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Enomoto Y, Matsubara H, Ishihara T, Shoda K, Mizutani D, Egashira Y, Ishii A, Sakamoto M, Sumita K, Nakagawa I, Higashi T, Yoshimura S. Optimal duration of dual antiplatelet therapy for stent-assisted coiling or flow diverter placement. J Neurointerv Surg 2024; 16:491-497. [PMID: 37344176 PMCID: PMC11041548 DOI: 10.1136/jnis-2023-020285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/04/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is necessary to prevent thromboembolic complications after stent-assisted coiling (SAC) or flow-diversion (FD) for cerebral aneurysms, but the optimal antiplatelet regimen remains unclear. OBJECTIVE To determine the optimal DAPT duration in patients with SAC/FD. METHODS This multicenter cohort study enrolled patients who received SAC/FD for cerebral aneurysms at seven Japanese institutions between January 2010 and December 2020. The primary outcome was the time from procedure to the occurrence of a composite of target vessel-related thromboembolic events, procedure-unrelated major bleeding events, or death. The cumulative event-free survival rates were analyzed using a Kaplan-Meier curve, and the differences in each outcome between the groups dichotomized by the duration of DAPT were analyzed using the log-rank test. RESULTS Of 632 patients (median observational period, 646 days), primary outcome occurred in 63 patients (10.0%), most frequently within 30 days after the procedure. The cumulative event-free survival rates at 30 days, 1 year, and 2 years after the procedure were 93.3% (91.4 to 95.3%), 91.5% (89.3 to 93.7%), and 89.5% (87.0 to 92.0%), respectively. The cumulative event-free survival rates after switching to monotherapy were similar for the >91 and <90 days DAPT groups in the population limited to patients who were switched from DAPT to monotherapy without major clinical events. CONCLUSIONS Thromboembolic events rarely occurred beyond 30 days after SAC/FD. The duration of DAPT may be shortened if patients have a periprocedural period without events. Further prospective studies are warranted to determine the optimal duration of antiplatelet therapy. TRIAL REGISTRATION NUMBER UMIN000044122 :https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000050384.
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Affiliation(s)
- Yukiko Enomoto
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | | | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Kenji Shoda
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Daisuke Mizutani
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Yusuke Egashira
- Neurosurgery, Gifu Univeristy Graduate School of Medicine, Gifu, Japan
| | - Akira Ishii
- Neurosurgery, Kyoto University, Graduate School of Medicine, Kyoto, Japan
| | - Makoto Sakamoto
- Division of Neurosurgery, Department of Neurological Sciences, Faculty of Medicine, Tottori University, Tottori, Japan
| | - Kazutaka Sumita
- Endovascular surgery, Tokyo Medical and Dental University, Bunkyo-ku, Japan
| | - Ichiro Nakagawa
- Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Toshio Higashi
- Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
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2
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Lazaro TT, Hoang AN, Cotton PC, Dang HQ, Tanweer O, Raper DMS. Management strategies of unanticipated intracranial stenosis during mechanical thrombectomy for acute stroke: A survey of academic neurointerventionalists. Interv Neuroradiol 2023; 29:725-730. [PMID: 35758313 PMCID: PMC10680963 DOI: 10.1177/15910199221110971] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The optimal approach to the management of intracranial atherosclerotic disease (ICAD) at the time of mechanical thrombectomy (MT) for large vessel occlusion (LVO) remains controversial. The goal of this study is to characterize current practices concerning this challenging clinical situation in a survey of practicing neurointerventionalists. METHODS An electronic questionnaire was sent to a cross-section of North American academic neurointerventionalists using publicly available contact information and departmental websites. Prior to analysis, responses were anonymized and categorized by region. RESULTS A total of 136/360 responses were recorded from the U.S. and Canada. The mean number of years of practicing as a neurointerventionalist among the respondents was 10.5 (± 6.2 years). ICAD was perceived as a causative factor during MT for LVO in 5-10% of thrombectomy cases. The most common first-line treatment approach for significant ICAD, assuming a TICI 2b or better reperfusion, was medical therapy (77.9% of respondents), followed by angioplasty + stent placement (8.8% of respondents). There were no significant differences in the first line treatment of ICAD in LVO between geographical regions (p = 0.815). CONCLUSION The approach to underlying ICAD in LVO varies widely; however, the majority of neurointerventionalists prefer medical therapy with DAPT as a first-line treatment approach. The current survey highlights the need for studies that better define the optimal timing and modality of treatment, along with an evidence-based framework for balancing the risks associated with these treatment approaches.
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Affiliation(s)
- Tyler T Lazaro
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Alex N Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Patrick C Cotton
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Huy Q Dang
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Daniel M S Raper
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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Dmytriw AA, Dibas M, Adeeb N, Salem MM, Salehani A, Waqas M, Saad Aldine A, Tutino VM, Ogilvy CS, Siddiqui AH, Harrigan MR, Thomas AJ, Cuellar H, Griessenauer CJ. The Pipeline Embolization Device: a decade of lessons learned in the treatment of posterior circulation aneurysms in a multicenter cohort. J Neurosurg 2022; 137:1454-1461. [PMID: 35276645 DOI: 10.3171/2021.12.jns212201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Pipeline Embolization Device (PED) has prompted a paradigm shift in the approach to posterior circulation aneurysms. The year 2021 marks a decade since FDA approval of this flow diverter, and during this time operators have adapted to its off-label uses. The authors examined whether case selection, practice trends, and patient outcomes have changed over this 10-year period. METHODS This study is a retrospective review of consecutive posterior circulation aneurysms managed with the PED at four academic institutions in the US between January 1, 2011, and January 1, 2021. Factors related to case selection, rates of aneurysm occlusion, or complications were identified and evaluated. Angiographic outcomes as well as thromboembolic and hemorrhagic complications were investigated. RESULTS This study included 117 patients (median age 60 years). At a median follow-up of 12 months, adequate occlusion (> 90%) was attained in 73.2% of aneurysms. Aneurysm occlusion rates were similar over the study interval. Thromboembolic and hemorrhagic complications were reported in 12.0% and 6.0% of the procedures, respectively. There was a nonsignificant trend toward a decline in the rate of thromboembolic (14.1% in 2011-2015 vs 9.4% in 2016-2021, p = 0.443) and hemorrhagic (9.4% in 2011-2015 vs 1.9% in 2016-2021, p = 0.089) complications. CONCLUSIONS The authors observed a trend toward a decline in the rate of thromboembolic and hemorrhagic complications with improved operator experience in using the PED for posterior circulation aneurysms. The use of single-device PED flow diversion significantly increased, as did the tendency to treat smaller aneurysms and observe large unruptured fusiform/dolichoectatic lesions. These findings reflect changes attributable to evolving judgment with maturing experience in PED use.
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Affiliation(s)
- Adam A Dmytriw
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mahmoud Dibas
- 2Departments of Neurosurgery and Interventional Neuroradiology, Louisiana State University Hospital, Shreveport, Louisiana
| | - Nimer Adeeb
- 2Departments of Neurosurgery and Interventional Neuroradiology, Louisiana State University Hospital, Shreveport, Louisiana
| | - Mohamed M Salem
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Arsalaan Salehani
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Muhammad Waqas
- 4Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Amro Saad Aldine
- 2Departments of Neurosurgery and Interventional Neuroradiology, Louisiana State University Hospital, Shreveport, Louisiana
| | - Vincent M Tutino
- 4Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adnan H Siddiqui
- 4Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Mark R Harrigan
- 3Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Hugo Cuellar
- 2Departments of Neurosurgery and Interventional Neuroradiology, Louisiana State University Hospital, Shreveport, Louisiana
| | - Christoph J Griessenauer
- 5Department of Neurosurgery, Christian Doppler Clinic, and
- 6Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Hohenstatt S, Ulfert C, Herweh C, Schönenberger S, Purrucker JC, Bendszus M, Möhlenbruch MA, Vollherbst DF. Acute Intraprocedural Thrombosis After Flow Diverter Stent Implantation: Risk Factors and Relevance of Standard Observation Time for Early Detection and Management. Clin Neuroradiol 2022; 33:343-351. [PMID: 36068407 DOI: 10.1007/s00062-022-01214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Acute intraprocedural thrombosis (AIT) is a severe complication of flow diverter stent (FDS) implantation for the treatment of intracranial aneurysms. Even though device-related thromboembolic complications are well known, there are no acknowledged risk factors nor defined surveillance protocols for their early detection. This study aimed to demonstrate that an angiographic active surveillance is effective to detect and treat AIT. Furthermore, we investigated risk factors for the occurrence of AIT. METHODS A prospective institutional protocol consisting of a defined observation period of 30 min following FDS deployment was established to detect AIT. Overall incidence, as well as the efficacy and safety of AIT treatment were assessed. Moreover, radiological and clinical outcomes of patients with AIT were analyzed. The influence of various patient- and procedure-related factors on the occurrence of AIT was investigated using multivariable forward logistic regression. RESULTS During active surveillance twelve cases of AIT were observed among a total of 161 procedures (incidence: 7.5%). The median time of first observation was 15.5 min (IQR 9.5) after FDS implantation. The early recognition of AIT ensured a prompt treatment with intravenous application of a glycoprotein IIb/IIIa inhibitor, which led to complete thrombus resolution in all cases without hemorrhagic complications. Patients with pre-existing arterial hypertension and side branches originating from the aneurysmal sac had a higher risk of AIT (respectively OR, 9.844; OR, 3.553). There were two cases of re-thrombosis in the short-term postoperative period, of whom one died. The remaining patients with AIT had a good clinical outcome. CONCLUSION Active surveillance for 30 min after FDS implantation is an effective strategy for early detection and ensuing treatment of AIT and can thus prevent secondary sequalae. Hypertension and side branches originating from the aneurysmal sac may increase the risk of AIT.
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Affiliation(s)
- Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Silvia Schönenberger
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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Kim J, Han HJ, Lee W, Park SK, Chung J, Kim YB, Park KY. Safety and Efficacy of Stent-Assisted Coiling of Unruptured Intracranial Aneurysms Using Low-Profile Stents in Small Parent Arteries. AJNR Am J Neuroradiol 2021; 42:1621-1626. [PMID: 34210666 DOI: 10.3174/ajnr.a7196] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Stent-assisted coiling of intracranial aneurysms arising from small vessels (≤ 2.0 mm) is a common procedure. However, data regarding its treatment outcomes are scarce. This study evaluated the clinical and radiologic outcomes of stent-assisted coiling using low-profile stents for aneurysms of small parent arteries. MATERIALS AND METHODS From November 2015 to October 2020, sixty-four patients with 66 aneurysms arising from parent arteries of ≤2.0 mm were treated with stent-assisted coiling using a Low-Profile Visualized Intraluminal Support Junior (LVIS Jr) or the Neuroform Atlas stent in a single institution. The clinical and radiologic data were retrospectively reviewed, and the risk factors for procedure-related complications were evaluated. RESULTS The LVIS Jr and Neuroform Atlas stents were used in 22 (33.3%) and 44 (66.7%) cases, respectively. Technical success was achieved in 66 cases (100%). Immediate postprocedural aneurysm occlusion grades assessed by the Raymond-Roy occlusion classification were I (57.6%), II (19.7%), and III (22.7%), respectively. Procedure-related complications occurred in 10 cases (15.2%), with 8 thromboembolic complications (12.1%) and 2 hemorrhagic complications (3.0%). Procedure-related morbidity was 4.5% without mortality. On multivariate analysis, current smoking (odds ratio = 7.1, P = .021) had a statistically significant effect on procedure-related complications. CONCLUSIONS Stent-assisted coiling of intracranial aneurysms with low-profile stents in small vessels (≤ 2.0 mm) had a 100% success rate and a 15.2% overall complication rate with 4.5% morbidity. Current smoking was a significant risk factor associated with procedure-related complications.
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Affiliation(s)
- J Kim
- From the Department of Neurosurgery (J.K., H.J.H., J.C., Y.B.K., K.Y.P.)
| | - H J Han
- From the Department of Neurosurgery (J.K., H.J.H., J.C., Y.B.K., K.Y.P.)
| | - W Lee
- Severance Stroke Center, and Department of Neurosurgery (W.L., S.K.P.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S K Park
- Severance Stroke Center, and Department of Neurosurgery (W.L., S.K.P.), Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - J Chung
- From the Department of Neurosurgery (J.K., H.J.H., J.C., Y.B.K., K.Y.P.)
| | - Y B Kim
- From the Department of Neurosurgery (J.K., H.J.H., J.C., Y.B.K., K.Y.P.)
| | - K Y Park
- From the Department of Neurosurgery (J.K., H.J.H., J.C., Y.B.K., K.Y.P.)
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Zhang Y, Wang C, Tian Z, Zhu W, Li W, Yang X, Liu J, Zhang Y. Risk factors for periprocedural ischemic stroke following endovascular treatment of intracranial aneurysms. Chin Neurosurg J 2021; 7:38. [PMID: 34425918 PMCID: PMC8381544 DOI: 10.1186/s41016-021-00255-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background The aim of this study was to comprehensively evaluate the risk factors of periprocedural ischemic stroke associated with endovascular treatment of intracranial aneurysms using a real-world database. Methods From August 2016 to March 2017, 167 patients were enrolled. Univariate analysis and multivariate logistic regression analysis were used to examine the risk factors for periprocedural ischemic stroke. Results Among the 167 cases, periprocedural ischemic stroke occurred in 20 cases (11.98%). After univariate analysis, the ischemic group had a higher proportion of large (≥ 10 mm) aneurysms than the control group (45.0% vs. 23.1%, p = 0.036). The incidence of periprocedural ischemic stroke was higher in cases treated by flow diverter (21.6%) or stent-assisted coiling (11.8%) than in cases treated by coiling only (2.7%), and the differences were statistically significant (p = 0.043). After multivariate logistic regression analysis, treatment modality was the independent risk factor for periprocedural ischemic stroke. Compared with the coiling-only procedure, flow diverter therapy was associated with a significantly higher rate of periprocedural ischemic stroke (OR 9.931; 95% CI 1.174–84.038; p = 0.035). Conclusions Aneurysm size and treatment modality were associated with periprocedural ischemic stroke. Larger aneurysms were associated with increased risk of periprocedural ischemic stroke. Flow diverter therapy was associated with significantly more periprocedural ischemic stroke than the coiling procedure alone.
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Affiliation(s)
- Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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8
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Samaniego EA, Dandapat S, Roa JA, Zanaty M, Nakagawa D, Hasan DM. Mechanical Thrombectomy of Acutely Occluded Flow Diverters. Oper Neurosurg (Hagerstown) 2020; 17:491-496. [PMID: 30892631 DOI: 10.1093/ons/opz023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 02/03/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Embolization of intracranial aneurysms with the pipeline embolization device (PED; Medtronic, Dublin, Ireland) is a widely used technique. Despite adequate dual antiplatelet therapy and intraprocedural anticoagulation, in-stent thrombosis has been described. There is limited evidence for best management of this complication. OBJECTIVE To describe in detail the technique used to perform thrombectomy of a recently placed PED with in-stent thrombosis. The aim of the procedure is to leave the PED in place and only perform thrombectomy of the luminal clot. METHODS We describe two cases of successful thrombectomy with a stentriever of acutely occluded PEDs. A total of 2 patients underwent PED embolization of 2 previously clipped aneurysms. Despite optimal deployment of the PEDs and excellent angiographic results, both patients developed symptoms of right hemispheric stroke within 1 h of the procedure. A thrombectomy was performed in each patient with the stentriever within the newly deployed PED. Thrombectomy was successful and there was no evidence of PED displacement of vascular injury. RESULTS Stentriever thrombectomy of intraluminal clot can be performed effectively when the entire stentriever device is deployed within the PED. We did not experience any PED displacement, vessel damage, spasm, or device malfunction using this technique. CONCLUSION We report the use of a stentriever to perform thrombectomy for in-stent thrombosis after PED placement as an additional treatment option of acute occlusion. This technique has not been previously described.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Jorge A Roa
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Daichi Nakagawa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Dmytriw AA, Phan K, Salem MM, Adeeb N, Moore JM, Griessenauer CJ, Foreman PM, Shallwani H, Shakir H, Siddiqui AH, Levy EI, Davies JM, Harrigan MR, Thomas AJ, Ogilvy CS. The Pipeline Embolization Device: Changes in Practice and Reduction of Complications in the Treatment of Anterior Circulation Aneurysms in a Multicenter Cohort. Neurosurgery 2020; 86:266-271. [PMID: 30860254 DOI: 10.1093/neuros/nyz059] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Pipeline Embolization Device (PED; Medtronic, Dublin, Ireland) has become an important tool for the treatment of cerebral aneurysms. Since FDA approval, there are ongoing efforts to increase aneurysm occlusion rates and reduce the incidence of complications. OBJECTIVE To assess aneurysm occlusion and complication rates over time. METHODS Retrospective analysis of consecutive anterior circulation aneurysms treated with a single PED between 2011 and 2016 at 3 academic institutions in the US was performed. Factors contributing to changes in aneurysm occlusion and complication rates over time were identified and evaluated. RESULTS A total of 284 procedures were performed on 321 anterior circulation aneurysms in 284 patients. At a median follow-up of 13 mo (mean 18 mo), complete or near complete occlusion (>90%) was achieved in 85.9% of aneurysms. There was no significant change in aneurysm occlusion rate or procedure length over time. Thromboembolic complication occurred in 8.1% of procedures, and there was a trend toward decreased incidence from 16.3% in 2011/2012 to 3.3% in 2016 (P = .14). Hemorrhagic complications significantly decreased from 8.2% in 2011/2012 to 0 to 1.0% in 2014-2016 (P = .1). CONCLUSION We report a notable drop in the rate of hemorrhagic and to a lesser extent thromboembolic complications with increased experience with PED in a multicenter cohort. Multiple factors are believed to contribute to this drop, including the evolved interpretation of platelet function testing, the switching of clopidogrel nonresponders to ticagrelor, and the reduced use of adjunctive coiling.
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Affiliation(s)
- Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Kevin Phan
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nimer Adeeb
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Geisinger School of Medicine, Danville, Pennsylvania
| | - Paul M Foreman
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Hussain Shallwani
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Hakeem Shakir
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, State University of New York, Buffalo Buffalo, New York
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama, Birmingham, Birmingham, Alabama
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Thromboembolism during coiling of intracranial aneurysms: predictors and clinical outcome. Wideochir Inne Tech Maloinwazyjne 2020; 15:319-328. [PMID: 32489493 PMCID: PMC7233158 DOI: 10.5114/wiitm.2019.89118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/04/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Thromboembolism is one of the most serious complications associated with coil embolization therapy. Aim To identify predisposing factors for thromboembolic complications, as well as to determine whether thromboembolism has an impact on clinical outcome. Material and methods From February 2008 to March 2015, 273 consecutive patients were treated at our institution via endovascular coil embolization. Patient medical records were reviewed with an emphasis on procedure description, potential risk factors and clinical outcomes related to thromboembolism. Thromboembolic incidents occurred in 19 (6.9%) cases. Multivariate logistic regression models were used to determine independent predictors of thromboembolism. Clinical outcome was analyzed using the Glasgow Outcome Scale (GOS). Results Multivariate analysis showed that subarachnoid hemorrhage was an independent risk factor for thromboembolic complications (p = 0.003; OR = 4.4; 95% CI: 1.67–12.02). The difference in frequency of perioperative mortality (GOS 1) in patients with thromboembolism and without thromboembolism was not statistically significant (p = 0.22). The differences in frequencies of severe disability (GOS 2–3) and moderate to low disability (GOS 4–5) between patients with thromboembolism and without thromboembolism were statistically significant in the general study population (p < 0.05). Conclusions Subarachnoid hemorrhage is an independent predictor of thromboembolic complications associated with endovascular coiling of cerebral aneurysms. Thromboembolism is associated with significantly increased risk of morbidity, and it affects to a certain extent the periprocedural mortality.
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Potts MB, Hurley MC, Ansari SA, Shaibani A, Geraghty SR, Grobelny TJ, Jahromi BS. Mechanical Thrombectomy for Delayed Thrombosis of Pipeline Embolization Device. World Neurosurg 2020; 140:237-240. [PMID: 32387404 DOI: 10.1016/j.wneu.2020.04.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In-stent thrombosis is a potentially dangerous complication of flow diversion for cerebral aneurysms. The optimal management strategy for such thrombosis is not known. Here we present a case of acute ischemic stroke caused by occlusion of a Pipeline Embolization Device (PED) construct placed 18 months earlier for treatment of a fusiform middle cerebral artery aneurysm. This was successfully treated with mechanical thrombectomy with good neurologic outcome. CASE DESCRIPTION A 40-year-old woman presented with acute onset of left-sided weakness and occlusion of the right middle cerebral artery harboring a PED construct. Intraarterial glycoprotein IIb/IIIa inhibitor was administered without success. Mechanical thrombectomy was then performed using a stent retriever and aspiration, and the patient was loaded with dual antiplatelet therapy. The patient showed initial neurologic improvement but several hours later demonstrated recurrent symptoms due to reocclusion of the PED construct. This was again treated with mechanical thrombectomy followed by an intravenous P2Y12 inhibitor infusion. She ultimately made an excellent neurologic recovery with persistent patency of the PED construct. CONCLUSIONS Mechanical thrombectomy with a stent retriever and aspiration is a therapeutic option for treatment of delayed thrombosis of a flow-diverting stent.
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Affiliation(s)
- Matthew B Potts
- Departments of Neurological Surgery and Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA.
| | - Michael C Hurley
- Departments of Neurological Surgery and Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Sameer A Ansari
- Departments of Neurological Surgery and Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Ali Shaibani
- Departments of Neurological Surgery and Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
| | - Scott R Geraghty
- Amita Neuroscience Institute, Amita Health System, Elk Grove Village, Illinois, USA
| | - Thomas J Grobelny
- Advocate Neurovascular Center, Advocate Aurora Health, Park Ridge, Illinois, USA
| | - Babak S Jahromi
- Departments of Neurological Surgery and Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA
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Roa JA, Hasan DM, Samaniego EA. Mechanical Thrombectomy of Acutely Occluded Flow-Diverters – Neuroendovascular Surgical Technique Demonstration: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 19:E176-E177. [DOI: 10.1093/ons/opz345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/04/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Flow-diversion with pipeline embolization devices (PED, Medtronic, Dublin, Ireland) is widely used for embolization of complex intracranial aneurysms.1 In-stent thrombosis can be a dreadful complication after PED deployment. Intra-arterial glycoprotein IIb-IIIa inhibitors and intravenous tissue plasminogen activator have been used in an attempt to achieve recanalization.2 However, large clots may not be effectively dissolved by pharmacological agents, thus requiring mechanical thrombectomy (MT).3 Our group recently published the first technical report on successful MT of acutely occluded PEDs in 2 patients.4 Here, we showcase the successful MT of a patient who sustained acute in-stent PED thrombosis. Informed written consent was obtained. In this case, we combined stentriever and contact aspiration thrombectomy techniques. We highlight important pitfalls and tips to prevent PED displacement, removal or vessel injury during endovascular manipulation. The most important consideration is to deploy the distal end of the stentriever inside the PED but also as distally as possible. Thus, correct apposition and alignment of the distal markers of both devices is performed under “native” unsubstracted fluoroscopic view (for better PED visualization) before MT. In this surgical video we describe the technique in detail.
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Affiliation(s)
- Jorge A Roa
- Department of Neurology and Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - David M Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Effect of Direct Neurologic Evaluation on Outcomes During Treatment of Unruptured Intracranial Aneurysms Under Local Anesthesia. World Neurosurg 2019; 131:e593-e598. [PMID: 31404688 DOI: 10.1016/j.wneu.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The greatest advantage of local anesthesia (LA) in endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is that direct neurologic evaluation can be performed during the procedure, unlike with general anesthesia. However, the usefulness of such direct evaluation has not been established. In this study, we attempted to assess the effects of direct neurologic evaluation by identifying the causes, management, and outcomes of clinical symptoms during the procedure and procedure-related events during EVT under LA. METHODS We retrospectively evaluated the medical and radiologic data of 1000 patients (1015 UIAs) who had undergone coil embolization under LA from 2008 to 2016. RESULTS Clinical symptoms were identified in 62 patients (6.2%) during the procedure. The symptoms improved during the procedure in 27 of these patients (44%) and after the procedure in another 28 (45%). One month after the procedure, 55 patients (89%) had good outcomes and 7 (11%) had poor outcomes. Procedure-related events occurred in 67 patients (6.7%); of these 67 events, 39 were symptomatic and 28 were asymptomatic. Thirty-five of the 39 symptomatic events (90%) [13 of 13 (100%) ruptures, 6 of 10 (60%) thrombus formations, and 16 of 16 (100%) thromboembolisms] were detected on the basis of clinical symptoms before angiographic changes were identified, and they were managed promptly. All 28 patients with asymptomatic events were managed safely without further complications before symptoms developed. CONCLUSIONS We demonstrated that appropriate management of clinical symptoms and procedure-related events under LA led to favorable outcomes of EVT of UIAs.
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Mohammad Seyedsaadat S, Rangel Castilla L, Lanzino G, Cloft HJ, Blezek DJ, Theiler A, Kadirvel R, Brinjikji W, Kallmes DF. Remote ischemic preconditioning for elective endovascular intracranial aneurysm repair: a feasibility study. Neuroradiol J 2019; 32:166-172. [PMID: 30942660 DOI: 10.1177/1971400919842059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Remote ischemic preconditioning has been proposed as a possible potential treatment for ischemic stroke. However, neuroprotective benefits of the pre-procedural administration of remote ischemic preconditioning have not been investigated in patients undergoing an elective endovascular intracranial aneurysm repair procedure. This study investigated the safety and feasibility of remote ischemic preconditioning in patients with an unruptured intracranial aneurysm who undergo elective endovascular treatment. METHODS In this single-center prospective study, patients with an unruptured intracranial aneurysm undergoing elective endovascular treatment with flow diverters or coiling were recruited. Patients received three intermittent cycles of 5 minutes arm ischemia followed by reperfusion using manual blood cuff inflation/deflation less than 5 hours prior to endovascular treatment. Patients were monitored and followed up for remote ischemic preconditioning-related adverse events and ischemic brain lesions by diffusion -weighted magnetic resonance imaging within 48 hours following endovascular treatment. RESULTS A total of seven patients aged 60 ± 5 years with an unruptured intracranial aneurysm successfully completed a total of 21 sessions of remote ischemic preconditioning and the required procedures. Except for two patients who developed skin petechiae over their arms, no other serious procedure-related adverse events were observed as a result of the remote ischemic preconditioning procedure. On follow-up diffusion -weighted magnetic resonance imaging, a total of 19 ischemic brain lesions with a median (interquartile range) volume of 245 (61-466) mm3 were found in four out of seven patients. CONCLUSIONS The application of remote ischemic preconditioning prior to endovascular intracranial aneurysm repair was well tolerated, safe and clinically feasible. Larger sham-controlled clinical trials are required to determine the safety and efficacy of this therapeutic strategy in mitigating ischemic damage following endovascular treatment of intracranial aneurysms.
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Affiliation(s)
| | - Leonardo Rangel Castilla
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Harry J Cloft
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Amy Theiler
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Waleed Brinjikji
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - David F Kallmes
- 1 Department of Radiology, Mayo Clinic, Rochester, MN, USA.,2 Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Liu Y, Wang J, Lin L, Sang C, Lin Z, Pan Y, Fu X. Clinical Study on Complications of Intracranial Ruptured Aneurysm Embolization by Stent-Assisted Coil. Med Sci Monit 2018; 24:8115-8124. [PMID: 30419569 PMCID: PMC6243916 DOI: 10.12659/msm.911773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to retrospectively analyze the incidence of complications of intracranial complex aneurysms embolization by stent-assisted coils, and to investigate the causes of complications and corresponding treatment methods. Material/Methods A total of 71 patients with subarachnoid hemorrhage (SAH) underwent stent-assisted coil embolization from 2015 to 2018 were enrolled in this study. Among them, 59 cases were single aneurysm, 12 cases were multiple aneurysms (11 cases with 2 aneurysms and 1 case with 3 aneurysms), for a total of 84 aneurysms. All enrolled patients received stent angioplasty except for 1 case. Results There were 62 aneurysms (73.81%) treated with complete tamponade, 21 aneurysms (25.00%) treated with near-total tamponade and 1 aneurysm (1.19%) treated with partial tamponade. All aneurysms were evaluated based on GOS (Glascow outcome scale): 55 cases had GOS of 5 scores, 12 cases had GOS of 4 scores, 3 cases had GOS of 3 scores, and 1 case had GOS of 1 score. There were 67 SAH patients with good prognosis (GOS of 4–5 scores). In our study, the incidence of complications was 12.7%. Three cases experienced acute thrombosis, 2 cases experienced aneurysm rupture during embolization, and 1 case experienced postoperative focal ischemic changes with mild neurological deficits. Conclusions Stent-assisted coil embolization is safe, effective, and feasible for the treatment of intracranial ruptured aneurysms. Patients had a favorable outcome of as high as 94.4%. However, clinical skills should be improved to reduce the occurrence of complications. Prompt and timely treatment for complications of intracranial ruptured aneurysm is also of great significance.
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Affiliation(s)
- Yinlong Liu
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Jianren Wang
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Liqing Lin
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Chunsheng Sang
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Zexi Lin
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
| | - Yaohua Pan
- Department of Neurosurgery, Renji Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China (mainland)
| | - Xi'an Fu
- Department of Neurosurgery, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, China (mainland)
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Controversies on treatment of unruptured intracranial aneurysms. Value of UIATS and PHASES scores in a daily practice in a Spanish population. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Laukka D, Rautio R, Rahi M, Rinne J. Acute Treatment of Ruptured Fusiform Posterior Circulation Posterior Cerebral, Superior Cerebellar, and Posterior Inferior Cerebellar Artery Aneurysms With FRED Flow Diverter: Report of 5 Cases. Oper Neurosurg (Hagerstown) 2018; 16:549-556. [DOI: 10.1093/ons/opy194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/01/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Flow diverter (FD) treatment of ruptured fusiform posterior cerebral artery (PCA), posterior inferior cerebellar artery (PICA), and superior cerebellar artery (SCA) aneurysms are limited to single reports.
OBJECTIVE
To study the safety and efficacy of FD treatment for ruptured fusiform aneurysms of the PCA, SCA, and PICA.
METHODS
Five patients with ruptured posterior circulation fusiform aneurysms and treated with a Flow-Redirection Endoluminal Device (FRED/FRED Jr; Microvention, Tustin, California) stent in the acute phase of subarachnoid hemorrhage between 2013 and 2016 were included and reviewed retrospectively.
RESULTS
Two aneurysms located on the PICA, 2 on PCA, and 1 on the SCA. Mean treatment time with FD was 5.8 d (range, 0-11 d) from ictus. The technical success rate was 100%. On admission 2 patients were Hunt and Hess grade 1, 2 patients grade 3, and 1 patient grade 4. At discharge, 4 patients (80%) were independent (modified Ranking Scale (mRS) ≤2) and 1 patient had severe disability (mRS 4). None of the patients had aneurysmal rebleeding. All 5 aneurysms were completely occluded on angiographic follow-up (range, 3-22 mo). One patient had permanent intraprocedural in stent thrombosis and brain infarction. One patient had spontaneous nonaneurysmal intracerebral hemorrhage 1 mo after FD treatment. External ventricular drainage was inserted in 3 patients and ventriculoperitoneal shunt in 2 patients without hemorrhagic complications despite dual antiplatelet therapy.
CONCLUSION
FD could be considered as a treatment option for ruptured fusiform aneurysms located on PCA, PICA, or SCA when other treatment options are challenging.
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Affiliation(s)
- Dan Laukka
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Riitta Rautio
- Department of Radiology and Interventional Radiology, Turku University Hospital, Turku, Finland
| | - Melissa Rahi
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Jaakko Rinne
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
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Lin LM, Jiang B, Campos JK, Beaty NB, Bender MT, Tamargo RJ, Huang J, Colby GP, Coon AL. Abciximab (ReoPro) Dosing Strategy for the Management of Acute Intraprocedural Thromboembolic Complications during Pipeline Flow Diversion Treatment of Intracranial Aneurysms. INTERVENTIONAL NEUROLOGY 2018; 7:218-232. [PMID: 29765391 DOI: 10.1159/000486458] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022]
Abstract
Background Flow diversion with the Pipeline embolization device (PED) is an effective neuro-endovascular method and increasingly accepted for the treatment of cerebral aneurysms. Acute in situ thrombosis is a known complication of PED procedures. There is limited experience in the flow diversion literature on the use of abciximab (ReoPro) for the management of acute thrombus formation in PED cases. Methods Data were collected retrospectively on patients who received intra-arterial (IA) ReoPro with or without subsequent intravenous (IV) infusion during PED flow diversion treatment of intracranial aneurysms. Results A total of 30 cases in patients with a mean age of 56.7 years (range 36-84) and a mean aneurysm size of 8.6 mm (range 2-25) were identified to have intraprocedural thromboembolic complications during PED treatment. IA ReoPro was administered in all cases, with 20 cases receiving increments of 5-mg boluses and 10 cases receiving a 0.125 mg/kg IA bolus (half cardiac dosing). Complete or partial recanalization was achieved in 100% of the cases. IV ReoPro infusion at 0.125 μg/kg/min for 12 h was administered postprocedurally in 22 cases with a residual thrombus. Postprocedurally, 18 patients were transitioned from clopidogrel (Plavix) to prasugrel (Effient). The majority of the cases (23/30; 77%) were discharged home. Periprocedural intracranial hemorrhage was noted in 2 cases (7%) and radiographic infarct was noted in 4 cases (13%), with an overall mortality of 0% at the time of initial discharge. Clinical follow-up was available for 28/30 patients. The average duration of follow-up was 11.7 months, at which time 23/28 (82%) of the patients had a modified Rankin Scale score of 0. Conclusions IA ReoPro administration is an effective and safe rescue strategy for the management of acute intraprocedural thromboembolic complications during PED treatment. Using a dosing strategy of either 5-mg increments or a 0.125 mg/kg IA bolus (half cardiac dosing) can provide high rates of recanalization with low rates of hemorrhagic complications and long-term morbidity.
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Affiliation(s)
- Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, UC Irvine Medical Center, Orange, California, USA
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Narlin B Beaty
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Jiang B, Bender MT, Westbroek EM, Campos JK, Lin LM, Xu R, Tamargo RJ, Huang J, Colby GP, Coon AL. Procedural complexity independent of P2Y12 reaction unit (PRU) values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms. Stroke Vasc Neurol 2018; 3:169-175. [PMID: 30294473 PMCID: PMC6169609 DOI: 10.1136/svn-2018-000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/24/2018] [Indexed: 12/03/2022] Open
Abstract
Background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device (PED) procedures with potentially high morbidity and mortality. There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events. There is limited knowledge on whether procedural complexity influences these events. Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution. Patients with intraprocedural acute thrombosis were compared with patients without these events. Results A cohort of 37 PED cases with acute in situ thrombosis (mean age 53.8 years, mean aneurysm size 8.4 mm) was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events (mean age 56.4 years, mean aneurysm size 6.9 mm). All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab. The two groups were evenly matched in patient demographics, previous treatment/subarachnoid hemorrhage (SAH) and aneurysm location. There was no statistical difference in postprocedural P2Y12 reaction unit (PRU) values between the two groups, with a mean of 156 in the in situ thrombosis group vs 148 in the control group (p=0.5894). Presence of cervical carotid tortuosity, high cavernous internal carotid artery grade, need for multiple PED and vasospasm were not significantly different between the two groups. The in situ thrombosis group had statistically significant longer fluoroscopy time (60.4 vs 38.4 min, p<0.0001), higher radiation exposure (3476 vs 2160 mGy, p<0.0001), higher rates of adjunctive coiling (24.3% vs 8.37%, p=0.0010) and higher utilisation of balloon angioplasty (37.8% vs 12.2%, p<0.0001). Clinically, the in situ thrombosis cohort had higher incidence of major and minor stroke, intracerebral haemorrhage and length of stay. Conclusions Predictors of procedural complexity (higher radiation exposure, longer fluoroscopy time, adjunctive coiling and need for balloon angioplasty) are associated with acute thrombotic events during PED placement, independent of PRU values.
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Affiliation(s)
- Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erick M Westbroek
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Li-Mei Lin
- Department of Neurosurgery, University of California, Irvine School of Medicine, Orange, California, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, California, USA
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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