Stent-assisted coil embolization of anterior communicating artery aneurysms using the LVIS Jr stent

Embolization of unruptured wide-necked aneurysms at the MCA bifurcation using the Neuroform atlas stent-assisted coiling: a two-center retrospective study

Background

The management of middle cerebral artery (MCA) aneurysms remains a controversial topic, and MCA aneurysms have traditionally been treated primarily by surgical clipping. The Neuroform Atlas Stent™ (NAS, available from Stryker Neurovascular, Fremont, California) represents the latest generation of intracranial stents with improved stent delivery system capabilities.

Objective

This study aims to investigate the safety, feasibility and efficacy exhibited by NAS in treating unruptured aneurysms at the MCA bifurcation.

Methods

This was a two-center retrospective study involving 42 patients with unruptured wide-necked aneurysms (WNAs) of the MCA treated with the NAS from October 2020 to July 2022.

Results

The stent was used to treat 42 cases of unruptured WNA at the MCA bifurcation. Endovascular treatment techniques had a 100% success rate. Immediate postoperative angiography found complete aneurysm occlusion in 34 patients (80.9%) (mRRC 1), neck remnant in 7 patients (16.7%) (mRRC 2), and residual aneurysm in 1 patient (2.4%) (mRRC 3). The thromboembolic complication rate was 2.4% (1/42). The follow-up period was 8.7 months on average (3-16 months). The last angiographic follow-up results revealed complete aneurysm occlusion in 39 patients (92.9%) (mRRC 1), neck remnant in 3 (7.1%) patients (mRRC 2), no aneurysm recanalization or recurrence, and no cases of stent intimal hyperplasia. During the latest clinical follow-up, all patients had an mRS score of 0.

Conclusion

Our study demonstrates that the NAS can be applied to treat unruptured WNAs at the MCA bifurcation with favorable safety, feasibility, and efficacy.

Does dual antiplatelet therapy increase the risk of haematoma enlargement in the acute stage? A retrospective study of the use of stent-assisted coiling versus coiling alone or balloon-assisted coiling for the treatment of ruptured intracranial aneurysms combined with intracranial haematoma

This study aims to identify the efficacy and safety of stent-assisted coiling (SAC) treatment of ruptured intracranial aneurysms (RIAs) combined with intracranial haematoma (ICH) compared to coiling alone or balloon-assisted coiling (non-SAC). A retrospective analysis of 54 consecutive patients receiving endovascular therapy from 2014 to 2020 was performed. The data collected included baseline characteristics, angiographic results, perioperative complications, immediate aneurysm occlusion, clinical outcomes, follow-up at discharge and after 6 months, hospitalisation costs, and inpatient length of stay. Patients were categorised into the SAC group and the non-SAC group. Univariate and multivariate logistic regression analyses were used to identify risk factors related to clinical outcomes. Of the 54 patients harbouring RIAs with ICH, 22 (40.74%) and 32 (59.26%) patients were subject to SAC and non-SAC treatments, respectively. Postoperative rebleeding (1 [4.5%] and 3 [9.3%] in SAC and non-SAC groups, respectively, p > 0.05) and Hunt-Hess grade (IV-V) lesions (13.6% vs. 40.6%, p = 0.067) did not differ between the two groups. In total, 10 (45.5%) patients treated with SAC received a Fisher scale score of 0-3 compared with 6 (18.8%) patients treated with non-SAC methods (p = 0.035). Compared with the non-SAC group (7/21.9%), the rate of wide-necked aneurysms was increased in the SAC group (11/50%) (p = 0.031). No differences in poor outcomes (mRS > 2) were noted between the SAC and non-SAC groups (p > 0.05). Multivariate analysis revealed that ischaemic complication events (p = 0.016) represent the only independent risk factor for adverse outcomes, and a trend towards unfavourable clinical outcomes was noted for patients who smoke (p = 0.087). SAC is a safe and efficient treatment for RIAs combined with ICH when dual antiplatelet therapy (DAPT) is used in the perioperative period. In addition, SAC should be preferentially used in wide-neck RIAs. Ischaemic complications are a risk factor for poor clinical outcomes. Given the small sample size and retrospective bias of this study, these findings should be further verified in a study with a larger sample size or a randomised controlled trial (RCT).

Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis

In recent years, intracranial aneurysms have been widely treated with endovascular methods. The anterior communicating artery (Acom) is the most common site of intracranial aneurysms. Despite its effectiveness, endovascular interventions can be associated with various intra-procedural and post-procedural complications. A systematic review of the literature was performed through PubMed, Embase, Scopus, and Web of Sciences databases up to March 18, 2022. The pooled rates of intra-procedural complications, mortality, procedure-related morbidities, the immediate and late aneurysm occlusion, and also the necessity for retreatment were calculated by applying random-effects models. A total of 41 articles with 4583 patients were included in the meta-analysis. The pooled rate of overall intra-procedural complications was 9.6% (95% CI: 7.7 to 11.8%). The initial rupture status and also type of EVT procedure did not affect the overall complication rate. The pooled rate of intra-procedural thrombosis, aneurysm rupture, coil prolapse, and early aneurysm rebleeding were 6.1% (95% CI: 4.5 to 8.2%); 4.2% (95% CI: 3.4 to 5.2%), 4.7% (95% CI: 3.2 to 6.7%), and 2.2% (95% CI: 1.5 to 3.2%), respectively. Our analysis showed that intra-procedural mortality occurred in 1.7% (95% CI: 1.1 to 2.5%) and procedure-related permanent morbidities in 3.3% (95% CI: 2.3 to 4.7%) of patients. Endovascular methods achieved complete and near to complete aneurysm occlusion (Raymond-Roy occlusion classification 1 and 2) in 89.2% (95% CI: 86.4 to 92.5%) of cases post-procedure, and 9.5% (95% CI: 7.3 to 12.4%) of patients needed retreatment due to recanalization in follow-ups. Endovascular treatment can serve as an acceptable method for Acom aneurysms. However, improved endovascular treatment equipment and new techniques provide more satisfactory outcomes for complicated cases.

Microsurgical clipping versus newer endovascular techniques in treatment of unruptured anterior communicating artery-complex aneurysms: a meta-analysis and systematic review

The aim of this study is to compare occlusion rate, complication rate, and clinical outcome of microsurgical clipping (MC) and advanced endovascular techniques (EVT) in unruptured anterior communicating artery-complex aneurysms (ACoCAs). We reviewed the scientific literature reporting occlusion rate, time of occlusion assessment, and clinical outcome of MC and EVT in patients with unruptured ACoCAs, from January 2009 to December 2019. We included in our analysis 25 studies and 872 patients with unruptured ACoCAs (434 treated with endovascular techniques and 438 with MC). Ninety-three (10.7%), 320 (36.7%), 21 (2.4%), and 438 (50.2%) were treated with flow diverter (FD), stent-assisted coiling (SAC), endosaccular devices (ES), and microsurgical clipping (MC) respectively. FD, SAC, ES, and MC subgroups presented minor complications in 11.8%, 3.8%, 14.3%, and 7.1% of cases (p=.016), and major complications in 3.2%, 4.4%, 0%, and 7.1% (p=.136) of patients. A total occlusion rate post-treatment has been achieved in 4.3%, 87.1%, 47.6%, and 98.2% of cases (p=.000), while at 12 months' follow-up in 50%, 66%, 83.3%, and 80% of patients (p=.001). FD, SAC, ES, and MC subgroups had a good clinical outcome at 12 months in 93.5%, 90.5%, 100%, and 67.8% of cases. MC is associated with higher post-treatment total occlusion rate, but higher complication and lower good clinical outcome rates. EVT are promising in treating unruptured anterior cerebral artery aneurysms with high margin of safety and good clinical outcome, despite the lower total occlusion rate.

Safety and Efficacy of Stent-Assisted Coiling of Unruptured Intracranial Aneurysms Using Low-Profile Stents in Small Parent Arteries

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.

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

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

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

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

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

Low-Profile Visualized Intraluminal Support Jr Braided Stent Versus Atlas Self-Expandable Stent for Treatment of Intracranial Aneurysms: A Single Center Experience

BACKGROUND

The Neuroform Atlas Stent and Low-profile Visualized Intraluminal Support (LVIS) and LVIS Jr stents are used to treat intracranial aneurysms (IAs), but their safety, performance, and outcomes have not been directly compared.

OBJECTIVE

To compare the technical performance and outcomes of Atlas and LVIS Jr stents for treatment of IAs.

METHODS

IAs treated by stent-assisted coiling using an Atlas (Stryker, Kalamazoo, Michigan) or LVIS Jr (MicroVention, Aliso Viejo, California) device between January 2014 to November 2019 were retrospectively evaluated. Patient demographics, aneurysm size and location, technical difficulties, and clinical and angiographic follow-up were analyzed.

RESULTS

A total of 116 patients, (mean age 64.2 ± 11.8 yr, 72.7% female) with 121 aneurysms underwent stent-assisted coiling with deployment of Atlas (n = 64) or LVIS Jr (n = 57) stents. Mean aneurysm size was 6.2 ± 2.7 mm. Immediate rates of Raymond-Roy (RR) 1/2 were 89.0% (57/64) and 80.7% (46/57) for the Atlas and LVIS Jr groups, respectively. Neither group had major postoperative thromboembolic complications; however, 15.8% (9/57) of the LVIS Jr procedures had technical issues. Additionally, 88.5% (46/52) and 91.2% (33/36) of patients in the Atlas and LVIS Jr groups had RR 1/2 at a mean follow-up of 13.6 and 18.7 mo, respectively.

CONCLUSION

Treatment of IAs with Atlas and LVIS Jr stents results in favorable clinical outcomes and angiographic results at follow-up, with low rates of recurrence and retreatment, suggesting both devices are safe and effective. Notably, LVIS Jr had more technical problems than Atlas.

Outcomes of Stent-Assisted Coiling Using the Neuroform Atlas Stent in Unruptured Wide-Necked Intracranial Aneurysms

Objective

Although stent-assisted coiling (SAC) has been reported to be safe and effective in treating wide-necked aneurysms, the technique has procedure-related complications. Thus, we reported our experiences of SAC using the Neuroform Atlas stent in treating wide-necked aneurysms and evaluated the incidence of and risk factors for procedure-related complications.

Methods

From March 2018 to August 2019, we treated 130 unruptured wide-necked aneurysms in 123 patients with Neuroform Atlas stents. Angiographic results and clinical outcomes were reviewed retrospectively. Clinical and angiographic follow-up were performed in all cases (mean, 12.4 months) after the procedure.

Results

There were eight cases (6.2%) of procedure-related complications (two dissections, five thromboembolisms, and one hemorrhage) and two (1.5%) of delayed complications (one ischemia and one hemorrhage). There was one case (0.8%) of failure of stent deployment and one (0.8%) of suboptimal positioning of the stent. Follow-up angiography showed complete obliteration in 103 (79.2%), residual neck in 16 (12.3%), and residual aneurysm in 11 cases (8.5%). Aneurysm locations in the middle cerebral artery (odds ratio [OR], 2.211; p=0.046) and the anterior communicating artery (OR, 2.850; p=0.039) were associated with procedure-related complications on univariate analysis. However, no independent risk factor for procedure-related complications was noted in multivariate analysis.

Conclusion

The Neuroform Atlas showed a high rate of technical success. Good clinical and radiographic outcomes in early follow-up suggests that the device is feasible and safe. SAC of aneurysms on the middle cerebral artery or anterior communicating artery may require more attention to prevent possible procedure-related complications.