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Young M, Enriquez-Marulanda A, Salih M, Shutran M, Budohoski K, Grandhi R, Taussky P, Ogilvy CS. Management of Intracranial Aneurysms that Do Not Occlude on Initial Follow-up After Treatment With the Pipeline Embolization Device. Neurosurgery 2024; 94:271-277. [PMID: 37655903 DOI: 10.1227/neu.0000000000002655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/30/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The pipeline embolization device (PED) has become widely accepted as a safe and efficacious treatment for intracranial aneurysms with high rates of complete occlusion at initial follow-up. For aneurysms that are not completely occluded at initial follow-up, further treatment decision-making is varied. Furthermore, the risk of aneurysmal rupture in these incompletely occluded aneurysms after PED is not known. The objective of this study was to determine treatment decision-making that results in increased occlusion status at final follow-up and to evaluate risk of rupture in those aneurysms that do not go onto occlusion. METHODS This study is a retrospective review of prospective data for intracranial aneurysms treated with PED at two institutions from 2013 to 2019. Aneurysms with near-complete or incomplete occlusion at initial follow-up were included in the statistical analysis. RESULTS There were 606 total aneurysms treated at two academic institutions with PED with incomplete occlusion at initial follow-up in 134 aneurysms (22.1%). Of the 134 aneurysms that were nonoccluded at initial follow-up, 76 aneurysms (56.7%) went on to complete or near complete occlusion with final complete or near complete occlusion in 90.4% of all aneurysms treated. The time to final imaging follow-up was 28.2 months (13.8-44.3) Retreatment with a second flow diverter was used in 28 aneurysms (20.9%). No aneurysms that were incompletely occluded at initial follow-up had delayed rupture. Furthermore, older patient age was statistically significant for incomplete occlusion at initial follow-up ( P = .05). CONCLUSION Intracranial aneurysms treated with the PED that do not occlude at initial follow-up may go on to complete occlusion with continuous observation, alteration in antiplatelet regimens, or repeat treatment. Delayed aneurysmal rupture was not seen in patients with incomplete occlusion.
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Affiliation(s)
- Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Karol Budohoski
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City , Utah , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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2
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Lee RP, Bhimreddy M, Kim J, Wicks RT, Xu R, Bender M, Yang W, Sattari SA, Hung A, Jackson CM, Gonzalez LF, Huang J, Tamargo R, McDougall CG, Caplan JM. No Delayed Ruptures on Long-Term Follow-Up of a Case Series of Persistently Filling Saccular Internal Carotid Artery Aneurysms After Flow Diversion With the Pipeline Embolization Device. Neurosurgery 2023; 93:994-999. [PMID: 37255292 DOI: 10.1227/neu.0000000000002521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/20/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Flow diversion of intracranial aneurysms results in high occlusion rates. However, 10% to 20% remain persistently filling at 1 year. Often, these are retreated, but benefits of retreatment are not well established. A better understanding of the long-term rupture risk of persistently filling aneurysms after flow diversion is needed. METHODS Our institutional database of 974 flow diversion cases was queried for persistently filling saccular aneurysms of the clinoidal, ophthalmic, and communicating segments of the internal carotid artery treated with the pipeline embolization device (PED, Medtronic). Persistent filling was defined as continued flow into the aneurysm on 1 year catheter angiogram. The clinical record was queried for retreatments and delayed ruptures. Clinical follow-up was required for at least 2 years. RESULTS Ninety-four persistent aneurysms were identified. The average untreated aneurysm size was 5.6 mm. A branch vessel originated separately in 55% of cases from the body of the aneurysm in 10.6% of cases and from the neck in 34% of cases. Eighteen percent of aneurysms demonstrated >95% filling at 1 year, and 61% were filling 5% to 95% of their original size. The mean follow-up time was 4.9 years, including 41 cases with >5 years. No retreatment was undertaken in 91.5% of aneurysms. There were no cases of delayed subarachnoid hemorrhage. CONCLUSION Among saccular internal carotid artery aneurysms treated with PED that demonstrated persistent aneurysm filling at 1 year, there were no instances of delayed rupture on long-term follow-up. These data suggest that observation may be appropriate for continued aneurysm filling at least in the first several years after PED placement.
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Affiliation(s)
- Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jennifer Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Robert T Wicks
- Miami Neuroscience Institute, Baptist Health South Florida, Miami , Florida , USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Matthew Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester , New York , USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - L Fernando Gonzalez
- 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
| | - Rafael Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Cameron G McDougall
- Department of Neurosurgery, Swedish Neuroscience Institute, Seattle , Washington , USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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3
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Ghaith AK, Greco E, Rios-Zermeno J, El-Hajj VG, Perez-Vega C, Ghanem M, Kashyap S, Fox WC, Huynh TJ, Sandhu SS, Ohlsson M, Elmi-Terander A, Bendok BR, Bydon M, Tawk RG. Safety and efficacy of the pipeline embolization device for treatment of small vs. large aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:284. [PMID: 37882896 DOI: 10.1007/s10143-023-02192-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
Flow diversion with the pipeline embolization device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (≥ 1 year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (< 10 mm) versus large (10-25 mm) aneurysms at long-term following treatment with PED. A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We conducted a comprehensive search of English language databases including Ovid MEDLINE and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12 months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Our analysis included 19 studies with 1277 patients and 1493 aneurysms. Of those, 1378 aneurysms met our inclusion criteria. The mean age was 53.9 years, and most aneurysms were small (89.75%; N = 1340) in women (79.1%; N = 1010). The long-term occlusion rate was 73% (95%, CI 65 to 80%) in small compared to 84% (95%, CI 76 to 90%) in large aneurysms (p < 0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3 to 9%) in small compared to 7% (95%, CI 4 to 13%) in large aneurysms (p = 0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p = 0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. The long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elena Greco
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Carlos Perez-Vega
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Samir Kashyap
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Thien J Huynh
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Marcus Ohlsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
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4
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Burel J, Gerardin E, Vannier M, Curado A, Verdalle-Cazes M, Magne N, Lefebvre M, Papagiannaki C. Follow-up of Intracranial Aneurysms Treated by Flow Diverters: Evaluation of Parent Artery Patency Using 3D-T1 Gradient Recalled-Echo Imaging with 2-Point Dixon in Combination with 3D-TOF-MRA with Compressed Sensing. AJNR Am J Neuroradiol 2022; 43:554-559. [PMID: 35241422 PMCID: PMC8993198 DOI: 10.3174/ajnr.a7448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/03/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE MRA assessment of parent artery patency after flow-diverter placement is complicated by imaging artifacts produced by these devices. The purpose of this study was to assess the accuracy of liver acquisition with volume acceleration-flex technique (LAVA-Flex) MRA in combination with 3D-TOF with HyperSense MRA for the evaluation of parent vessel status after intracranial flow-diverter placement. MATERIALS AND METHODS Fifty-six patients treated by flow diversion and followed with both DSA and 3T MRA between November 2020 and August 2021 were included. All patients were evaluated for parent artery patency using the same imaging protocol (DSA, noncontrast MRA including 3D-TOF with HyperSense and LAVA-Flex, and contrast-enhanced MRA, including time-resolved imaging of contrast kinetics MRA and delayed contrast-enhanced MRA). RESULTS With DSA as a criterion standard to evaluate the patency of the parent vessel, noncontrast MRA had a good specificity (0.83) and positive predictive value (0.65), better than contrast-enhanced MRA (0.55 and 0.41, respectively). Both had excellent sensitivity and negative predictive value: noncontrast MRA, 0.93 and 0.97, respectively; contrast-enhanced MRA, 0.93 and 0.96, respectively. Specificity and positive predictive value tended to be lower for patients treated with additional devices than for those treated with flow diverters exclusively and for patients treated with a specific type of flow diverter. CONCLUSIONS Noncontrast MRA can be used for noninvasive follow-up of intracranial aneurysms treated by flow diverters. The combined use of LAVA-Flex and 3D-TOF with HyperSense sequences allows monitoring the status of the parent artery and aneurysm occlusion.
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Affiliation(s)
- J Burel
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - E Gerardin
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - M Vannier
- Biostatistics (M.V.), Rouen University Hospital, Rouen, Normandie, France
| | - A Curado
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - M Verdalle-Cazes
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - N Magne
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - M Lefebvre
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
| | - C Papagiannaki
- From the Department of Radiology (J.B., E.G., A.C., M.V.-C., N.M., M.L., C.P.)
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5
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Hanel RA, Monteiro A, Nelson PK, Lopes DK, Kallmes DF. Predictors of incomplete aneurysm occlusion after treatment with the Pipeline Embolization Device: PREMIER trial 1 year analysis. J Neurointerv Surg 2021; 14:1014-1017. [PMID: 34716215 DOI: 10.1136/neurintsurg-2021-018054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Flow diverters have revolutionized the treatment of intracranial aneurysms. Nevertheless, some aneurysms fail to occlude with flow diversion. The Prospective Study on Embolization of Intracranial Aneurysms with the Pipeline Device (PREMIER) was a prospective, multicenter and single-arm trial of small and medium wide-necked unruptured aneurysms. In the current study, we evaluate the predictors of treatment failure in the PREMIER cohort. METHODS We analyzed PREMIER patients who had incomplete occlusion (Raymond-Roy >1) at 1 year angiographic follow-up and compared them with those who achieved Raymond-Roy 1, aiming to identify predictors of treatment failure. RESULTS 25 aneurysms demonstrated incomplete occlusion at 1 year. There was a median reduction of 0.9 mm (IQR 0.41-2.43) in maximum diameter between pre-procedure and 1 year measurements, with no aneurysmal hemorrhage. Patients with incomplete occlusion were significantly older than those with complete occlusion (p=0.011). Smoking (p=0.045) and C6 segment location (p=0.005) were significantly associated with complete occlusion, while location at V4 (p=0.01) and C7 (p=0.007) and involvement of a side branch (p<0.001) were significantly associated with incomplete occlusion. In multivariable logistic regression, significant predictors of incomplete occlusion were non-smoker status (adjusted OR 4.49, 95% CI 1.11 to 18.09; p=0.03) and side branch involvement (adjusted OR 11.68, 95% CI 3.84 to 35.50; p<0.0001), while C6 location had reduced odds of incomplete occlusion (adjusted OR 0.29, 95% CI 0.10 to 0.84; p=0.02). CONCLUSIONS The results of our study are consistent with previous retrospective series and warrant consideration for technique adaptations to achieve higher occlusion rates. Further follow-up is needed to assess progression of aneurysm occlusion and clinical behavior in these cases.
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Affiliation(s)
- Ricardo A Hanel
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Andre Monteiro
- Cerebrovascular and Endovascular Surgery, Lyerly Neurosurgery and Baptist Medical Center, Jacksonville, FL, USA
| | - Peter K Nelson
- Radiology, NYU Langone Medical Center Neuroradiology Section, New York, New York, USA
| | - Demetrius K Lopes
- Brain and Spine Institute, Advocate Aurora Health, Park Ridge, Illinois, USA
| | - David F Kallmes
- Interventional Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
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6
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Salem MM, Sweid A, Kuhn AL, Dmytriw AA, Gomez-Paz S, Maragkos GA, Waqas M, Parra-Farinas C, Salehani A, Adeeb N, Brouwer P, Pickett G, Ku J, X D Yang V, Weill A, Radovanovic I, Cognard C, Spears J, Cuellar-Saenz HH, Renieri L, Kan P, Limbucci N, Mendes Pereira V, Harrigan MR, Puri AS, Levy EI, Moore JM, Ogilvy CS, Marotta TR, Jabbour P, Thomas AJ. Repeat Flow Diversion for Cerebral Aneurysms Failing Prior Flow Diversion: Safety and Feasibility From Multicenter Experience. Stroke 2021; 53:1178-1189. [PMID: 34634924 DOI: 10.1161/strokeaha.120.033555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal persistence after flow diversion (FD) occurs in 5% to 25% of aneurysms, which may necessitate retreatment. There are limited data on safety/efficacy of repeat FD-a frequently utilized strategy in such cases. METHODS A series of consecutive patients undergoing FD retreatment from 15 centers were reviewed (2011-2019), with inclusion criteria of repeat FD for the same aneurysm at least 6 months after initial treatment, with minimum of 6 months post-retreatment imaging. The primary outcome was aneurysmal occlusion, and secondary outcome was safety. A multivariable logistic regression model was constructed to identify predictors of incomplete occlusion (90%-99% and <90% occlusion) versus complete occlusion (100%) after retreatment. RESULTS Ninety-five patients (median age, 57 years; 81% women) harboring 95 aneurysms underwent 198 treatment procedures. Majority of aneurysms were unruptured (87.4%), saccular (74.7%), and located in the internal carotid artery (79%; median size, 9 mm). Median elapsed time between the first and second treatment was 12.2 months. Last available follow-up was at median 12.8 months after retreatment, and median 30.6 months after the initial treatment, showing complete occlusion in 46.2% and near-complete occlusion (90%-99%) in 20.4% of aneurysms. There was no difference in ischemic complications following initial treatment and retreatment (4.2% versus 4.2%; P>0.99). On multivariable regression, fusiform morphology had higher nonocclusion odds after retreatment (odds ratio [OR], 7.2 [95% CI, 1.97-20.8]). Family history of aneurysms was associated with lower odds of nonocclusion (OR, 0.18 [95% CI, 0.04-0.78]). Likewise, positive smoking history was associated with lower odds of nonocclusion (OR, 0.29 [95% CI, 0.1-0.86]). History of hypertension trended toward incomplete occlusion (OR, 3.10 [95% CI, 0.98-6.3]), similar to incorporated branch into aneurysms (OR, 2.78 [95% CI, 0.98-6.8]). CONCLUSIONS Repeat FD for persistent aneurysms carries a reasonable success/safety profile. Satisfactory occlusion (100% and 90%-99% occlusion) was encountered in two-thirds of patients, with similar complications between the initial and subsequent retreatments. Fusiform morphology was the strongest predictor of retreatment failure.
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Affiliation(s)
- Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Ahmad Sweid
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Anna L Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Adam A Dmytriw
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Carmen Parra-Farinas
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Arsalaan Salehani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Nimer Adeeb
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Patrick Brouwer
- Department of Neuroradiology, Karolinska Universitetssjukhuset, Stockholm, Sweden (P.B.)
| | - Gwynedd Pickett
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada (G.P.)
| | - Jerry Ku
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Victor X D Yang
- Department of Neuroradiology and Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada (J.K., V.X.D.Y.)
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre Hospitalier de l'Université de Montréal, QC, Canada (A.W.)
| | - Ivan Radovanovic
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, France (C.C.)
| | - Julian Spears
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Hugo H Cuellar-Saenz
- Department of Neurosurgery, Ochsner-Louisiana State University Hospital, Shreveport (N.A., H.H.C.-S.)
| | - Leonardo Renieri
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K.)
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, University of Florence, Florence, Italy (L.R., N.L.)
| | - Vitor Mendes Pereira
- Department of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, ON, Canada (A.A.D., I.R., V.M.P.)
| | - Mark R Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham (A.S., M.R.H.)
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester (A.L.K., A.S.P.)
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, NY (M.W., E.I.L.)
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
| | - Thomas R Marotta
- Department of Therapeutic Neuroradiology, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.).,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada. (C.P.-F., J.S., T.R.M.)
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA (A.S., P.J.)
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Teaching Hospital, Boston, MA (M.M.S., S.G.-P., G.A.M., J.M.M., C.S.O., A.J.T.)
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7
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Salem MM, Salih M, Nwajei F, Williams N, Thomas AJ, Moore JM, Ogilvy CS. Longitudinal Cost Profiles of Pipeline Embolization Device Versus Stent-Assisted Coiling in Propensity-Matched Unruptured Small Anterior Circulation Aneurysms. Neurosurgery 2021; 89:867-872. [PMID: 34383055 DOI: 10.1093/neuros/nyab304] [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: 12/11/2020] [Accepted: 06/09/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The cost profiles of stent-assisted coiling (SAC) vs Pipeline embolization device (PED) in small unruptured anterior circulation aneurysms have not been studied. OBJECTIVE To compare the 2 modalities cost profiles in a propensity-matched cohort controlling for potential technical complexity confounders including size and location. METHODS Patients treated with either SAC or PED at our institution were identified. Following propensity-score algorithm, 46 patients, 23 in each group were matched. The procedural and follow-up costs in each group were analyzed and compared. RESULTS Median maximal aneurysm size in the SAC and PED cohort were 5.3 vs 5.1 mm, respectively. Costs of access guide materials were significantly higher in the SAC group (P < .01). The average implant cost was not significantly different between the SAC and PED cohorts (${\$}$13973.2 ± ${\$}$2886.2 vs ${\$}$14,760.7 ± ${\$}$3782.1, respectively; P = .43). Similarly, total procedural costs were not different (${\$}$18341.5 ± 4104 vs ${\$}$17484.3 ± 2914.1, respectively, P = .42). Although there were significantly more total follow-ups (P = .02) and longer follow-up duration (P = .01) in SAC cohort, no significant difference in follow-up costs between the 2 groups was identified (${\$}$20557 ± ${\$}$9247 vs ${\$}$18958 ± ${\$}$9171.9, P = .56). Overall cost was similar between the SAC (${\$}$38898.9 ± ${\$}$9645.5) and PED groups (${\$}$36442.4 ± ${\$}$9076) (P = .38). CONCLUSION In small unruptured anterior circulation aneurysms (excluding anterior communicating artery aneurysms) matched for technical complexity confounders, SAC and PED offer an overall equivalent economic cost profile. Postprocedural noninvasive imaging was more frequent in the SAC group. However, follow-up costs and total costs were not significantly different.
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Affiliation(s)
- Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Felix Nwajei
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie Williams
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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8
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Lauzier DC, Cler SJ, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. The value of long-term angiographic follow-up following Pipeline embolization of intracranial aneurysms. J Neurointerv Surg 2021; 14:585-588. [PMID: 34210838 DOI: 10.1136/neurintsurg-2021-017745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is commonly performed, but the value of long-term angiographic follow-up has not been rigorously evaluated. Here we examine the prevalence of actionable findings of aneurysm recurrence and development of in-stent stenosis in a cohort of patients that underwent long-term angiographic follow-up at multiple time points. METHODS Angiographic data from eligible patients were retrospectively assessed for aneurysm occlusion, in-stent stenosis, and aneurysm regrowth or recurrence. Patients were included in this study if they underwent angiographic imaging at 6 months post-treatment and at least one later time point. RESULTS 100% (132/132) of aneurysms occluded at 6 months remained occluded at final follow-up. 85.7% (6/7), 56.3% (27/48), and 25% (6/24) of aneurysms with entry remnant, subtotal filling, and total filling, respectively, at 6 months were completely occluded at final follow-up. 98.7% (147/149) of PED constructs that demonstrated no stenosis at 6 months demonstrated no stenosis at final angiography, while 44.4% (8/18) of PED constructs demonstrating in-stent stenosis at 6 months had resolution of stenosis on final angiography. CONCLUSIONS Among patients who undergo treatment of intracranial aneurysms with PED, the value of long-term angiography in patients demonstrating complete aneurysm occlusion and no in-stent stenosis on 6 month post-treatment angiography is low.
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Affiliation(s)
- David C Lauzier
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Samuel J Cler
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua W Osbun
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA .,Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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9
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Wang Y, Yuan C, Shen S, Xu L, Duan H. Whether Intracranial Aneurysm Could Be Well Treated by Flow Diversion: A Comprehensive Meta-Analysis of Large-Sample Studies including Anterior and Posterior Circulation. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6637780. [PMID: 33778074 PMCID: PMC7969082 DOI: 10.1155/2021/6637780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 02/12/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Flow diversion (FD) has become a widely adopted treatment method for intracranial aneurysms in the clinic, but a comprehensive meta-analysis of large-sample studies including anterior and posterior circulation is still lacking. METHODS The PubMed, Embase, Web of Science, and Cochrane databases were searched between January 1, 2008, and December 1, 2019. A random-effect model was used to calculate the efficacy and safety data as well as 95% confidence intervals (CIs). RESULTS The pooled sample size of all included studies was 6695 patients; the mean age was 55.5 years old, with a total of 7406 aneurysms. For efficacy, the complete occlusion rate in angiographic follow-up (AFU) at 6 months was 78% (95% CI, 0.77, 0.80), and the AFU rate at 6-12 months was 90% (95% CI, 0.88, 0.92). For safety, the hemorrhagic event rate was 2%, the ischemic event rate was 5%, and the mortality rate was 3%. CONCLUSION FD is an effective and safe treatment for intracranial aneurysm with high complete occlusion rate and acceptable complication rate.
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Affiliation(s)
- Yingjin Wang
- Department of Neurosurgery, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Changwei Yuan
- Department of Neurosurgery, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Shengli Shen
- Department of Neurosurgery, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Liqing Xu
- Department of Neurosurgery, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China
| | - Hongzhou Duan
- Department of Neurosurgery, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing 100034, China
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10
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Sunohara T, Imamura H, Goto M, Fukumitsu R, Matsumoto S, Fukui N, Oomura Y, Akiyama T, Fukuda T, Go K, Kajiura S, Shigeyasu M, Asakura K, Horii R, Sakai C, Sakai N. Neck Location on the Outer Convexity is a Predictor of Incomplete Occlusion in Treatment with the Pipeline Embolization Device: Clinical and Angiographic Outcomes. AJNR Am J Neuroradiol 2021; 42:119-125. [PMID: 33184073 DOI: 10.3174/ajnr.a6859] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up. MATERIALS AND METHODS In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle, <160°), inner convexity type (included angle, >200°), and lateral wall type (160° ≤ included angle ≤200°). This classification reflects the metal coverage rate and flow dynamics. RESULTS Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity-type saccular aneurysms (versus inner convexity type: OR, 30.3; P < .001; versus lateral wall type: OR, 9.71; P = .001) were independently associated with a higher rate of incomplete occlusion at the last follow-up. No permanent neurologic deficits or rupture were observed in the follow-up period. CONCLUSIONS The aneurysm neck located on the outer convexity is a new, incomplete occlusion predictor, joining older age, fusiform aneurysms, and aneurysms with the branching artery from the dome. No permanent neurologic deficits or rupture was observed in the follow-up, even with incomplete occlusion.
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Affiliation(s)
- T Sunohara
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - H Imamura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - M Goto
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - R Fukumitsu
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - S Matsumoto
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - N Fukui
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Y Oomura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - T Akiyama
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - T Fukuda
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - K Go
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - S Kajiura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - M Shigeyasu
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - K Asakura
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - R Horii
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - C Sakai
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - N Sakai
- From the Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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