Woven EndoBridge (WEB) device in the treatment of ruptured aneurysms

Retreatment rate and strategies for recurrent and residual aneurysms after Woven EndoBridge (WEB) treatment: a comprehensive systematic review and meta-analysis

Woven Endo Bridge (WEB) is a flow diverter device used to treat wide-necked intracranial aneurysms. We conducted a systematic review and meta-analysis to determine the retreatment rate and strategies following aneurysmal recurrence after WEB treatment. A systematic literature search was conducted through four electronic databases. The Cochrane risk of bias tool for non-randomized trials (ROBINS-I) was used for risk of bias assessment. A meta-analysis and meta-regression were performed on relevant variables. A total of 29 studies with 2067 patients were included. Initially treated aneurysms had an adequate occlusion rate of 84.7% (20 studies, 980/1156, 95%CI: 79%-89%) at the last follow-up. The overall retreatment rate was 8.6% (24 studies, 251/2893, 95%CI: 6.5%-10.9%). Following retreatment, the immediate complete occlusion rate post retreatment and complete occlusion rate at last follow-up were 52% (six studies, 95%CI, 11%-91%) and 65% (six studies, 77/120, 95%CI: 56%-73%) respectively. Stent-assisted coiling achieved a 100% (95%CI: 57%-100%, P-value < 0.01) immediate adequate occlusion rate and 74% complete occlusion rate (95%CI: 16%-100%, P-value = 0.63) at last follow-up, which was higher than clipping, coiling, and flow diversion. On meta-regression, aneurysm height and neck width significantly associated with higher retreatment rate. The current meta-analysis showed a 9% retreatment rate after initial aneurysms treatment with WEB and overall adequate retreatment occlusion was high. Although stent-assisted coiling showed a higher adequate occlusion rate post-operatively, there was no significant difference between retreatment strategies in long-term radiological outcomes.

CLinical EValuation of WEB 17 device in intracranial aneuRysms (CLEVER): procedural, 30-day and 1-year safety results for ruptured and unruptured aneurysms

BACKGROUND

Intrasaccular flow disruption is an endovascular approach for the treatment of wide-neck aneurysms and, more specifically, wide-neck bifurcation aneurysms, which are challenging to treat with previously developed technologies. The Woven EndoBridge (WEB) device has demonstrated its efficacy and safety, for both unruptured and ruptured aneurysms.

METHODS

The CLEVER study was an observational, multicenter, prospective study conducted in 17 European investigational sites using the WEB 17 device, for the treatment of ruptured and unruptured aneurysms. The study objective was to provide safety and efficacy data on the WEB 17 device in the treatment of wide-neck bifurcation aneurysms. Imaging results were assessed independently by a Corelab and adverse events adjudicated by a Clinical Event Adjudicator. This analysis reports procedural results and safety at 30 days and 12 months.

RESULTS

A total of 163 patients (mean age 58.1 years; 68.1% women) with 103 unruptured aneurysms and 60 ruptured aneurysms were enrolled. Most aneurysms were located on the anterior communicating artery (ACom) (37.4%) or the middle cerebral artery (MCA) bifurcation (30.1%). Aneurysm widths ranged from 2.0-9.2 mm, and the mean sac width was 5.0 mm. The WEB procedure was successfully completed in 163 patients (100%). At the 12-month follow-up, major stroke events occurred in 3 of 163 patients (1.8%), and no device-related mortality was observed.

CONCLUSION

Endovascular treatment of ruptured and unruptured wide-neck bifurcation aneurysms using WEB 17 is safe, with a low complication rate and no device-related mortality. In particular, none of the ruptured aneurysms bled again up to 1 year of follow-up.

TRIAL REGISTRATION NUMBER

NCT03844334.

Association of radiation-induced epilation and interventional neuroradiology procedures

INTRODUCTION

The aim of this study is to quantify the association of temporary epilation following interventional neuroradiology (INR) procedures and compare the peak skin dose (Dskin,max) threshold to published values.

METHODS

Gold Coast University Hospital (GCUH) is a major centre for INR with over 500 primarily interventional procedures performed every year. Dskin,max is calculated when the reference air kerma (Ka,r) exceeds 3 Gy. If the Dskin,max exceeds 3 Gy, the patient is followed up for any skin effects. An audit was undertaken of these results over a 2-year period.

RESULTS

From January 2020 to December 2021, 140 patients who underwent INR procedures had a Ka,r > 3 Gy, 66 resulted in a calculated Dskin,max >3 Gy, and 45 were successfully followed up. Twenty patients (44%) reported no skin effects and 25 (56%) reported skin effects, which were almost exclusively epilation. The mean (range) Dskin,max for patients with no reported skin effects and those with observed skin effects was 4.6 Gy (3.0-11.1 Gy) and 4.2 Gy (3.0-7.0 Gy), respectively.

CONCLUSION

These results demonstrate that temporary epilation was observed in 56% of patients, in a cohort of 45 patients who underwent an INR procedure with calculated Dskin,max >3 Gy and successful follow-up. The results support evidence in the literature that suggests the approximate threshold for temporary epilation reported by the International Commission on Radiological Protection (ICRP) may be too high for incidence of this effect, specifically on the scalp, when Dskin,max is calculated from Ka,r (using commonly used corrections and assumptions in the calculation).

Endovascular treatment of intracranial aneurysms: Past and present

Intracranial aneurysm is common in stroke and, once rupturing, will cause disaster to patients. Nowadays, endovascular treatment has become a routine to reduce the risk of intracranial aneurysms rupture. Successive endovascular methods, like balloon-assisted coiling, stent-assisted coiling, and flow diversion, have become new choices for doctors. More and more doctors have been entering this field. Understanding the current general situation is crucial for more medical workers to learn the endovascular treatment of intracranial aneurysms. In the past, many devices and ideas about the treatment of intracranial aneurysms appeared. Although developing unceasingly, endovascular treatment still has some deficiencies to overcome. The advantages and drawbacks of current endovascular methods are discussed.

The Clinical and Radiological Outcomes of the Multimodal Use of the Woven EndoBridge Device: A Large Multicenter Study

BACKGROUND

The Woven EndoBridge (WEB) is a device used for intrasaccular flow diversion, designed for the elimination of wide-necked bifurcation aneurysms from the circulation. In this study, we aim to assess the safety and efficacy of the WEB and its uses in treating aneurysms of different morphologies and locations.

METHODS

In a retrospective analysis, we compiled a comprehensive dataset from patients treated with the WEB device across three major Australian neurovascular centers from May 2017 to September 2023. The case series encompassed a spectrum of aneurysm types, including wide-necked bifurcation, sidewall, and irregularly shaped aneurysms, as well as cases previously managed with alternative therapeutic strategies. This study additionally encompasses cases where aneurysms were managed using the WEB device in combination with supplementary endovascular devices.

RESULTS

The study included 169 aneurysms in 161 patients. The rate of satisfactory aneurysm occlusion was 85.6%, with 86.7% of patients maintaining good functional status at their most recent follow-up. The procedure exhibited a low mortality rate of 0.6% and a thromboembolic complication rate of 7.1% (n = 12/161). There were no instances of postoperative re-rupture and the procedure-related hemorrhage rate was low (1.2%, n = 2/169), aligning with the literature regarding the safety and efficacy of the WEB device.

CONCLUSIONS

Our multicenter trial reinforces the WEB device's role as an effective and safe modality for intracranial aneurysm management, supporting its expanded application beyond wide-necked bifurcation aneurysms. Further prospective studies are required to delineate its evolving role fully.

Treatment for middle cerebral artery bifurcation aneurysms: in silico comparison of the novel Contour device and conventional flow-diverters

Endovascular treatment has become the standard therapy for cerebral aneurysms, while the effective treatment for middle cerebral artery (MCA) bifurcation aneurysms remains a challenge. Current flow-diverting techniques with endovascular coils cover the aneurysm orifice as well as adjacent vessel branches, which may lead to branch occlusion. Novel endovascular flow disruptors, such as the Contour device (Cerus Endovascular), are of great potential to eliminate the risk of branch occlusion. However, there is a lack of valid comparison between novel flow disruptors and conventional (intraluminal) flow-diverters. In this study, two in silico MCA bifurcation aneurysm models were treated by specific Contour devices and flow-diverters using fast-deployment algorithms. Computational fluid dynamic simulations were used to examine the performance and efficiency of deployed devices. Hemodynamic parameters, including aneurysm inflow and wall shear stress, were compared among each Contour device, conventional flow-diverter, and untreated condition. Our results show that the placement of devices can effectively reduce the risk of aneurysm rupture, while the deployment of a Contour device causes more flow reduction than using flow-diverters (e.g. Silk Vista Baby). Besides, the Contour device presents the flow diversion capability of targeting the aneurysm neck without occluding the daughter vessel. In summary, the in silico aneurysm models presented in this study can serve as a powerful pre-planning tool for testing new treatment techniques, optimising device deployment, and predicting the performance in patient-specific aneurysm cases. Contour device is proved to be an effective treatment of MCA bifurcation aneurysms with less daughter vessel occlusion.

Long term WEB results - still going strong at 5 years?

OBJECTIVE

The aim of our multi-center study is to examine 5-year radiological outcomes of intracranial aneurysms (IAs) treated with the Woven EndoBridge (WEB).

METHODS

All patients treated with WEB between January 2013 and December 2016 were included. Patient and aneurysm characteristic data was collected from the electronic patient record. Aneurysm occlusion was assessed using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant. Complete occlusion and neck remnant were considered as adequate occlusion, whereas aneurysm remnant was assessed as an inadequate occlusion.

RESULTS

A total of 66 patients (72.7% female) with 66 IAs (n = 25 acutely ruptured) were treated with WEB. The mean age of patients was 55.6 years (range: 36-71 years). The mean width of the aneurysm neck was 4.5 mm (range: 2-9 mm). 5-year imaging follow-up data was not available for 16.6% patients (n = 11). During the follow up period, 14.5% of IAs (n = 8/55) required retreatment within 24 months of initial treatment with the WEB. A total of 55 IAs were analyzed for 5-year radiological outcome. Of these, including IAs required retreatment, 47.3% of IAs (n = 26/55) were occluded completely, 36.4% (n = 20/55) had neck remnant and 16.3% (n = 9/55) had recanalized. 83.7% of IAs were occluded adequately. None of the IAs rebled after initial treatment with WEB.

CONCLUSION

WEB can provide acceptable adequate occlusion rates at 5 years. Furthermore, recanalization appears to be unlikely after the first two years post-treatment. The results of large studies are needed to confirm these promising long term radiological outcomes.

Long-Term Follow-Up of Cerebral Aneurysms Completely Occluded at 6 Months After Intervention with the Woven EndoBridge (WEB) Device: a Retrospective Multicenter Observational Study

The Woven EndoBridge (WEB) device has been widely used to treat intracranial wide neck bifurcation aneurysms. Initial studies have demonstrated that approximately 90% of patients have same or improved long-term aneurysm occlusion after the initial 6-month follow up. The aim of this study is to assess the long-term follow-up in aneurysms that have achieved complete occlusion at 6 months. We also compared the predictive value of different imaging modalities used. This is an analysis of a prospectively maintained database across 13 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB device who achieved complete occlusion at first follow-up and had available long-term follow-up. A total of 95 patients with a mean age of 61.6 ± 11.9 years were studied. The mean neck diameter and height were 3.9 ± 1.3 mm and 6.0 ± 1.8 mm, respectively. The mean time to first and last follow-up was 5.4 ± 1.8 and 14.1 ± 12.9 months, respectively. Out of all the aneurysms that were completely occluded at 6 months, 84 (90.3%) showed complete occlusion at the final follow-up, and 11(11.5%) patients did not achieve complete occlusion. The positive predictive value (PPV) of complete occlusion at first follow was 88.4%. Importantly, this did not differ between digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA). This study underlines the importance of repeat imaging in patients treated with the WEB device even if complete occlusion is achieved short term. Follow-up can be performed using DSA, MRA or CTA with no difference in positive predictive value.

WEB embolization of very broad-based intracranial aneurysms with a dome-to-neck ratio ≤ 1.1

OBJECTIVE

The Woven EndoBridge (WEB) is a well-studied intrasaccular device for endovascular treatment of wide-necked bifurcation aneurysms. We evaluated the feasibility, safety and efficacy of the WEB for the treatment of very broad-based aneurysms with a dome-to-neck ratio ≤ 1.1.

METHODS

Thirty-four aneurysms treated at three neurovascular centers were retrospectively identified. The mean aneurysm size was 5.5 ± 1.6 mm with a mean neck width of 4.7 ± 1.5 and a mean dome-to-neck ratio of 1.0 ± 0.1. The primary outcome measures were immediate technical treatment success by WEB only, complete or near-complete occlusion at 6-month follow-up and ischemic stroke.

RESULTS

Aneurysm embolization by WEB only was technically feasible in 79.4%. Additional stenting was required in 14.7%. In two aneurysms (5.9%), WEB implantation failed, and the aneurysm was treated by stent- and balloon-assisted coiling, respectively. Thromboembolic events occurred during 5 interventions (14.7%), all of these performed in ruptured aneurysms. One patient (2.9%) remained asymptomatic (follow-up modified Rankin scale [mRS] score: 0), 2 patients (5.9%) had a transient deficit (mRS 0 and 1, respectively), and 2 (5.9%) had a disabling ischemic stroke (mRS 3, respectively). Mid-term angiographic follow-up of 29 patients (4.0 ± 2.6 months, range: 2-9 months) showed complete occlusion (WEB occlusion scale [WOS] A) in 41.4%, near-complete occlusion (WOS B) in 34.5%, a neck remnant (WOS C) in 10.3%, and aneurysm remnants (WOS D) in 13.8%.

CONCLUSIONS

WEB embolization of very broad-necked aneurysms was technically feasible and could be achieved by WEB only in the majority of cases. Considering the challenging anatomy of very broad-based aneurysms, the WEB procedure was reasonably safe and efficient.

Endovascular Treatment of Bifurcation Aneurysms with the Woven EndoBridge: Product Features and Selected Results of Off-Label Use

Treatment for wide-neck bifurcation cerebral aneurysms (WNBAs) is widely performed by endovascular treatment as well as open surgical clipping. However, due to factors such as the shape and size of the aneurysms, as well as the anatomical features of surrounding branch vessels, there are some cases in which simple coiling or conventional adjunctive techniques, such as balloon-assisted or neck bridge stent-assisted coiling, are not sufficient to achieve a satisfactory cure. Against this backdrop, the device known as the Woven EndoBridge (WEB) (MicroVention, Aliso Viejo, CA, USA) was developed and can be deployed directly into the aneurysm for treatment. Over a decade has passed since its development, and it is now used in many countries worldwide. This review provides insights into the evolution of the WEB device from its development to the date of this writing, highlighting the unique features of the device and its treatment indications. Additionally, it discusses the posttreatment course, perspectives on recurrence and retreatment, imaging assessments, and potential off-label use based on numerous studies primarily conducted in Europe and the USA.

Woven EndoBridge versus stent-assisted coil embolization for the treatment of ruptured wide-necked aneurysms: A multicentric experience

BACKGROUND

The potentially higher risk of hemorrhagic complications is of concern in stent-assisted coiling (SAC) of ruptured wide-necked intracranial aneurysms (IAs). The Woven EndoBridge (WEB) is considered an appealing alternative since antiplatelet therapy is not required. Herein, we aimed to compare the safety and effectiveness of WEB vs. SAC for the treatment of ruptured wide-necked IAs.

METHODS

This was an international cross-sectional study of consecutive patients treated for ruptured wide-neck IAs with WEB or SAC at four high-volume neurovascular centers between 2019 and 2022. Primary and secondary efficacy outcomes were radiographic aneurysm occlusion at follow-up and functional status at last follow-up. Safety outcomes included periprocedural hemorrhagic/ischemia-related complications.

RESULTS

One hundred five patients treated with WEB and 112 patients treated with SAC were included. The median procedure duration of endovascular treatment was shorter for WEB than for SAC (69 vs. 76 min; p = 0.04). There were no significant differences in complete aneurysm occlusion rates (SAC: 64.5% vs. WEB: 60.9%; adjusted OR [aOR] = 0.70; 95%CI 0.34-1.43; p = 0.328). SAC had a significantly higher risk of complications (23.2% vs. 9.5%, p = 0.009), ischemic events (17% vs. 6.7%, p = 0.024), and EVD hemorrhage (16% vs. 0%, p = 0.008). The probability of procedure-related complications across procedure time was significantly lower with WEB compared with SAC (aOR = 0.40; 95%CI 0.20-1.13; p = 0.03).

CONCLUSION

WEB and SAC demonstrated similar obliteration rates at follow-up when used for embolization of ruptured wide-necked IAs. However, SAC showed higher rates of procedure-related complications primarily driven by ischemic events and higher rates of EVD hemorrhage. The overall treatment duration was shorter for WEB than for SAC.

Aneurysmal recurrence and retreatment modalities after Woven EndoBridge (WEB) device implantation: A systematic review and meta-analysis

BACKGROUND

The Woven EndoBridge (WEB) device is used to treat wide-neck bifurcation aneurysms (WNBAs). We conducted a systematic review and meta-analysis to determine the retreatment rate strategies following aneurysmal recurrence of WEB device treated WNBAs.

METHODS

This study is reported following the PRISMA 2020 guidelines. We conducted a systematic review of the literature using PubMed, Scopus, Embase, and Web of Science. Data were pooled using a random-effects model. We calculated pooled prevalence and corresponding 95% confidence intervals (CI).

RESULTS

We included 11 studies. The overall retreatment rate was 171/1875 aneurysms (10.3%; 95% CI  =  8.3-12.9). Stent-assisted coiling was used to treat 59 aneurysms (36.7%; 95% CI  =  26.4-48.5), and flow diverters were used to treat 44 aneurysms (18.7%; 95% CI  =  9.9-32.5). Following retreatment, the complete occlusion rate was 57/91 aneurysms (62.8%; 95% CI  =  48.2-75.3) and the adequate occlusion rate was 24/91 aneurysms (26.4%; 18.4%-36.4%). The most common aneurysmal recurrence site was the anterior communicating artery (44/136 aneurysms, 32.4%; 95% CI  =  25.0-40.7).

CONCLUSIONS

Roughly 10% of WNBAs initially treated with the WEB device will undergo retreatment. Retreatment is an effective strategy for WEB-treated aneurysms, with high rates of adequate and complete occlusion. Future studies should work to identify risk factors for aneurysmal recurrence.

Identifying risk factors for perioperative thromboembolic complications in patients treated with the Woven EndoBridge device

INTRODUCTION

Woven EndoBridge (WEB) is a new endovascular treatment option for wide necked bifurcation aneurysms. Results from the WEB-IT trial showed a 0% risk of thromboembolic complications within 30 days post-op but the rate reported in the literature is as high as 10%. We are exploring potential risk factors associated with immediate thromboembolic complications in patients treated with the WEB device.

METHODS

Retrospective study of forty-two patients with intracranial aneurysms who were treated with WEB at a single center from 2019-2021. Data was collected on patient demographics, comorbidities, aneurysm characteristics, procedural details, and hospital course. Bivariate analyses were performed to compare patients who experienced a periprocedural ischemic stroke to those who did not. Multiple logistic regression modeling was performed to identify independent risk factors for thromboembolic complications.

RESULTS

Of the 42 patients that were treated with WEB, 6 suffered an ischemic stroke (AIS). These patients were more likely to have an underlying diagnosis of arrythmias (p value = 0.007). Furthermore, they had a median angle of 32.0° in the true neck view on diagnostic angiogram compared to 19.5° (p value = 0.046). Lastly, they had a longer procedure length of 228 min compared to 178 min (p value = 0.002). Patients with thromboembolic complications had a longer length of stay in the hospital and worse outcomes at three months follow up. On logistic regression modeling, these risk factors did not reach statistical significance.

CONCLUSION

Risk factors of thromboembolic complications after WEB placement include cardiac arrythmias, acute aneurysmal angle in the true neck view and a longer procedure length.

WEB vs coiling in ruptured aneurysms: A propensity score matched comparison of safety and efficacy

BACKGROUND

We aim to compare the safety and efficacy of WEB with coiling for acutely ruptured aneurysms.METHODS: All consecutive ruptured aneurysms with width suitable for WEB (2-10 mm) treated over 5 years (1/1/2015 to 31/12/2019) were included. We recorded WFNS, Fisher grade, patient demographics and aneurysm characteristics (size, location, D/W and aspect ratio, lobulation). Primary endpoints were mRS status at 3 months, aneurysm occlusion on latest available imaging follow-up, retreatment rate and procedural complications. We applied propensity score matching using aneurysm morphology (size, D/N ratio, ASPECT ratio and lobulation) to optimise matching for WEB versus coil comparison and minimise the effects of confounding.

RESULT

A total of 493 patients were identified, 97 treated with the WEB device. 1:1 propensity score matching was used to establish a matched group of 97 patients treated with coiling. The WEB arm showed 3% procedural complication rate, with no haemorrhagic complications and use of adjunctive device in 4%. Satisfactory occlusion on follow-up (mean 14 months) was 79%, with 19% retreatment rate. The coil arm had 8% complication rate, with use of an adjunctive device in 52% of cases (balloon 44%, stent 8%). Satisfactory occlusion on follow-up (mean 22 months) was 90%, with 8% retreatment rate.

CONCLUSION

Treatment of ruptured wide-necked bifurcation aneurysms with WEB has a lower complication rate than coiling with high rate of satisfactory occlusion. However, there was a higher retreatment rate when compared with patients treated with coiling. An adjunct device (balloon or stent), was used in over 50% of aneurysms in the coiling group.

Impact of aneurysm diameter, angulation, and device sizing on complete occlusion rates using the woven endobridge (WEB) device: Single center United States experience

BACKGROUND

The Woven EndoBridge device is a novel treatment option for wide-necked bifurcation intracranial aneurysms (WNBA). While this device has had good results, there remains a subset of WNBA that fail this treatment. The main objective of this study is to identify risk factors that are associated with incomplete occlusion of WEB treated aneurysms at short-term follow up.

METHODS

This was a retrospective study of 31 patients with intracranial aneurysms who were treated with WEB at a single institution in the USA in 2019-2021. Data was collected via chart review on patient demographics, aneurysm characteristics, procedural details, and occlusion status at six months follow up. Bivariate analyses were performed comparing completely occluded aneurysms with neck remnants and residual aneurysms.

RESULTS

16 (52%) had completely occluded aneurysms while 11 (35%) patients had a neck remnant, and 4 (13%) patients had a residual aneurysm at follow up. Patients with neck remnants and residual aneurysms had aneurysms with a larger diameter. A large aneurysm diameter is an independent risk factor for incomplete occlusion (OR 4.23 95% CI 1.08-16.53 P value = 0.038). Patients with residual aneurysms had an average difference between the aneurysm width and WEB diameter of -0.08mm compared to 1.2 mm in patients with occluded aneurysms. 75% of patients with a residual aneurysm presented with a ruptured aneurysm. Lastly, more patients with a residual aneurysm had an immediate angiographic outcome of incomplete occlusion.

CONCLUSION

Larger aneurysms are at risk for incomplete occlusion status post WEB treatment. Larger, ruptured aneurysms with minimal difference in aneurysm and WEB diameter that fail to occlude immediately post-treatment are more likely to present as residual aneurysms at short-term follow up.

Comparative effectiveness of stent-assisted coiling and Woven EndoBridge embolization for the treatment of unruptured wide-neck bifurcation intracranial aneurysms

OBJECTIVE

Woven EndoBridge (WEB) intrasaccular flow disruptors and stent-assisted coiling (SAC) are viable endovascular treatment options for wide-neck bifurcation intracranial aneurysms (WNBAs). Data directly comparing these two treatment options are limited. The authors aimed to compare radiographic occlusion rates and complication profiles between patients who received WEB and those who received SAC for WNBAs.

METHODS

Retrospective review of a prospectively maintained cerebrovascular procedural database was performed at a single academic medical center between 2017 and 2021. Patients were included if they underwent WEB embolization or SAC of an unruptured WNBA. SAC patients were propensity matched to WEB-embolized patients on the basis of aneurysm morphology. Complete and adequate (complete occlusion or residual neck remnant) occlusion rates at last angiographic follow-up, as well as periprocedural complications, were compared between the two groups. A cost comparison was performed for a typical 5-mm WNBA treated with WEB versus SAC by using manufacturer-suggested retail prices.

RESULTS

Thirty-five WEB and 70 SAC patients were included. Aneurysm width, neck size, and dome-to-neck ratio were comparable between groups. Follow-up duration was significantly longer in the SAC group (median [interquartile range] 545 [202-834] days vs 228 [177-494] days, p < 0.001, Mann-Whitney U-test). Complete (66% of WEB patients vs 69% of SAC patients) and adequate (94% WEB vs 91% SAC) occlusion rates were similar between groups at the last available angiographic follow-up (p = 0.744, chi-square test). Complete occlusion rates were comparable on Cox regression analysis after correction for follow-up duration (hazard ratio 1.5, 95% CI 0.8-3.1). Average time to residual aneurysm or neck formation was not statistically different between treatment groups (613 days for SAC patients vs 347 days for WEB patients, p = 0.225, log-rank test). Periprocedural complications trended higher in the SAC group (0% WEB vs 9% SAC, p = 0.175, Fisher exact test), although this finding was not significant. The equipment costs for a typical SAC case were estimated at $18,950, whereas the costs for a typical WEB device case were estimated at $18,630.

CONCLUSIONS

Midterm complete and adequate occlusion rates were similar between patients treated with WEB and those treated with SAC. Given these comparable outcomes, there may be equipoise in treatment options for WNBAs.

Microsurgical clipping as a retreatment strategy for previously ruptured aneurysms treated with the Woven EndoBridge (WEB) device: a mono-institutional case series

BACKGROUND

Since its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping.

METHODS

A retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified.

RESULTS

Overall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms.

CONCLUSIONS

Microsurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.

The Woven EndoBridge for intracranial aneurysms: Radiological outcomes and factors influencing occlusions at 6 and 24 months

PURPOSE

To identify factors influencing short- and mid-term radiological outcomes of intracranial aneurysms (IAs) treated with the Woven EndoBridge (WEB).

METHODS

A total of 112 patients were treated for IAs with the WEB in at our institution between 2013 and 2020. Patients with 6- and/or 24-months follow-up data were included in the study. Aneurysm occlusion was evaluated using the Raymond-Roy occlusion classification (RR). RR 1 and RR 2 were considered as adequate outcomes, while RR 3 inadequate.

RESULTS

Data were available for 91 patients (56 females, 62%) at 6 months and 62 of those patients (39 females, 58%) at 24 months. The adequate occlusion (RR 1/RR 2) rate was 89% (n = 81/91) at the 6-months follow-up and 91% (n = 56/62) at the 24-months follow-up. The treatment-related morbidity rate was 4% (n = 4/91), and mortality rate was 1% (n = 1/91). The predictor for inadequate occlusion at the 6-months follow-up was the lobular shape of an aneurysm (p = .01). The aneurysm's height (p = .02), maximal diameter (p = .001), width (p = .002), aspect ratio (p = .03), dome-to-neck ratio (p = .04), and lobular shape (p= .03) were predictive factors for inadequate occlusion at 24 months. All the thrombosed aneurysms (n = 3) showed unfavorable radiological outcomes and required re-treatment within 24 months. None of the patient-related factors were significant.

CONCLUSIONS

The WEB provides favorable occlusion rates and low complications for both ruptured and unruptured wide-necked IAs. Unfavorable radiological outcomes after WEB treatment may be related to aneurysm morphology and size.

Aneurysm Treatment with Woven EndoBridge-17: Angiographic and Clinical Results at 12 Months from a Retrospective, 2-Center Series

BACKGROUND AND PURPOSE

This retrospective, 2-center study investigated the feasibility, safety, and efficacy at 12-month follow-up of the treatment of ruptured, unruptured, and recurrent intracranial aneurysms using the latest generation of the Woven EndoBridge (WEB) device, the WEB-17 system.

MATERIALS AND METHODS

Aneurysms treated with WEB-17 were extracted from the databases of 2 neurovascular centers. Patients, aneurysm characteristics, complications, and clinical and anatomic results were analyzed.

RESULTS

From February 2017 to May 2021, two hundred twelve patients with 233 aneurysms (181/233, 77.7%, unruptured-recurrent, and 52/233, 22.3%, ruptured) were included. High treatment feasibility (95.3%) was reported and was similar in ruptured aneurysms (94.2%) and unruptured-recurrent aneurysms (95.6%) (P = .71) and in typical (95.4%) and atypical (94.7%) locations (P = .70), but it was lower in aneurysms with an angle between the parent artery and main aneurysm axis of ≥45° (90.2%) compared with those with an angle of <45° (97.1%) (P = .03). Global mortality and morbidity were 1.9% and 3.8% at 1 month, respectively, and 4.4% and 1.9% at 12 months, respectively. One-month morbidity (P = .02) and mortality (P = .003) were higher in the ruptured group (10.0% and 8.0%, respectively) compared with unruptured-recurrent group (1.9% and 0.0%, respectively). Overall adequate occlusion (complete occlusion and neck remnant) was 86.3%. The percentage of adequate occlusion was higher (P = .05) in the unruptured-recurrent group (88.5%) compared with the ruptured group (77.5%).

CONCLUSIONS

The WEB-17 system showed high feasibility for ruptured and unruptured aneurysms, typical and atypical locations, and some aneurysms with an angle of ≥45°. As the most recent generation device, the WEB-17 also demonstrates high safety and good efficacy.

Comparative assessment of woven endobridge embolization and standard coil occlusion for the treatment of ruptured basilar tip aneurysms

PURPOSE

Endovascular coil occlusion represents the standard treatment for basilar tip aneurysms. Recently, this role has been rivalled by intrasaccular flow disruptors across numerous centres. We retrospectively compared WEB embolization and coiling for the treatment of ruptured basilar tip aneurysms.

METHODS

Patients treated with WEB or coiling at four neurovascular centres were reviewed. Procedure-related complications, clinical outcome, and angiographic results were retrospectively compared.

RESULTS

The study included 23 patients treated with the WEB (aneurysm size: 6.6 ± 1.9 mm) and 56 by coiling (aneurysm size: 6.7 ± 2.5 mm). Stent-assistance was more often necessary with coiling than with WEB embolization (32% vs. 4%, p = 0.009). A modified Rankin scale score ≤ 2 at discharge had 21 (37.5%) patients in the coiling group and 12 (52.2%) in the WEB group (p = 0.235). Immediate complete and adequate occlusion rates were 52% for the WEB and 87% for coiling. At short-term follow-up, these rates were 87% for the WEB and 72% for coiling, respectively. There was no delayed aneurysm re-bleeding during follow-up.

CONCLUSION

Both coiling and WEB seem to prevent rebleeding in ruptured BTA aneurysms. WEB embolization required less frequently stent-support than coiling, potentially advantageous for SAH patients to avoid anti-platelet therapy in the light of concomitant procedures like ventricular drainage.

Trends of Expanding Indications of Woven EndoBridge Devices for the Treatment of Intracranial Aneurysms: A Systematic Review and Meta-analysis

PURPOSE

Woven EndoBridge (WEB) was introduced for the endovascular therapy of wide-neck intracranial aneurysms. The safety and efficacy have been evaluated through several meta-analyses. However, these reviews did not cover the expanding indications in detail. Therefore, we aimed to show the changing trends for intracranial aneurysm treatment using the WEB device.

METHODS

A systematic review and meta-analysis was conducted with PubMed, Embase, and Cochrane databases. We searched for studies that reported baseline characteristics of aneurysms and the WEB devices, which had treated more than 20 aneurysms consecutively. The pooled proportions of aneurysm indications and used WEB device types were obtained. To evaluate the changing indications for the treated aneurysm size, including the neck diameter, a trend line and linear regression model was measured.

RESULTS

A total of 27 cohorts were included encompassing 1831 aneurysms treated with the WEB. A total of 86% were used in the four major locations as on-label indications (middle cerebral artery bifurcation; 34%, anterior communicating artery; 26%, basilar tip; 18%, internal carotid artery terminus; 7%). Among off-label indications, the most common location was the posterior communicating artery (8%), followed by the anterior cerebral artery including the pericallosal artery (6%). The median aneurysm size and neck diameter was 7 mm and 4.6 mm, respectively. The WEB device has been used for the treatment of smaller aneurysms than the initial indication. Also, the proportion for ruptured aneurysm treatment was increased up to 15%.

CONCLUSION

The mechanical and technical development of the WEB resulted in expanding the indications for the treatment of intracranial aneurysms. The off-label indications accounted for 14% in total and an increasing number of small aneurysms are treated with WEB devices. Moreover, the proportion for ruptured aneurysm treatment was currently increased up to 14% more than in the beginning.

Results of Temporary Stent-assisted Coil Embolization (CATS) for the Treatment of Wide-neck Aneurysms : A 10-year Single Center Experience

PURPOSE

In intracranial wide-neck aneurysms, simple coil embolization is often not a feasible treatment option. Balloon-assisted coiling comes with the drawback of blood flow impairment, whereas permanent stent placement requires long-term antiplatelet therapy. Temporary stent-assisted coiling (coiling assisted by temporary stenting, CATS) is an alternative that eliminates both disadvantages. Because prior studies included only small numbers of patients, it was our aim to analyze the safety and effectiveness of this technique in a larger cohort of patients.

METHODS

We retrospectively evaluated all endovascular aneurysm treatments at our institution from 2011 to 2020. Out of a total of 688 aneurysm treatments, we intended to perform 95 (14%) with temporary stent-assisted coiling and included them in our study.

RESULTS

Sixty-four (64)% of aneurysms were acutely ruptured, 3% were symptomatic but unruptured, and 33% were incidental. Successful stent recovery was possible in 93% of treatments. Initial complete and adequate occlusion rate were 53% and 82%, respectively. Long-term follow-up at 6 and 12 months was available for 71% and 44% of cases. Aneurysm recurrence was observed in 10% of cases after 6 months, and in 17% after 1 year or later. Periprocedural complications were noted in 12 cases (13%), of which only 1 complication was definitely associated with temporary stent-assisted coiling (1%). One of the periprocedural complications resulted in neurological damage, the other complications were asymptomatic.

CONCLUSION

Temporary stent-assisted coiling appears to be a safe and effective treatment method in intracranial wide-neck aneurysms. Procedural safety appears to be comparable with balloon remodeling or permanent stent-assisted coiling, but it comes with the further benefit of diminished need for posttreatment antiplatelet therapy, which may improve the outcome of patients. However, to define the true value and potential benefit of this technique, further prospective studies are required.

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.

A review of technological innovations leading to modern endovascular brain aneurysm treatment

Tools and techniques utilized in endovascular brain aneurysm treatment have undergone rapid evolution in recent decades. These technique and device-level innovations have allowed for treatment of highly complex intracranial aneurysms and improved patient outcomes. We review the major innovations within neurointervention that have led to the current state of brain aneurysm treatment.

Worldwide productivity and research trends of publications concerning stent application in acutely ruptured intracranial aneurysms: A bibliometric study

Background

Stenting is a common clinical practice to treat acutely ruptured intracranial aneurysm (RIA). Although multiple studies have demonstrated its long-term safety and effectiveness, there is currently a lack of bibliometric analysis on stent application in acutely RIA. This study sought to summarize the current status of research in this field and lay a foundation for further study.

Materials and methods

Related publications were searched in the Web of Science Core Collection (WoSCC) database. Data analysis and visualization were performed by R and CiteSpace software.

Results

A total of 275 publications published in English from 1997 to 2022 were included in this study. The growth of publications slowed down. The reference co-citation network identified 13 clusters with a significant network (Q = 0.7692) and convincing clustering (S = 0.9082). The research focus was acutely RIA and the application of stents during interventional procedures. The main trends of research were: (1) development of materials, and (2) safety of stent application in acutely RIA. The United States contributed the most articles, and Jianmin Liu was the most prolific author. Mayo Clinic was the leading institution in this field. Most articles were published in Interventional Neuroradiology.

Conclusions

This study analyzed the research trends, hotspots and frontiers of stent application in acutely RIA. It is our hope that the results obtained could provide useful information to researchers to get a clearer picture about their future research directions in this field.

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.

CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS): 12-month angiographic results of a multicenter study

BACKGROUND

The CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS) study has shown that the endovascular treatment of ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) is safe and effective and provides protection against rebleeding at 1 month and 1 year. The 12-month angiographic follow-up is an important endpoint of the study.

METHODS

The CLARYS study is a prospective multicenter study conducted in 13 European centers. The study enrolled 60 patients with 60 ruptured aneurysms of the anterior and posterior circulation. The study was conducted with an independent assessment of safety outcomes and imaging.

RESULTS

Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. Fifty-three aneurysms (88.3%) had a broad base with a dome to neck ratio <2 (mean 1.6). Of these, 46 patients were evaluated by an independent core laboratory with follow-up imaging performed at 12 months or before eventual retreatment. At 1 year, 19/46 aneurysms (41.3%) were completely occluded (Raymond-Roy grade I), 21/46 (45.7%) had a residual neck and 6/46 (13.0%) had residual aneurysm filling. Adequate occlusion was reported in 40/46 (87%) aneurysms. Six patients underwent target aneurysm retreatment.

CONCLUSIONS

The CLARYS study has previously shown that the use of the WEB in the endovascular treatment of ruptured bifurcation aneurysms provides effective protection against rebleeding with a good safety profile. The angiographic occlusion rates at 1 year reported here are comparable to those already seen in previous multicenter studies which primarily included unruptured aneurysms.

Delayed rupture of an anterior communicating artery aneurysm after elective Woven EndoBridge embolization, re-treated with microsurgical clipping: operative technique and systematic review

BACKGROUND

The Woven EndoBridge (WEB) device is designed for intrasaccular flow disruption for embolization of intracranial aneurysms. In limited experience so far, the rate of rupture after adequate occlusion by embolization is low.

TECHNICAL REPORT

A 58-year-old man initially had an incidental, unruptured 10.4 mm anterior communicating artery (ACoA) aneurysm treated with WEB embolization. Although his 6-month follow-up angiogram showed adequate occlusion of the aneurysm, he presented to our facility with aneurysmal recurrence due to WEB compaction and rupture. This was treated with surgical clipping of the aneurysm.

METHODS

The literature was systematically reviewed for cases of delayed rupture after WEB embolization. Statistical analyses included studies with at least 20 patients and follow-up of 3 months.

RESULTS

We identified 36 studies, which were primarily retrospective observational studies. The rate of complete occlusion ranged from 33% to 89%, and the rate of re-treatment ranged from 1.5% to 27%. Across four studies, the rate of recanalization ranged from 8.7% to 13%. Two cases of delayed rupture were reported; an additional four cases were found in case reports and case series. In only one previous case, the aneurysm was reported as previously untreated.

CONCLUSION

Early retrospective data has begun to define the history of WEB-treated aneurysms. Rupture of a previously unruptured, WEB-treated aneurysm with adequate initial occlusion is rare. We describe such a case with techniques for management, demonstrating that aneurysm recurrence and delayed rupture is possible despite good interim angiographic result. This report raises questions about follow-up for WEB-treated aneurysms.

Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms

OBJECTIVE

Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices.

METHODS

This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography.

RESULTS

The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385-6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107-0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116-0.795], p = 0.015) and multiple imputations.

CONCLUSIONS

Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.

CLinical Assessment of WEB device in Ruptured aneurYSms (CLARYS): results of 1-month and 1-year assessment of rebleeding protection and clinical safety in a multicenter study

Background

The primary goal of the CLARYS study is to assess the protection against rebleeding when treating ruptured bifurcation aneurysms with the Woven EndoBridge (WEB) device.

Methods

The CLARYS study is a prospective, multicenter study conducted in 13 European centers. Patients with ruptured bifurcation aneurysms were consecutively included between February 2016 and September 2017. The primary endpoint was defined as the rebleeding rate of the target aneurysm treated with the WEB within 30 days postprocedure. Secondary endpoints included periprocedural and postprocedural adverse events, total procedure and fluoroscopy times, and modified Rankin Scale score at 1 month and 1 year.

Results

Sixty patients with 60 ruptured bifurcation aneurysms to be treated with the WEB were included. A WEB device was successfully implanted in 93.3%. The rebleeding rate at 1 month and 1 year was 0%. The mean fluoroscopy time was 27.0 min. Twenty-three periprocedural complications were observed in 18 patients and resolved without sequelae in 16 patients. Two of these complications were attributed to the procedure and/or the use of the WEB, leading to a procedure/device-related intraoperative complication rate of 3.3%. Overall mortality at 1 month and 1 year was 1.7% and 3.8%, respectively and overall morbidity at 1 month and 1 year was 15% and 9.6%, respectively. WEB-related 1-month and 1-year morbidity and mortality was 0%.

Conclusions

The interim results of CLARYS show that the endovascular treatment of ruptured bifurcation aneurysms with the WEB is safe and effective and, in particular, provides effective protection against rebleeding. It may induce profound change in the endovascular management of ruptured bifurcation aneurysms.

Predictors of aneurysm occlusion following treatment with the WEB device: systematic review and case series

The Woven EndoBridge (WEB) device is becoming increasingly popular for treatment of wide-neck aneurysms. As experience with this device grows, it is important to identify factors associated with occlusion following WEB treatment to guide decision making and screen patients at high risk for recurrence. The aim of this study was to identify factors associated with adequate aneurysm occlusion following WEB device treatment in the neurosurgical literature and in our case series. A systematic review of the present literature was conducted to identify studies related to the prediction of WEB device occlusion. In addition, a retrospective review of our institutional data for patients treated with the WEB device was performed. Demographics, aneurysm characteristics, procedural variables, and 6-month follow-up angiographic outcomes were recorded. Seven articles totaling 450 patients with 456 aneurysms fit our criteria. Factors in the literature associated with inadequate occlusion included larger size, increased neck width, partial intrasaccular thrombosis, irregular shape, and tobacco use. Our retrospective review identified 43 patients with 45 aneurysms. A total of 91.1% of our patients achieved adequate occlusion at a mean follow-up time of 7.32 months. Increasing degree of contrast stasis after WEB placement on the post-deployment angiogram was significantly associated with adequate occlusion on follow-up angiogram (p = 0.005) and with Raymond-Roy classification (p = 0.048), but not with retreatment (p = 0.617). In our systematic review and case series totaling 450 patients with 456 aneurysms, contrast stasis on post-deployment angiogram was identified as a predictor of adequate aneurysm occlusion, while morphological characteristics such as larger size and wide neck negatively impact occlusion.

Safety and Efficacy of the Woven EndoBridge Device for Treatment of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis

BACKGROUND

The Woven EndoBridge device has been increasingly used to treat wide-neck aneurysms, particularly ruptured ones.

PURPOSE

Our aim was to investigate the safety and efficacy of the Woven EndoBridge device in the treatment of ruptured intracranial aneurysms.

DATA SOURCES

All studies evaluating the outcomes of Woven EndoBridge device use in the treatment of ruptured intracranial aneurysms from inception through 2020 were searched on Ovid Evidence-Based Medicine Reviews, EMBASE, MEDLINE, Scopus, and the Web of Science Core Collection.

STUDY SELECTION

Eighteen studies encompassing 487 patients with 496 ruptured aneurysms treated with the Woven EndoBridge device were included.

DATA ANALYSIS

We studied rates of rerupture and retreatment, angiographic outcomes at the last follow-up point, complications, and mortality rates. Data were collected on anticoagulation and antiplatelet use. Meta-analysis was performed using the random effects model.

DATA SYNTHESIS

The rate of late rebleeding was 1.1% (95% CI, 0.1%-2.1%). The treatment-related perioperative complication rate and the overall clinical complication rate were 13.2% (95% CI, 9.2%-17.2%) and 3.2% (95% CI, 1.6%-4.7%), respectively. Thirteen hemorrhagic (2%; 95% CI, 0.8%-3.3%) and 41 thromboembolic (6.8%; 95% CI, 4.6%-9%) complications occurred. Favorable clinical outcomes were achieved in 85% of patients. Procedure-related mortality and overall mortality rates were 2.1% (95% CI, 0.8%-3.3%) and 11.5% (95% CI, 7%-16%), respectively. At last follow-up, an adequate occlusion rate was 87.3% (95% CI, 82.1%-92.4%) and the retreatment rate was 5.1% (95% CI, 3%-7.3%).

LIMITATIONS

Our meta-analysis is limited by selection bias and high heterogeneity.

CONCLUSIONS

This meta-analysis demonstrated the safety and efficacy of the Woven EndoBridge device in the management of ruptured aneurysms, but further studies are needed.

Woven EndoBridge device for the treatment of ruptured intracranial aneurysms: A systematic review of clinical and angiographic results

BACKGROUND AND OBJECTIVE

The clinical outcome and angiographic outcome data of Woven EndoBridge (WEB) device for the treatment of ruptured intracranial aneurysms (IAs) are limited. We conducted a meta-analysis of the latest literature on the WEB device in the treatment of ruptured IAs.

METHODS

A comprehensive literature search of 4 databases (PubMed, Web of Science, Cochrane library, and Embase) was conducted for studies published from January 1, 2010 to December 31, 2020. Two reviewers independently extracted variables (aneurysm and patient characteristics) using a prespecified data-collection sheet. Outcomes studied included initial and latest follow-up angiographic outcomes, technical success rate, perioperative mortality, retreated rate, perioperative re-bleeding, complication, intraoperative rupture, favorable neurologic outcome at discharge. We used random-effects model to pool the data.

RESULTS

We finally presented the results of 7 articles including 276 patients with 283 aneurysms. Initial complete and adequate occlusion rate were 38% (95% CI, 25%-50%) and 98% (95% CI, 95%-100%), respectively. Latest follow-up complete and adequate occlusion rate were 61% (95% CI, 46%-75%) and 91% (95% CI, 84%-98%), respectively.Technical success rate was 99% (95% CI, 98%-100%). Perioperative mortality rates and perioperative re-bleeding rate were 9% (95% CI, 3%-15%) and 1% (95% CI, 0%-2%), respectively. Retreated rate was 6% (95% CI, 3%-10%). Overall and WEB treatment-related thromboembolic complication was 10% (95% CI, 6%-13%) and 7% (95% CI, 2%-12%), respectively. Intraoperative rupture rate was 3% (95% CI, 0%-6%).

CONCLUSION

Endovascular treatment of ruptured IAs with the WEB device has a good safety profile and an acceptable aneurysm occlusion rate.

The Woven EndoBridge device for ruptured intracranial aneurysms: international multicenter experience and updated meta-analysis

PURPOSE

The Woven EndoBridge (WEB) can be used to treat wide-necked aneurysms without antiplatelet medications, suggesting it may have advantages in the setting of aneurysmal subarachnoid hemorrhage (aSAH). The goal was assessment of safety and efficacy of WEB in aSAH given the delayed nature of aneurysmal thrombosis.

METHODS

An international retrospective analysis of patients with aSAH treated with WEB was conducted at 7 tertiary centers from 2016 to 2020. Outcomes included rates of rebleeding, retreatment, complications, and complete occlusion. Furthermore, a systematic review and meta-analysis was conducted from 2011 to 2020 assessing the same outcomes. All pooled event rates were calculated using a random effect model.

RESULTS

Consecutive patients with aSAH harbored 25 aneurysms that were treated with 29 WEB devices. The mean age was 53 years, and 65% were female. Zero experienced rebleeding, 2 were retreated, 2 experienced complications, 16 were completely occluded at 3 months, and 21 were completed occluded at 9-12 months. Meta-analysis of 309 WEB treatments for aSAH from 7 case series revealed 2.5% (95% CI 1-5%) had rebleeding, 9% (95% CI 4-17%) were retreated, 17% (95% CI 10-30%) had complications, and 61% (95% CI 51-71%) were completely occluded at 3-6 months.

CONCLUSION

WEB embolization in the setting of aSAH provides similar protection against rebleeding with comparable retreatment rates to traditional approaches. However, there is a higher rate of incomplete radiographic occlusion and operative complications compared to WEB embolization of unruptured aneurysms. Long-term prospective studies are needed to fully delineate the role of WEB embolization in aSAH.

Recurrent and Residual Aneurysms After Woven EndoBridge (WEB) Therapy: What's Next?

The prevalence of recurrent and residual aneurysms following Woven EndoBridge (WEB) treatment is not insignificant. The goal of this systematic review was to evaluate retreatment methods for such aneurysms and their outcomes. PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Original studies reporting on aneurysms that were retreated after WEB were included. Sixteen studies (n = 901 aneurysms), of which three were prospective, reported on retreated aneurysms following initial WEB treatment. Of those 901 aneurysms, on average 18.7 ± 11.5% were recurrent or residual at the last follow-up and 10.7 ± 11% required some form of retreatment. When compared to WEB-IT (WEB Intra-saccular Therapy) data, retreated aneurysms were more likely to be large in size (p < 0.0001) and more likely to have been initially treated with the WEB dual-layer configuration. The mean age of those with retreated aneurysms was 58 ± 5.7 years old, and the mean size of aneurysm dome was 11.1 ± 5.5 millimeters. Majority (34.1%) of the aneurysms were located at the basilar apex. Retreatment modalities included coiling (20%), stent-assisted coiling (38.7%), additional WEB device (13.3%), flow diversion (16%), and clipping (12%). Majority of retreated cases had favorable outcomes, with 96.4 ± 13.4% of the cases demonstrating technical success and 90.5 ± 18.2% having adequate occlusion at the last follow-up. Our systematic review suggests that retreatment of recurrent and residual aneurysms after initial WEB treatment is feasible. Future prospective studies would be helpful in validating these results.

Endovascular treatment for aneurysms at the A1 segment of the anterior cerebral artery: current difficulties and solutions

Aneurysms located at the A1 segment of the anterior cerebral artery are considered rare and unique entities. Endovascular treatment (EVT) is effective in preventing aneurysmal bleeding. However, EVT for A1 aneurysms is difficult due to their distinctive configurations. A current review of EVT for A1 aneurysms is lacking. Therefore, we focused on the available literature on this specific issue. To more clearly expound this entity, we also provided some illustrative cases. The A1 segment can be equally divided into the proximal, middle, and distal segments. Proximal aneurysms are most common and difficult to treat via EVT. The A1 segment has a complex anatomy and many important branches. Due to the small size, predominant posterior direction, and sharp upturn of the microcatheter from the parent artery, microcatheter positioning and support is difficult for A1 aneurysms. EVT for A1 aneurysms mainly includes reconstructive and deconstructive strategies. The complications of EVT for A1 aneurysms include aneurysmal perforation, thromboembolic events, and coil protrusion related to stent-assisted embolization. A1 aneurysms represent rare and difficult vascular lesions. EVT is quite challenging for A1 aneurysms due to their distinctive configurations. The outcomes are acceptable.

The safety and efficacy of low-dosage tirofiban for stent-assisted coiling of ruptured intracranial aneurysms

Stent-assisted coiling (SAC) of acutely ruptured aneurysms with antiplatelet therapy has been controversial. Tirofiban has been used for the treatment of thromboembolism of ruptured aneurysms with a stent. However, there are few comparative studies of a reasonable dosage for the prophylactic use of tirofiban. This study evaluated the safety and efficacy of reducing the dosage of tirofiban for the ruptured aneurysms with SAC. Patients with ruptured intracranial aneurysms in our institution from January 2014 to June 2018 were retrospectively reviewed. Three hundred and nine patients were treated using SAC within 72 h of onset. Patients were divided into either a standard group (211 patients, 10 μg/kg intravenous bolus within 3 min, maintained with 0.15 μg/kg/min) or a half-dose group (98 patients, 5 μg/kg intravenous bolus within 3 min, maintained with 0.075 μg/kg/min) according to the dose of tirofiban received intraoperatively. Medical records including clinical and radiological details were reviewed. No significant differences in demographic information or aneurysm characteristics existed between the two groups. Thromboembolic complications were found in 15 patients (4.9%), including 11 patients (5.2%) in the standard group and four patients (4.1%) in the half-dose group, without significant difference (P = 0.782). Intracranial hemorrhage was found in 13 patients (4.2%), and all occurred in the standard group, which was significantly different (6.2% vs 0%, P = 0.011). Of these 13 patients, four were left disabled and five died. Except for three patients who had intraoperative aneurysm rupture, the incidence of postoperative early rebleeding (10 patients) was significantly different between the two groups (4.7% vs 0%, P = 0.034). The rate of initial complete occlusion in the half-dose group was significantly higher than that in the standard group (55.1% vs 39.8%). The rate of a good outcome (modified Rankin Scale 0-2) was not significantly different between the standard group and half-dose group (78.7% vs 87.8%, P > 0.05). Intravenous tirofiban for SAC of acutely ruptured intracranial aneurysms is feasible and safe. The half-dose tirofiban treatment was associated with a decrease in the prevalence of intracranial hemorrhage but no increase in thromboembolic events compared with those in standard-dose tirofiban treatment.