Flow diverter stents in the treatment of recanalized intracranial aneurysms

Acute Coiling With Delayed Flow Diversion for Posterior Communicating Segment Internal Carotid Artery Aneurysms: A Multicenter Case Series

BACKGROUND AND OBJECTIVES

In ruptured posterior communicating artery (PcomA) aneurysms, the protection of the aneurysm dome alone with initial subtotal coiling decreases the risk of rerupture in the acute setting but does not provide durable/definitive long-term protection against delayed rupture. Delayed flow diverter (FD) placement can be a potential alternative to definitively secure these aneurysms without increasing the risk of complications and PComA occlusion. We analyzed PComA aneurysms treated with a planned delayed FD after primary coiling and assess radiographic and clinical outcomes.

METHODS

We performed a retrospective study of prospectively collected data for intracranial aneurysms treated with planned FD at 2 institutions from 2013 to 2022. PComA aneurysms that underwent primary coiling and delayed FD placement were included for analysis.

RESULTS

There were 29 PComA aneurysms identified that were included in the analysis. Patients were mostly female (79.3%), with a median age of 60 years. The mean aneurysm maximum diameter was 7.2 mm ± (5.3). Immediate Raymond-Roy occlusion grade after primary coiling was I in 48.3%, II in 41.4%, and III in 10.3% of aneurysms. The median time from initial coiling to planned delayed FD placement was 6.3 months (3.2-18.6). A total of 21 (72.4%) aneurysms underwent follow-up radiological imaging. Complete and near-complete occlusion status was achieved in 76.2% of the evaluated aneurysms. There were no retreatments and no evidence of delayed aneurysm rupture. One case (3.5%) presented thromboembolic complications and 1 (3.5%) intracranial hemorrhagic complication after FD placement, which was associated with mortality. Most patients (90.5%) had a modified Rankin scale of ≤2 on the last follow-up.

CONCLUSION

Primary coiling with planned staged FD placement is effective for treating ruptured PComA aneurysms with high occlusion rates and low complications.

Extended monitoring of re-coiled cerebral aneurysms after initial postcoiling recanalization: Safety and durability of repeat coil embolization

PURPOSE

In the endovascular era, postcoiling recanalization of cerebral aneurysms is occurring with greater frequency. Repeat coiling is usually done to prevent rebleeding, although long-term outcomes of re-embolization have yet to be adequately investigated. The present study was undertaken to assess clinical and radiographic outcomes of re-embolization in recanalized aneurysms, focusing on procedural safety, efficacy, and durability.

METHOD

In this retrospective review, we examined 308 patients with 310 recurrent aneurysms. All lesions were re-coiled, once major recanalization (after initial coil embolization) was established. Medical records and radiologic data amassed during extended follow-up were then subject to review. Cox proportional hazards regression analysis was undertaken to identify risk factors for subsequent recurrence.

RESULT

During a lengthy follow-up (mean, 40.2 ± 33.0 months), major recanalization developed again in 87 aneurysms (28.1%). Multivariable Cox regression analysis linked re-recanalization to initial saccular neck width (p=.003) and autosomal dominant polycystic kidney disease (ADPKD; p<.001). Stent implantation (p=.038) and successful occlusion at second coiling (p=.012) were protective against later recanalization in this setting. The more recent the second embolization was performed, the lower the risk of further recurrence (p=.023). Procedure-related complications included asymptomatic thromboembolism (n = 9), transient ischemic neurologic deficits (n = 2), procedural bleeding (n = 1), and coil migration (n = 1), but there were no residual effects or deaths.

CONCLUSION

Repeat coil embolization is a safe therapeutic option for recanalized cerebral aneurysms. Wide-necked status and ADPKD emerged as risks for subsequent recanalization, whereas successful occlusion and stent implantation seemed to reduce the likelihood of recurrence after re-embolization procedures.

Retreatment with a pipeline embolization device for recanalized aneurysms following stent-assisted coiling embolization

Background and purpose

Flow diverters have emerged as viable alternatives for the retreatment of recanalized aneurysms following stent-assisted coiling embolization. In this study, we aim to present our experience of retreatment for such aneurysms using the pipeline embolization device (PED).

Materials and methods

This case series presents a retrospective single-center analysis of patients with recanalized aneurysms who underwent retreatment using the PED between July 2019 and April 2023, subsequent to stent-assisted coiling embolization.

Results

The study includes five female patients, whose relevant clinical data were recorded. All patients had aneurysms located in the internal carotid artery, comprising two blood blister-like aneurysms and two giant aneurysms. Prior to the retreatment, two LVIS stents, two enterprise stents, and one solitaire stent were implanted. Among the five patients, one experienced a fatal post-operative subarachnoid hemorrhage, while two patients achieved complete embolization, and another patient achieved near-complete embolization during the last follow-up. Furthermore, one patient faced challenges during the placement of the PED and was unable to achieve successful deployment. We propose four overlapping relationships between a newly implanted PED and a previously deployed stent: (1) PED covering only the proximal end of the previous stent, (2) PED covering only the distal end of the previous stent, (3) PED covering both the proximal and distal ends of the previous stent, and (4) PED deployed within the previous stent. Antiplatelet therapy at our center involved daily dual therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) for at least 5 days before PED placement. Intra-arterial bolus administration of tirofiban (5 mcg/kg) was administered during or immediately after PED deployment, followed by a maintenance dose of 0.08 mcg/kg/min IV infusion for at least 24-48 h if necessary. Postprocedural dual antiplatelet therapy included clopidogrel (75 mg/day) for 6 months and aspirin (100 mg/day) for 12 months.

Conclusion

The findings of this study support the efficacy of the PED for the retreatment of recanalized aneurysms following stent-assisted coiling embolization.

Pipeline embolization of ruptured, previously coiled cerebral aneurysms: Case series and considerations for management

PURPOSE:

Aneurysmal recurrence represents a significant drawback of endovascular coiling, particularly in aneurysms that have previously ruptured. Given the high recurrence rate of coiled aneurysms and particularly the risk of posttreatment rupture in previously ruptured aneurysms that have been treated by coiling, the question of how best to treat ruptured aneurysms that recur postcoiling remains.

MATERIALS AND METHODS:

We conducted a retrospective analysis of twenty patients who underwent pipeline embolization of previously ruptured, coiled cerebral aneurysms.

RESULTS:

Pipeline embolization device (PED) treatment resulted in complete aneurysmal occlusion in 10 patients (62.5%) at first angiographic follow-up, and 11 patients (68.75%) at last follow-up. No PED-related complications were encountered and there were no peri-procedural or postprocedural hemorrhages, or symptomatic ischemic events following flow diversion.

CONCLUSIONS:

PED as a second-line treatment is a safe and effective modality for achieving aneurysmal occlusion in recurrent, previously ruptured, primarily coiled aneurysms. Additionally, a staged coil-to-PED approach may be considered for the management of acutely ruptured aneurysms to achieve aneurysmal obliteration in an effort to mitigate recurrence, and reduce the amount of postprocedural studies.