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Bender MT, Colby GP, Lin LM, Jiang B, Westbroek EM, Xu R, Campos JK, Huang J, Tamargo RJ, Coon AL. Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up. J Neurosurg 2019; 130:259-267. [PMID: 29600915 DOI: 10.3171/2017.11.jns171738] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Flow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence. METHODS Data from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors' institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence. RESULTS Follow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used. CONCLUSIONS This is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.
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Affiliation(s)
- Matthew T Bender
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- 2Department of Neurosurgery, University of California, Los Angeles; and
| | - Li-Mei Lin
- 3Department of Neurosurgery, University of California, Irvine, California
| | - Bowen Jiang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erick M Westbroek
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Risheng Xu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica K Campos
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander L Coon
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Zhang Y, Huang QH, Fang Y, Yang P, Xu Y, Hong B, Liu J. A Novel Flow Diverter (Tubridge) for the Treatment of Recurrent Aneurysms: A Single-Center Experience. Korean J Radiol 2017; 18:852-859. [PMID: 28860903 PMCID: PMC5552469 DOI: 10.3348/kjr.2017.18.5.852] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022] Open
Abstract
Objective The Tubridge flow diverter (FD) is a novel device aimed at reconstructing the parent artery and occluding complex aneurysms. Retreatment of recurrent aneurysms using the FD is challenging. We report our initial experience in the repair of aneurysm recurrence with the FD. Materials and Methods A database was reviewed prospectively, and 8 patients with 8 recurrent aneurysms (mean size, 16.7 mm) were identified. Four aneurysms had previously ruptured. The previous aneurysm treatment consisted of coiling in 1 aneurysm and single-stent-assisted coiling in 7 aneurysms. The procedural complications and clinical and angiographic outcomes were analyzed. Results Six aneurysms were treated by using a single Tubridge FD alone, while the remaining 2 were treated with FD + coiling. The immediate results of the 8 aneurysms were that they all showed incomplete occlusion. Neither major ischemic nor hemorrhagic complications occurred; however, 1 patient experienced a vasospasm. Follow-up angiographies were available for 7 aneurysms; the mean follow-up was 16.9 months (7–36 months). Five aneurysms were completely occluded, whereas 2 had a residual neck. Severe asymptomatic stenosis of 1 parent artery of a vertebral artery dissecting aneurysm was found. All visible branches covered by the FD were patent. All patients were clinically assessed as having attained a favorable outcome (modified Rankin Scale score ≤ 2) at discharge and follow-up. Conclusion In selected patients, the Tubridge FD can provide a safe and efficient option for the retreatment of recurrent aneurysms. Nevertheless, attention should be paid to several technical points.
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Affiliation(s)
- Yongxin Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Yibin Fang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, P.R. China
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Soize S, Gawlitza M, Raoult H, Pierot L. Imaging Follow-Up of Intracranial Aneurysms Treated by Endovascular Means. Stroke 2016; 47:1407-12. [DOI: 10.1161/strokeaha.115.011414] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 02/23/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Sebastien Soize
- From the Department of Neuroradiology, Hôpital Maison Blanche, Université Reims-Champagne-Ardenne, Reims, France (S.S., L.P.); Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany (M.G.); and Department of Neuroradiology, Hôpital Pontchaillou, University of Rennes, Rennes, France (H.R.)
| | - Matthias Gawlitza
- From the Department of Neuroradiology, Hôpital Maison Blanche, Université Reims-Champagne-Ardenne, Reims, France (S.S., L.P.); Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany (M.G.); and Department of Neuroradiology, Hôpital Pontchaillou, University of Rennes, Rennes, France (H.R.)
| | - Hélène Raoult
- From the Department of Neuroradiology, Hôpital Maison Blanche, Université Reims-Champagne-Ardenne, Reims, France (S.S., L.P.); Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany (M.G.); and Department of Neuroradiology, Hôpital Pontchaillou, University of Rennes, Rennes, France (H.R.)
| | - Laurent Pierot
- From the Department of Neuroradiology, Hôpital Maison Blanche, Université Reims-Champagne-Ardenne, Reims, France (S.S., L.P.); Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany (M.G.); and Department of Neuroradiology, Hôpital Pontchaillou, University of Rennes, Rennes, France (H.R.)
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Rouchaud A, Brinjikji W, Ding YH, Dai D, Zhu YQ, Cloft HJ, Kallmes DF, Kadirvel R. Evaluation of the Angiographic Grading Scale in Aneurysms Treated with the WEB Device in 80 Rabbits: Correlation with Histologic Evaluation. AJNR Am J Neuroradiol 2016; 37:324-9. [PMID: 26405081 DOI: 10.3174/ajnr.a4527] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/14/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The WEB Occlusion Score has been proposed to assess angiographic outcomes for intracranial aneurysms treated with the Woven EndoBridge (WEB) device. Using a large series of experimental aneurysms treated with the WEB, we had the following objectives: 1) to compare angiographic outcomes as measured by the WEB Occlusion Scale with histologic results, and 2) to assess interobserver and intraobserver agreement of the WEB Occlusion Scale. MATERIALS AND METHODS Intracranial aneurysms were created in 80 rabbits and treated with WEB devices. Animals were sacrificed at last follow-up for histologic evaluation. DSA was performed just after the deployment of the device and at follow-up. Four investigators independently and retrospectively graded the DSA twice according to the WEB Occlusion Scale. One histopathologist blinded to the angiographic results graded the occlusion according to a 4-point scale patterned on the WEB Occlusion Scale. Intra- and interobserver agreement were evaluated for DSA. Follow-up angiographic grading and histologic reference were compared to determine the WEB Occlusion Scale accuracy for complete (with or without recess filling) versus incomplete occlusion and adequate (complete occlusion or neck remnant) versus inadequate occlusion. RESULTS Inter- and intraobserver weighted κ for the angiographic WEB Occlusion Scale were, respectively, 0.76 and 0.76, indicating substantial agreement. The sensitivity and specificity of the WEB Occlusion Scale for complete occlusion at follow-up compared with the histologic reference standard were, respectively, 75% and 83.3%, with an overall accuracy of 80%. Similarly, for adequate occlusion at follow-up, sensitivity was 97.7%, specificity was 64.9%, and overall accuracy was 82.5%. CONCLUSIONS The WEB Occlusion Scale appears to be consistent, reliable, and accurate compared with a histologic reference standard.
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Affiliation(s)
- A Rouchaud
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota the Department of Radiology (A.R., W.B., H.J.C., D.F.K.), Mayo Clinic, Rochester, Minnesota.
| | - W Brinjikji
- the Department of Radiology (A.R., W.B., H.J.C., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Y-H Ding
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota
| | - D Dai
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Y Q Zhu
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota
| | - H J Cloft
- the Department of Radiology (A.R., W.B., H.J.C., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - D F Kallmes
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota the Department of Radiology (A.R., W.B., H.J.C., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - R Kadirvel
- From the Neuroradiology Research Laboratory (A.R., Y.-H.D., D.D., Y.Q.Z., D.F.K., R.K.), Mayo Clinic College of Medicine, Rochester, Minnesota
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Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms: safety and efficacy based on a propensity score-matched analysis. Eur Radiol 2015; 26:2369-77. [PMID: 26471273 DOI: 10.1007/s00330-015-4052-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The flow diverter (FD) is a device aimed at reconstructing the parent artery and occluding an aneurysm. We performed a propensity score-matched analysis to compare safety and efficacy between the FD and stent-assisted coiling. METHODS A database review was conducted to identify patients with large and giant unruptured aneurysms (aneurysms located in the ACA, MCA, or PCA were excluded) treated with the FD or stent-assisted coiling. A propensity score, representing the probability of using the FD, was generated for each aneurysm using the relevant patient and aneurysmal variables. Angiographic results, complications, and clinical outcomes were compared. RESULTS Forty-five aneurysms treated with the FD (FD alone: 32; FD+Coils: 13) and 45 treated with stent-assisted coiling were matched. The rate of complete occlusion was significantly (P = 0.0002) higher in the FD cohort than the conventional stent cohort at the 6-month follow-up. The FD cohort achieved greater improvement (P < 0.0001) and a lower rate of recurrence (P = 0.0001). The rate of periprocedural complications was similar, as was the proportion of patients who attained mRS ≤ 2 at discharge and at the 6-month follow-up. CONCLUSIONS Our findings provide reliable evidence demonstrating that the FD may be a preferred treatment option for large and giant unruptured aneurysms. KEY POINTS • Flow Diverter provided a higher complete occlusion rate at 6-month follow-up. • Flow Diverter achieved more progress occlusion and less recurrence. • Compared with the conventional stents, procedure-related morbidity of Flow Diverter was similar. • Flow Diverter is a preferred treatment for large and giant unruptured aneurysms.
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Ernst M, Yoo AJ, Kriston L, Schönfeld MH, Vettorazzi E, Fiehler J. Is visual evaluation of aneurysm coiling a reliable study end point? Systematic review and meta-analysis. Stroke 2015; 46:1574-81. [PMID: 25944331 DOI: 10.1161/strokeaha.114.008513] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 04/10/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Angiographic occlusion as a surrogate marker of satisfactory aneurysm treatment is commonly used in clinical trials although some pitfalls have to be considered. To investigate the inter-rater reliability of visual rating of aneurysm occlusion as study end point, we performed a systematic review and meta-analysis. METHODS Electronic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library) were searched up to June 2014. Assessment of risk for bias was based on the Quality Appraisal Tool for Studies of Diagnostic Reliability and the Guidelines for Reporting Reliability and Agreement studies. Inter-rater reliability estimates were pooled across studies using meta-analysis, and the influence of several factors (eg, imaging methods, grading scales, and occlusion rate) was tested with meta-regression. RESULTS From 1193 titles, 644 abstracts and 87 full-text versions were reviewed. Twenty-six articles met the inclusion criteria and provided 77 reliability estimates. Twenty-one different rating scales were used, and statistical analysis varied. Mean inter-rater agreement of the pooled studies was substantial (κ=0.65; 95% confidence interval, 0.60-0.69). Reliability varied significantly as a function of imaging methods, grading scales, occlusion rates, and their interaction. Observer agreement substantially increased with increasing occlusion rate in digital subtraction angiography but not in MR angiography. Reliability was higher in studies using 2- or 3-value grading scales than in studies with 4-value grading scales. CONCLUSIONS There is significant heterogeneity between studies evaluating the reliability of visual evaluation of aneurysm coiling. On the basis of our analysis, we found that the combination of magnetic resonance angiography, 3-value grading scale, and 2 trained raters seems most promising for usage as surrogate study end points.
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Affiliation(s)
- Marielle Ernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.).
| | - Albert J Yoo
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.)
| | - Levente Kriston
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.)
| | - Michael H Schönfeld
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.)
| | - Eik Vettorazzi
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.)
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (M.E., M.H.S., J.F.), Department of Medical Psychology (L.K.), and Department of Medical Biometry and Epidemiology (E.V.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston (A.J.Y.)
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Fiorella D, Arthur A, Byrne J, Pierot L, Molyneux A, Duckwiler G, McCarthy T, Strother C. Interobserver variability in the assessment of aneurysm occlusion with the WEB aneurysm embolization system. J Neurointerv Surg 2014; 7:591-5. [PMID: 24984707 DOI: 10.1136/neurintsurg-2014-011251] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/08/2014] [Indexed: 11/04/2022]
Affiliation(s)
- David Fiorella
- Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Adam Arthur
- Semmes-Murphy Clinic, Memphis, Tennessee, USA
| | - James Byrne
- Oxford University Neurovascular and Neuroradiology Research Unit, Oxford, UK
| | - Laurent Pierot
- Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Andy Molyneux
- Oxford University Neurovascular and Neuroradiology Research Unit, Oxford, UK
| | - Gary Duckwiler
- Department of Interventional Neuroradiology, UCLA, Los Angeles, California, USA
| | | | - Charles Strother
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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