIS-assisted coiling of acutely ruptured wide-necked intracranial aneurysms compared with contemporary coiling-only strategy via propensity score matching in a high-volume center.

METHODS

A retrospective review of patients with acutely ruptured intracranial aneurysms who underwent LVIS stent placement or coiling only from November 2013 to October 2017 was performed. Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared.

RESULTS

All baseline characteristics were equivalent between the 2 groups except for neck size. The immediate angiographic results, procedure-related complications, procedure-related mortality, and clinical outcomes between the 2 groups demonstrated no significant differences (P = .087, P = .207, P = .685, and P = .865, respectively). The angiographic follow-up outcomes of the LVIS-assisted coiling group showed a significantly higher complete occlusion rate and lower recurrence rate compared with the coiling-only group (92.3% vs 59.9%, 4.8% vs 26.1%, P &lt; .001). Multivariable analysis showed no significant predictors for the overall perioperative procedure-related complications, hemorrhagic complications, and ischemic complications.

CONCLUSION

The LVIS stent is a safe and effective device for stent-assisted coiling of acutely ruptured wide-necked intracranial aneurysms, with comparable procedure-related complication rates, higher complete occlusion rates, and lower recurrence rates at follow-up compared with coiling only.

Comparative Outcome Analysis of Enterprise and Neuroform Stent-Assisted Coiling of Cerebral Aneurysms: A Review of the Literature

Introduction

One of the popular treatment strategies for complex cerebral aneurysms with wide necks or low dome-to-neck ratios is stent-assisted coiling. The most widely used intracranial stents for stent-assisted coiling are Neuroform (NF) and Enterprise (EP) stents. The purposes of this study are to review the recent literature of the past 5 years to compare outcomes between the EP and NF stent-assist coiling systems so as to comment on the safety, efficacy, complications, and recurrence rate of stent-assisted coiling in general.

Methods

PubMed was used to search for all published literature of NF or EP stent-assisted coiling of unruptured cerebral aneurysms from January 2014 to August 2019 with the search terms of "Enterprise stent-assisted coiling," "Neuroform stent," and "Neuroform vs. Enterprise stent."

Results

Twenty two publications met the inclusion criteria which encompass 1764 patients and 1873 aneurysms. Out of these 1873 aneurysms, 1007 aneurysms were treated with EP stent and 866 aneurysms were treated with NF stent. The overall outcome was low rates of thromboembolic complications (4.37%) and intracranial hemorrhage (1.13%), low permanent morbidity (1.70%) and mortality (0.40%), and lower rate of recanalization (11%). Data analysis shows an overall higher rate of complication and recurrence of aneurysm and lower overall rate of aneurysmal occlusion in the patients where EP stent was used in comparison to NF stent. However, this difference was not statistically significant.

Conclusions

The review of two stent-assisted coiling devices using EP and NF stents including 1873 aneurysms in 1764 patients revealed that overall, it is safe and effective with comparable outcomes.

Stent-assisted coiling of cerebral aneurysms: multi-center analysis of radiographic and clinical outcomes in 659 patients

INTRODUCTION

The endovascular stent-assisted coiling approach for the treatment of cerebral aneurysms is evolving rapidly with the availability of new stent devices. It remains unknown how each type of stent affects the safety and efficacy of the stent-coiling procedure.

METHODS

This study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS) stents. Patient characteristics, treatment details and angiographic results using the Raymond-Roy grade scale (RRGS), and procedural complications were analyzed in our study.

RESULTS

Our study included 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n=182; EP, n=158; LVIS, n=330) that were retrospectively collected from six academic centers. Patient characteristics included mean age 56.3±12.1 years old, female prevalence 73.9%, and aneurysm rupture on initial presentation of 18.8%. We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64.4%, 210/326; NEU 56.2%, 95/169; EP 47.6%, 68/143; P=0.008. The difference of complete occlusion on 10.5 months (mean) and 8 months (median) angiographic follow-up remained significant: LVIS 84%, 251/299; NEU 78%, 117/150; EP 67%, 83/123; P=0.004. There were 7% (47/670) intra-procedural complications and 11.5% (73/632) post-procedural-related complications in our cohort. Furthermore, procedure-related complications were higher in the braided-stents vs laser-cut, P=0.002.

CONCLUSIONS

There was a great variability in techniques and choice of stent type for stent-assisted coiling among the participating centers. The type of stent was associated with immediate and long-term angiographic outcomes. Randomized prospective trials comparing the different types of stents are warranted.

Long Term Outcome of In-Stent Stenosis after Stent Assisted Coil Embolization for Cerebral Aneurysm

Objective

The objective of this study was to evaluatelong-term radiologic prognosis and characteristics of in-stent stenosis (ISS) after stent assisted coiling (SAC) for cerebral aneurysm and analyze its risk factors.

Methods

Radiological records of 362 cases of SAC during 10 years were retrospectively reviewed. Patients were included in this study if they had follow-up angiogram using catheter selected angiography at least twice. All subjected were followed up from 12 months to over 30 months. Of 120 patients, 123 aneurysms were enrolled. Patient data including age, sex, aneurysm size, neck size, procedural complication, kinds of stent, ISS associated symptom, ruptured state, location of ISS, degree of ISS, radiologic prognosis of ISS, follow-up period of time, and medical comorbidities such as hypertension, diabetes mellitus (DM), dyslipidemia, and smoking were collected.Statistical comparisons of group clinical characteristics were conducted for the total population.

Results

Among 123 casesof aneurysm, 22 cases (17.9%) of ISS were revealed on follow-up angiography. Multiple stenting was performed in three cases and intra-procedural rupture occurred in two cases. Most cases were asymptomatic and symptomatic stenosis was identified in only one case. Sixteen cases were ruptured aneurysm. Mild stenosis was observed in 11 cases. Moderate stenosis was found in eight cases and severe stenosis was identified in three cases. Mean timing of identification of ISS was 8.90 months. The most common type was proximal type. Most cases were improved or not changed on follow-up angiography. Only one case was aggravated from mild stenosis to occlusion of parent artery. Mean follow-up period was 44.3 months. We compared risk factors and characteristic between ISS group and non-ISS group using univariate analysis. Multiple stenting was performed for three cases (13.6%) of the ISS group and four cases (4.0%) of the non-ISS group, showing no statistical difference between the two groups (p=0.108). Additionally, the proportion of patients who had more than two risk factors among four medical risk factors (hypertension, DM, dyslipidemia, and smoking) was higher in the ISS group than that in the non-ISS group, the difference between the two was not statistically significant either (31.8% vs. 12.9%, p=0.05).

Conclusion

Clinical course and long-term prognosis of ISS might be benign. Most cases of ISS could be improved or not aggravated. Control of medical co-morbidity might be important. To the best of our knowledge, our study had more cases with longer follow-up period of time than other reports.

Comparison of endovascular treatment for middle cerebral artery aneurysm with a low-profile visualized intraluminal support stent or pipeline embolization device

The aim of the present study was to evaluate the safety and effectiveness of low-profile visualized intraluminal support (LVIS) stent and the pipeline embolization device (PED) for middle cerebral artery (MCA) aneurysm treatment. Data of patients with MCA aneurysms who received endovascular treatment with LVIS stent or PED added to the hospital's database between August 2016 and March 2018 were retrospectively collected, and the clinical results and angiographic outcomes were evaluated. A total of 43 patients were included in the study, of whom 23 received LVIS stents and 20 received PED. The rate of complete occlusion was similar in the two groups at 6 months post-treatment (90.9 vs. 88.9%; P=0.832). Peri-operative complications were more frequent in the PED group; however, the LVIS group had more ischemic symptoms during the long-term follow-up. A larger aneurysm size (P=0.032) was associated with recanalization in the two groups. In conclusion, the LVIS stent and PED had acceptable rates of complete occlusion and aneurysm size was an independent predictor for recanalization. LVIS is more effective during the peri-operative period, while PED appears to have higher long-term safety.

Thirty-Day Outcomes of the Enterprise Stent in Treating Hypoperfusion of Symptomatic Intracranial Stenosis

OBJECTIVE

To evaluate the 30-day outcomes of using the Enterprise stent to treat patients with hypoperfusion of symptomatic severe intracranial stenosis.

METHODS

Patients with symptomatic severe intracranial stenosis (70%-99%) who underwent Enterprise stent intervention between August 2014 and November 2018 were retrospectively analyzed. The 30-day primary outcomes included the success rate of stenting and the incidence of complications, including ischemic stroke, cerebral hemorrhage, and death. The 30-day complication rates of patients with different lesion locations and classifications of Mori morphology were compared.

RESULTS

Sixty-eight patients were treated using 70 Enterprise stents. The success rate was 100%. The 30-day complication rate was 4.4%. The rates of ischemic stroke, cerebral hemorrhage, and death were 1.5%, 2.9%, and 0%, respectively. No significant difference was found in the 30-day complication rate between patients with different lesion locations and classifications of Mori morphology (P > 0.05).

CONCLUSION

Enterprise stents were relatively safe in treating patients with hypoperfusion of symptomatic severe intracranial stenosis.

Small ruptured and unruptured complex cerebral aneurysms: Single center experience of low-profile visualized intraluminal support stent

Objectives:

Even though low-profile visualized intraluminal support (LVIS) device is used extensively currently and provide intraluminal support in complex cerebral aneurysm embolization, only few studies have reported its clinical results. This study presents the results of patients treated with LVIS.

Patients and methods:

Cerebral aneurysms with an undefined neck, fusiform shape, and blood blister-like aneurysms that were treated with LVIS between May 2017 and May 2019 were reviewed retrospectively.

Results:

Overall, 112 aneurysms in 104 patients were treated using LVIS, and 105 LVISs were placed. Of these, 101 aneurysms (90%) were small (< 10 mm) in size, 17 were fusiform aneurysms, and 3 were blood blister-like aneurysms. Overall, 39 patients suffered a subarachnoid hemorrhage and 65 had no bleeding history. 2 patients died of internal carotid artery (ICA) thrombosis, resulting in 1.9% mortality rate. Follow-up angiography was obtained in 68 patients (65%), and the complete obliteration rate was 98.5% in 6–12 months.

Conclusion:

The LVIS is a safe and effective treatment for small ruptured or unruptured complex intracranial aneurysms.

Preliminary experience with the use of low profile visualized intraluminal support device in basilar artery for aneurysm treatment

BACKGROUND

The low profile visualized intraluminal support (LVIS) device is being increasingly used for the treatment of intracranial aneurysms. Its application in the basilar artery (BA) has not yet been reported.

OBJECTIVE

To evaluate the safety and early efficacy of the LVIS device for the treatment of BA aneurysms.

METHODS

A prospectively maintained database was retrospectively reviewed for all patients with BA aneurysms treated by LVIS stents at our institution. Angiographic results were evaluated using the modified Raymond-Roy classification (mRRC).

RESULTS

23 patients (mean age 52.8 years) with a BA aneurysm that was treated by LVIS stent implantation, with (n=21) or without (n=2) adjunctive coiling, were included in our study. 7 aneurysms were treated in the setting of subarachnoid hemorrhage (SAH). 10 aneurysms were located at the basilar tip, 10 at the basilar trunk, and 3 at the superior cerebellar artery. Procedure related complications developed in three patients (13%), including two perforator infarction and one worsening mass effect. Complications resulted in permanent morbidity (4%) in one case. One fatality was related to severe poor grade SAH. At a mean follow-up of 6.9 months, 13 of the 20 patients were mRRC I closure, 3 were mRRC II closure with an improvement from class IIIa, 3 were observed to be recanalized from class IIIa to IIIb, and 1 with stenting only was still patent similar to the immediate angiography.

CONCLUSION

The LVIS stent represents a feasible and safe option for endovascular embolization of BA aneurysms. Although recanalization may occur after LVIS treatment, the mid term complete occlusion rate was acceptable.

Treatment of Intracranial Aneurysms with Self-Expandable Braided Stents: A Systematic Review and Meta-Analysis

BACKGROUND

The safety and efficacy of treatment with self-expandable braided stents (LEO and LVIS) required further investigation.

PURPOSE

Our aim was to analyze the outcomes after treatment with braided stents.

DATA SOURCES

A systematic search of 3 databases was performed for studies published from 2006 to 2017.

STUDY SELECTION

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting patients treated with LEO or LVIS stents.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and neurologic outcomes.

DATA SYNTHESIS

Thirty-five studies evaluating 1426 patients treated with braided stents were included in this meta-analysis. Successful stent delivery and complete aneurysm occlusion were 97% (1041/1095; 95% CI, 95%-98%) (I² = 44%) and 88.3% (1097/1256; 95% CI, 85%-91%) (I² = 72%), respectively. Overall, treatment-related complications were 7.4% (107/1317; 95% CI, 5%-9%) (I² = 44%). Ischemic/thromboembolic events (48/1324 = 2.4%; 95% CI, 1.5%-3.4%) (I² = 27%) and in-stent thrombosis (35/1324 = 1.5%; 95% CI, 0.6%-1.7%) (I² = 0%) were the most common complications. Treatment-related morbidity was 1.5% (30/1324; 95% CI, 0.9%-2%) and was comparable between the LEO and LVIS groups. Complication rates between the anterior (29/322 = 8.8%; 95% CI, 3.4%-12%) (I² = 41%) versus posterior circulation (10/84 = 10.5%; 95% CI, 4%-16%) (I² = 0%) and distal (30/303 = 8%; 95% CI, 4.5%-12%) (I² = 48%) versus proximal aneurysms (14/153 = 9%; 95% CI, 3%-13%) (I² = 46%) were comparable (P > .05).

LIMITATIONS

Limitations were selection and publication biases.

CONCLUSIONS

In this analysis, treatment with the LEO and LVIS stents was relatively safe and effective. The most common complications were periprocedural thromboembolisms and in-stent thrombosis. The rate of complications was comparable among anterior and posterior circulation aneurysms, as well as for proximal and distally located lesions.

A clinical comparison of Atlas and LVIS Jr stent-assisted aneurysm coiling

BACKGROUND

Case series have described the safety and efficacy of LVIS Jr and Atlas stent-assisted aneurysm coiling, but their comparative clinical performance has not yet been formally studied.

OBJECTIVE

To clinically compare LVIS Jr and Atlas stents, emphasizing comparative rates of technical success and complications.

METHODS

Our institutional endovascular database was queried for aneurysms treated by stent-assisted coiling with either the LVIS Jr or Atlas stents. Demographic data, aneurysm information, treatment technique, periprocedural and device-related complications, and initial and follow-up angiographic results were evaluated.

RESULTS

Thirty-seven patients underwent Atlas stent placement and 27 patients underwent LVIS Jr stent placement for aneurysm coiling. There was no significant difference in aneurysm location, size, coiling technique, and coil packing density between the two cohorts. The rate of initial Raymond 1 occlusion was significantly greater in the Atlas cohort (57% vs 41%, P=0.03). The rate of postoperative ischemic complications, both clinically apparent and as defined on postoperative MRI diffusion-weighted imaging, did not significantly differ between the two groups. Follow-up DSA demonstrated a significantly greater rate of Raymond 1 or 2 occlusion for the Atlas cohort (100% vs 81%, P=0.04), and a significantly lower rate of in-stent stenosis (0% vs 19%, P=0.04).

CONCLUSION

This institutional analysis demonstrates greater obliteration rates and lower in-stent stenosis rates for aneurysms treated via Atlas stent-assisted coiling as compared with those treated via LVIS Jr stent-assisted coiling.