Dual stenting using low-profile LEO baby stents for the endovascular management of challenging intracranial aneurysms

A comparison of Atlas and Leo Baby stents-assisted coiling of intracranial aneurysms with small parent vessels

Some studies have reported the efficacy and safety of the Atlas stent and the Leo Baby stent-assisted coiling (SAC) of intracranial aneurysms arising from small cerebral vessels. The authors aimed to compare the clinical performance of the Atlas and the Leo Baby stents in small parent arteries.

METHODS AND MATERIALS

Between January 2019 and November 2022, 56 patients at our centre were treated using either Atlas or Leo Baby SAC of intracranial aneurysms arising from small parent vessels (<2 mm). The clinical and angiographic imaging data of the two cohorts were retrospectively collected and comparatively analyzed.

RESULTS

A total of 56 patients were included in this study. Thirty-two patients were treated with the Atlas SAC, and 24 patients were treated with the Leo Baby SAC. The mean age of the Atlas stent cohort was older, and the mean aneurysm size was smaller than the Leo Baby stent. The immediate complete occlusion rate was 68.6% in the Atlas stent cohort and 62.5% in the Leo Baby stent cohort. The mean angiographic follow-up time for Atlas stent cohort was 8.9±2.5 months, and the final aneurysm complete occlusion rate was 81.0%. The mean follow-up time for Leo Baby stent cohort was 18.9±6.0 months, and the final aneurysm complete occlusion rate was 83.3%.

CONCLUSIONS

At the final follow-up, the Atlas or the Leo baby stent SAC of intracranial aneurysms with small parent vessels resulted in favourable angiographic results and clinical outcomes, with a low rate of associated complications.

The Angiographic and Clinical Follow-up Outcomes of the Wide-Necked and Complex Intracranial Aneurysms Treated With LVIS EVO-Assisted Coiling

BACKGROUND

The Low Profile Visible Intraluminal Support EVO (LVIS EVO) is a self-expandable braided stent, which was recently introduced for the treatment of intracranial aneurysms. Full visibility of the stent and a relatively high metal coverage ratio are the unique features of the LVIS EVO.

OBJECTIVE

To assess the safety, efficacy, and midterm durability of LVIS EVO stent-assisted coiling for the treatment of wide-necked intracranial aneurysms.

METHODS

The endovascular databases were reviewed to identify patients treated with LVIS EVO-assisted coiling. The technical success and immediate clinical/angiographic outcomes were assessed. Periprocedural and delayed complications were evaluated. The follow-up angiographic/clinical outcomes were investigated. The preprocedural/follow-up neurological statuses were assessed with the modified Rankin Scale.

RESULTS

One hundred three aneurysms in 103 patients (63 females) with a mean age of 54.9 ± 11.3 years were included. The mean maximum sac diameter was 6.2 ± 2.9 mm. The procedural technical success rate was 100%. Immediate postprocedural angiography showed complete occlusion in 77.7%. The mean duration of the angiographic follow-up was 8.8 ± 3.6 months. Follow-up angiography showed complete aneurysm occlusion in 89% of the 82 patients with angiographic follow-up. Recanalization was observed in 7.3% of 82 patients. Two patients (2.4%) required retreatment. In addition, 8.7% of the patients had at least 1 complication, and 2.9% of the patients developed a permanent morbidity. All patients had mRS scores ≤2.

CONCLUSION

The results of this study demonstrate that SAC with LVIS EVO is a relatively safe, efficient, and durable treatment for wide-necked and complex intracranial aneurysms.

Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms

PURPOSE

This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms.

METHODS

Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively.

RESULTS

We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up.

CONCLUSION

The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Results of Y-stent-assisted-coiling with a low-profile Neuroform Atlas stent in complex bifurcation aneurysms

Aim: Neuroform Atlas is a low-profile stent with an open-cell structure that can be deployed via a low-profile microcatheter. This study analyzed the safety, durability, and efficiency of Y-stent-assisted coiling (Y-SAC) with two Neuroform Atlas stents for treating unruptured wide-neck complex bifurcation aneurysms. Material and method: We retrospectively reviewed patients who were treated for intracranial bifurcation aneurysms using the Y-SAC technique with two Neuroform Atlas stents. A total of 94 consecutive patients were included in the study. Clinical and angiographic results and complications were evaluated before and after the procedure. Results: Y-SAC was successfully performed (100%) without any technical complications in any case. The mean angiographic follow-up period was 14.6±6.6 months. Follow-up DSA was performed on 93.6% of patients. The last follow-up angiograms demonstrated complete occlusion (RROC I) in 92%, and near-complete occlusion (RROC II) in 7% of the aneurysms. There was no mortality in this study. A procedure-related complication occurred in 4.2% of patients and caused permanent morbidity in 1% of patients. Conclusion: In the endovascular treatment of wide-neck complex bifurcation aneurysms, the Y-SAC method with two Neuroform Atlas stents is safe and effective with high aneurysm occlusion rates and a low risk of procedural complications.

Initial and mid-term results of LEO Baby stent-assisted coiling of intracranial aneurysms located in small arteries: A single-center experience with 131 consecutive patients

Background and purpose

Low-profile intracranial stents such as the LEO Baby stents are considered to be advantageous for the treatment of intracranial aneurysms originating from small arteries. This study aimed to evaluate the initial and mid-term clinical and angiographic results of LEO Baby stents in stent-assisted coiling of intracranial aneurysms with small parent arteries (<2.5 mm).

Methods

We performed a retrospective study to identify 131 patients with aneurysms arising from small parent arteries treated with Leo Baby stent-assisted coiling in a single institution between October 2018 and June 2021. We assessed the immediate and progressive aneurysm occlusion rates, procedure-related complications, and clinical outcomes.

Results

A total of 131 patients with 135 aneurysms were identified, including 65 (48.1%) cases of acutely ruptured aneurysms. Technical success was achieved in all cases (100%). The immediate angiography showed complete occlusion in 111 aneurysms (82.2%), neck remnants in 19 (14.1%), and residual sac in 5 (3.7%). Procedure-related complications occurred in 14 cases (10.3%), including 13 (9.6%) thromboembolic complications and 1 (0.7%) hemorrhagic complication. Six-month follow-up angiography was achieved in 106 (78.5%) aneurysms, which showed complete occlusion in 102 (96.2%) aneurysms, neck remnants in 2 (1.9%), and residual sac in 2 (1.9%). Clinical follow-up was available in all patients with a median duration of 6.8 months, and favorable clinical outcomes (modified Rankin Scale score: 0–2) reached 91.6%. The mortality rate was 4.6%.

Conclusion

Our results demonstrate that stent-assisted coiling of intracranial aneurysms located on small arteries using LEO Baby stents is technically feasible, highly effective, and has midterm durability in aneurysmal occlusion.

Low-profile LEO baby stents using dual stenting technique in treating complex intracranial aneurysms located in small artery: Initial and mid-term outcome

BACKGROUND

Endovascular treatment of complex intracranial aneurysms (IAs) was challenging. Our retrospective study aimed to assess the efficacy and safety of LEO Baby stents using the dual stenting technique for complex IAs.

METHODS

Clinical and angiographic data of 15 IAs located in small arteries treated by LEO Baby stents in our neurosurgical center were retrospectively collected and analyzed between April 2019 to January 2021.

RESULTS

15 patients received dual stent-assisted coiling procedures and the stent configurations include 7 cases of T- configuration, 5 cases of parallel- configuration, 2 cases of Y- configuration, and 1case of X- configuration. 11 patients received dual stents deployment with only LEO Baby stents and 4 patients received LEO Baby stent combined with LVIS stent. Immediate postprocedural results showed Raymond I in 4 patients (26.7%), Raymond II in 5 patients (33.3%), and Raymond III in 6 patients (40.0%). One patient (6.7%) was confirmed with an ischemic complication during the procedure. All 15 patients (100%) received clinical follow-up ranging between 6 and 28 months. An mRS score of 0-2 was reached in all patients. 13 patients (86.7%) received angiographic clinical follow-up ranging between 6 and 20 months. The results revealed that Raymond I was achieved in 10 patients (76.9%) and Raymond II was achieved in 3 patients (23.1%). One patient (7.7%) in 6 months after the procedure was confirmed with asymptomatic in-stent stenosis.

CONCLUSION

This preliminary study suggests that dual stents deployment of LEO Baby stents was a feasible strategy for the treatment of complex IAs located in the small arteries.

Comprehensive review of the recent advances in devices for endovascular treatment of complex brain aneurysms

The International Subarachnoid Aneurysm Trial (ISAT) showed superiority for endovascular treatment of ruptured aneurysms and technology has since moved on rapidly. Many approaches and technology now exist for the endovascular management of ruptured and unruptured intracranial aneurysms, which reflects their varied nature - there is no one-size-fits-all technique. We aim to provide an overview of the various classes of device and the major developments over the past decade. Coiling is the oldest of the technology and continues to demonstrate high levels of occlusion and acceptable risks, making it the default treatment choice, particularly in the acutely ruptured aneurysm setting. Advances on coiling include the use of adjuncts such as balloons, stents and fully retrievable temporary neck-bridging devices, which have facilitated the treatment of more complex aneurysms. Flow divertors have also revolutionised complex aneurysm treatment with small added risk in acute aneurysm treatment and seek to remodel the aneurysm-vessel interface without accessing the aneurysm sac. The latest development and most promising avenue appears to be intrasaccular flow disrupting devices like WEB, Contour and Neqstent that provide excellent opportunities to treat wide neck complex aneurysm with minimal mortality and morbidity and good occlusion rates and may in future replace a significant number of stent-assisted coiling too.

Five-Years Angiographic Follow-Up of Wide-Neck Intracranial Aneurysms Treated With LEO Plus Stent

Background: This study aimed to evaluate the angiographic and clinical outcome, with an emphasis on long-term follow-up, of the LEO Plus stent for wide-neck intracranial aneurysms treated in a single center.

Methods: We retrospectively examined a prospectively maintained database of patients treated with LEO Plus devices between January 2004 and December 2016. Data regarding patient demographics, aneurysm characteristics, and technical procedures were analyzed. Angiographic and clinical findings were recorded during the procedure and followed up over a period of at least 5 years.

Results: We identified 101 patients with 116 aneurysms. In 16 patients, the stent could not safely be placed. Thus, a total of 97 LEO Plus devices were implanted in 97 aneurysms of 85 patients. Adverse events (acute and delayed) were observed in 21.6% of cases (17/85), and most were resolved (70.6%; 12/17). Moreover, 5 years after the procedure, total morbidity and mortality were 2.3% (2/85) and 3.5% (3/85), respectively. Long-term imaging follow-up showed complete occlusions, neck remnants, and residual aneurysms in 73.1% (57/78), 14.1% (11/78), and 12.8% (10/78) of cases, respectively.

Conclusions: Long-term results of treatment of brain aneurysms with LEO stent show high rates of adequate and stable occlusion over time, with acceptable morbidity and mortality.

Short- and Long-Term Safety and Efficacy of Self-Expandable Leo Stents Used Alone or with Coiling for Ruptured and Unruptured Intracranial Aneurysms: A Retrospective Observational Study

To assess the efficacy and safety of the Leo stent used alone or with coiling to treat complex intracranial aneurysms (IAs) not eligible for simple or balloon-assisted coiling, this single-center retrospective study included consecutive adults with ruptured or unruptured IAs treated in 2011-2018 by stenting with or without coiling. The indication for stenting was IA complexity precluding simple or balloon-assisted coiling. Extensive data on the patients, IAs, antiplatelet treatments, procedures, and outcomes over the first 36 months were collected. Risk factors for early complications (univariate analysis) and delayed ischemia (multivariate analysis) were sought. We include 64 patients with 66 IAs. The procedural success rate was 65/66 (98.5%). Obliteration was Raymond Roy class I or II for 85% of IAs. Six patients died including four of the 12 patients presenting with subarachnoid hemorrhage, which was the only significant risk factor for early major complications. At 1 month, 45/64 (69%) had no disabilities. No rebleeding was reported. Ischemia was detected by routine MRI in 20 (35%) of the 57 patients with long-term data and was asymptomatic in 14. The stent-within-a-stent configuration was the only independent risk factor for ischemia. The Leo stent used alone or with coils to manage challenging IAs was associated with a high procedural success rate and complete or nearly complete IA obliteration of 85% of IAs. The high frequency of ischemia is ascribable to our use of routine serial MRI. In patients with bleeding, the Leo stent was associated with an excess risk of early, major, intracranial complications, as compared to patients without bleeding. Long-term follow-up was marked by the occurrence of ischemic events in the vascular territory of the stent, mostly silent.

Y-stent-assisted coiling with Neuroform Atlas stents for wide-necked intracranial bifurcation aneurysms: A preliminary report

Objective

To report our experience on Neuroform Atlas Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms.

Methods

From March 2018 to January 2021, we treated 473 aneurysms in 436 patients with coil embolization, of which 15 cases with wide-necked bifurcation aneurysms were treated by Y-stent-assisted coiling with two Neuroform Atlas stents. We retrospectively reviewed the characteristics of patients and aneurysms, procedure-related complications, radiographic results, and clinical outcomes.

Results

All 15 cases using Neuroform Atlas Y-stenting were successful. Patients included 6 men and 9 women with a mean age ± standard deviation of 56.4±6.6 years. The mean dome and neck sizes were 6.4±3.1 mm and 4.7±1.8 mm, respectively. Immediate post-procedural angiograms showed complete occlusion in 46.7%, neck remnant in 13.3%, and incomplete occlusion in 40% of cases. No treatment-related morbidity or mortality occurred in any patients. All patients had good clinical outcomes (Glasgow Outcome Score 5) at both discharge and during a mean 12.3-month (range 1-28 months) follow-up. All aneurysms showed improved or stable occlusion on follow-up imaging. Further, the latest follow-up angiography showed complete occlusion in 73.3%, neck remnant in 6.7%, and incomplete occlusion in 20%.

Conclusions

Y-stent-assisted coiling with Neuroform Atlas stents might be a feasible and safe option for wide-necked bifurcation aneurysms.

Safety, Efficacy, and Durability of Stent Plus Balloon-Assisted Coiling for the Treatment of Wide-Necked Intracranial Bifurcation Aneurysms

BACKGROUND

Wide-necked bifurcation aneurysms remain a challenge for endovascular surgeons. Dual-stent-assisted coiling techniques have been defined to treat bifurcation aneurysms with a complex neck morphology. However, there are still concerns about the safety of dual-stenting procedures. Stent plus balloon-assisted coiling is a recently described endovascular technique that enables the coiling of wide-necked complex bifurcation aneurysms by implanting only a single stent.

OBJECTIVE

To investigate the feasibility, efficacy, safety, and durability of this technique for the treatment of wide-necked bifurcation aneurysms.

METHODS

A retrospective review was performed of patients with wide-necked intracranial bifurcation aneurysms treated with stent plus balloon-assisted coiling. The initial and follow-up clinical and angiographic outcomes were assessed. Preprocedural and follow-up clinical statuses were assessed using modified Rankin scale.

RESULTS

A total of 61 patients (mean age: 54.6 ± 10.4 yr) were included in the study. The immediate postprocedural digital subtraction angiography revealed complete aneurysm occlusion in 86.9% of the cases. A periprocedural complication developed in 11.5% of the cases. We observed a delayed ischemic complication in 4.9%. There was no mortality in this study. The permanent morbidity rate was 3.3%. The follow-up angiography was performed in 55 of 61 patients (90.1%) (the mean follow-up period was 25.5 ± 27.3 mo). The rate of complete aneurysm occlusion at the final angiographic follow-up was 89.1%. The retreatment rate was 1.8%.

CONCLUSION

The results of this study showed that stent plus balloon-assisted coiling is a feasible, effective, and relatively safe endovascular technique for the treatment of wide-necked bifurcation aneurysms located in the posterior and anterior circulation.

Flow diversion via telescoping stent with Low-profile Visualized Intraluminal Support Junior for treatment of ruptured dissecting aneurysm located at proximal posterior inferior cerebellar artery

Dissecting aneurysm involving the posterior inferior cerebellar artery (PICA) are challenging because of its nature and anatomic relationship to medulla and lower cranial nerve. We introduce a case of ruptured dissecting aneurysm located at the proximal PICA treated with telescoping stents for flow diversion and dissection healing. A 49 years old female visited to the emergency room for ruptured dissecting aneurysm at right proximal PICA. Telescoping stent was deployed along the right vertebral artery to PICA covering the dissecting aneurysm bleb using two Low-profile Visualized Intraluminal Support Jr (LVIS Jr) stents. Three months follow up angiography revealed a disappearance of aneurysm bleb and healing of dissection by parent artery remodeling. Telescoping stent with LVIS Jr may be an effective treatment for dissecting aneurysm with small diameter (<2 mm) parent artery. Convenient navigation and targeted telescoping stent for minimizing metal coverage at perforating arteries are an advantage for this method.

Staged Approach for Stent-Assisted Coiling of Cerebral Aneurysms after Failure of Initial Intra-Saccular Catheterization

Purpose

Microcatheter navigation into an aneurysm sac can present difficulties through negative interactions between the deployed stent mesh and microcatheter. We hypothesized that endothelialization of the stent mesh would minimize these interactions. We aimed to assess the feasibility of staged coiling after stenting by reviewing our experiences with unavoidably staged embolization cases.

Materials and Methods

Between 2011 and 2019, 7 patients (mean age 57.2 years, range 49–76 years) including 5 females, experienced 9 unruptured aneurysms treated with staged stenting and coiling due to unstable microcatheter navigation into the aneurysm after stent placement. The aneurysms were in the paraclinoid internal carotid artery (ICA) (n=3), ophthalmic origin ICA (n=1), superior cerebellar artery origin (n=2), basilar tip (n=2), and the middle cerebral artery bifurcation (n=1). The stents used were the Neuroform Atlas (n=4), Neuroform EZ (n=2), and Low-profile Visualized Intraluminal Support Blue (n=1).

Results

The mean interval between stenting and coiling was 15 weeks (range, 12–21 weeks). The average navigation time between the first roadmap imaging and microcatheter insertion in the sac was 14 minutes (range, 8–20 minutes). One aneurysm was occluded without further coiling on follow-up. Staged coiling successfully treated the remaining aneurysms (n=8). No complications were identified.

Conclusion

In cases of difficult intra-saccular catheterization, intentional staged coiling may be a feasible option for stent-assisted coiling of the cerebral aneurysms.

Strut remodeling with hypercompliant balloon: A new approach to Y stent-assisted coil embolization in the treatment of complex wide-neck bifurcation aneurysms

BACKGROUND

The objective of this study was to present the long-term safety and effectiveness of strand remodelling with a hypercompliant balloon.

METHODS

Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent strand remodelling with a hypercompliant balloon via Y-stent-assisted coil embolization (Y-SACE) between September 2016 and January 2020 were included in the study. The feasibility, safety, effectiveness, and complication rates of the strand remodelling technique were investigated.

RESULTS

A total of 12 patients (6 females, 6 males) were included in this study. Significant expansion was obtained in the intersection zone after remodelling. No regression was observed in the expansion rates during follow-up. There was no additional morbidity or mortality. No delayed thromboembolic complications occurred in our patients during long-term follow-up.

CONCLUSIONS

Performing strand remodelling to reduce thromboembolic complications triggered by structural faults caused by the Y-stent configuration is feasible, safe, and effective. This new approach can aid in the prevention of thromboembolic complications in Y-SACE.

Analysis of branch artery orifice angulation: Feasibility of the shelf technique for the treatment of wide-neck bifurcation aneurysms

BACKGROUND AND PURPOSE

The aim of this study was to investigate the feasibility of the shelf technique by analyzing the angle between the two branch orifices and to present its safety and effectiveness compared with that of the double-stent technique.

MATERIALS AND METHODS

Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent stent-assisted coiling (SAC) were reviewed. The study sample was divided into two groups: single SAC (shelf technique) and double SAC. The angle between the lines connecting the superior and inferior points of each branch orifice (α angle) was measured by two neurointerventional radiologists in both groups. The inter- and intraobserver repeatability and consistency of the α angle were assessed. The effect of the α angle on the feasibility of using the shelf technique to treat WNBA was analyzed. Technical and clinical success rates were investigated by comparing both groups.

RESULTS

Forty-eight patients (32 shelf technique and 16 double-stent technique) were included. There was excellent agreement between the intra- and interobserver repeatability and consistency of α angle measurements. The α angle was smaller in the shelf technique group than in the double-SAC group (p < 0.001). The technical and clinical success rates of both groups were similar based on long-term follow-up (p > 0.05).

CONCLUSION

WNBA treatment with the shelf technique is safe and effective. The α angle is a useful parameter to evaluate the performance of the shelf technique. The shelf technique is more suitable for WNBAs with a narrow α angle.

Recent advances in stent-assisted coiling of cerebral aneurysms

INTRODUCTION

Stent-assisted coiling (SAC) of intracranial aneurysms paved the way for endovascular coiling of wide-neck and bifurcation aneurysms, improving rates of aneurysm obliteration and recurrence. In this review, we provide a comprehensive review of the most recent advances related to stent-assisted coiling of intracranial aneurysm.

AREAS COVERED

The authors have made an attempt to cover the inception, applications, and limitations of SAC of intracranial aneurysms. Special focus is given to 1) the current and recently introduced SAC techniques, 2) most recent advances in device technology, and 3) outcome data for the discussed techniques and devices. The authors also discuss the potential future direction of SAC.

EXPERT OPINION

technical refinements in the field of SAC should continue to focus on device development and addressing the limitations of SAC, namely aneurysm recurrence and need of antiplatelet agents. Although the recurrence rate of SAC has not been shown to be inferior to flow diverters, the use of intrasaccular and intravascular flow diverters are likely to expand in the future at the expense of SAC.

Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms

BACKGROUND AND PURPOSE

The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent.

MATERIALS AND METHODS

On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up.

RESULTS

Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03).

CONCLUSIONS

This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.

Cerebral aneurysms treated with low-profile visualized intraluminal support device (LVIS Jr) Y-stent constructs: Technical experience with a single microcatheter technique

BACKGROUND

The LVIS Jr device holds a number of advantages but poses unique technical challenges compared to such, especially, complex multistent constructs. We report our experience with the technical feasibility and early to mid-term outcomes of Y-stent-assisted coiling with the LVIS Jr using a simple, single microcatheter technique.

METHODS

Using a departmental database, we retrospectively reviewed a single surgeon's experience with Y-stent-assisted coiling with LVIS Jr over a three-year period. Eighteen aneurysms in 17 patients were treated over this period. We assessed the technical success of the procedures, the initial and follow-up radiographic success with the modified Raymond-Roy occlusion score and follow-up clinical outcome with the modified Rankin scale.

RESULTS

All stents were successfully deployed, and 17 of 18 aneurysms were successfully coiled at the initial treatment for a technical success rate of 94.4%. Of the 17 aneurysms with follow-up imaging, all were modified Raymond-Roy grade 1 or 2. One aneurysm required retreatment for coil compaction and a growing neck. There were two immediate postprocedure symptomatic strokes and one delayed stroke related to antiplatelet non-compliance. The two immediate symptomatic strokes recovered to neurological baseline with no residual deficits by the time of discharge. The long-term morbidity rate was 5.5%. The mortality rate was 0%. All patients had a modified Rankin Scale ≤ 2 at most recent follow-up.

CONCLUSION

Treatment with LVIS Jr Y-stent constructs via a single microcatheter technique is technically feasible with good radiographic and clinical outcomes.

Y-Stent-Assisted Coiling With Low-Profile Neuroform Atlas Stents for Endovascular Treatment of Wide-Necked Complex Intracranial Bifurcation Aneurysms

BACKGROUND

Y-stent-assisted coiling is one of the eligible techniques for the treatment of complex bifurcation aneurysms. In majority of previous literature, Y-stenting has been performed using stents that could be delivered through large profile microcatheters that are often difficult to manipulate during navigation through sharply angled side branches. Attempts to navigate with these large profile catheters might cause serious complications during Y-stenting procedure.

OBJECTIVE

To investigate the safety, feasibility, and efficacy of Y-stent-assisted coiling procedure with Neuroform Atlas stents for the treatment of complex bifurcation aneurysms; Neuroform Atlas is a recently introduced open-cell stent that can be delivered though low-profile microcatheters.

METHODS

We identified the patients with intracranial bifurcation aneurysms treated by Y-stent-assisted coiling procedure with Neuroform Atlas stents. We assessed the immediate postoperative and follow-up clinical and angiographic outcomes. We also investigated the periprocedural and delayed complications.

RESULTS

A total of 30 aneurysms in 30 patients were included in the study. Y-stenting was successfully performed without any technical complications in all cases (100%). Immediate postprocedural angiography revealed total aneurysm occlusion in 83.3% of patients. The mean angiographic follow-up time was 11.8 mo. The last follow-ups showed complete occlusion in 93.3% of patients. There was no mortality in this study. A procedure-related complication developed in 6.7% and resulted in permanent morbidity in 3.3% of patients.

CONCLUSION

Neuroform Atlas stent combines the advantages of low-profile deployment microcatheters with an open-cell structure to achieve a successful Y-stenting procedure. Y-stent-assisted coiling with Neuroform Atlas stents provides a safe and effective endovascular treatment for wide-necked complex bifurcation aneurysms.

Long-term outcomes of wide-necked intracranial bifurcation aneurysms treated with T-stent-assisted coiling

OBJECTIVE

The endovascular treatment of complex bifurcation aneurysms possessing a neck that incorporates multiple side branches remains a surgical challenge. Double-stent-assisted coiling techniques, such as those with stents in an X and Y configuration, enable the endovascular treatment of wide-necked complex intracranial bifurcation aneurysms. However, the intraluminal struts at the intersection point in X- and Y-stents are not amenable to endothelialization, which may lead to thromboembolic complications. Stenting in the T configuration is a relatively new double-stent coiling technique. T-stenting differs from X- or Y-stenting in that there are no overlapping or intersecting stent segments. Promising short-term results of T-stent-assisted coiling were recently reported. However, the long-term results have not yet been demonstrated. This retrospective study investigated the long-term angiographic and clinical results in patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent-assisted coiling.

METHODS

A retrospective review was performed to identify patients with wide-necked complex intracranial bifurcation aneurysms treated with T-stent-assisted coiling at 4 institutions. The technical success and the initial and follow-up clinical and angiographic outcomes were assessed. Aneurysm filling status was assessed according to the Raymond classification. Periprocedural and delayed complications were reviewed. The neurological status of the patients was evaluated using the modified Rankin Scale (mRS).

RESULTS

One hundred two aneurysms in 102 patients (54 females), whose mean age was 57.9 ± 13.0 years, were included in the study. T-stenting was performed successfully in all patients. Immediate postprocedural angiography revealed complete occlusion in 83.3% of patients. Periprocedural complications developed in 13.7%, resulting in permanent morbidity in 1.9% and death in 1%. Eighty patients (78.4%) had at least one follow-up DSA examination performed at 6 months or later following the endovascular procedure. The mean duration of angiographic follow-up was 30.0 ± 16.3 months. The last follow-up examinations showed complete occlusion in 90.0% of patients. During the follow-up period, only 1 patient (1.3%) required retreatment. Delayed thromboembolic complications were observed in 4 patients (3.9%) without permanent morbidity. The mRS scores of all patients at the last clinical follow-up were between 0 and 2.

CONCLUSIONS

The short-term angiographic findings showed that T-stent-assisted coiling is a feasible and effective endovascular method to treat wide-necked complex bifurcation aneurysms. The long-term angiographic follow-up results suggest that T-stent-assisted coiling provides a durable treatment for wide-necked complex bifurcation aneurysms with favorable clinical outcomes, demonstrating the long-term safety of T-stent-assisted coiling.

Double stent assisted coiling of intracranial bifurcation aneurysms in Y and X configurations with the Neuroform ATLAS stent: immediate and mid term angiographic and clinical follow-up

Purpose

Self-expandable stents have broadened the spectrum of endovascular treatment of intracranial aneurysms. However, procedures involving double stenting in Y/X configurations carry a relatively high risk of procedural complications. The Neuroform ATLAS, the evolution of Neuroform EZ, is a nitinol self-expanding hybrid/open cell stent which can be delivered through a low profile 0.017 inch catheter. We present our experience in the treatment of intracranial aneurysms with this stent in Y and X configurations.

Materials and methods

We prospectively maintained a database from consecutive patients who underwent double stent assisted coiling with the Neuroform ATLAS, from July 2015 to February 2019. Clinical and angiographic results were analyzed.

Results

55 patients harboring 55 bifurcation aneurysms were treated with double stenting: 52 ‘Y’ configurations, 3 ‘X’ configurations. Deployment was successful in all cases. Post-treatment control angiography showed complete occlusion in 33 cases (60%), neck remnant in 8 cases (14.5%), and incomplete occlusion in 14 cases (25.4%). The overall symptomatic periprocedural complication rate was 12.7%. 38 aneurysms underwent follow-up (69%, mean duration 16 months): 33 aneurysms (87%) were completely occluded, 3 aneurysms (8%) had a neck remnant, and 2 aneurysms (5%) were incompletely occluded.

Conclusion

The Neuroform ATLAS is an effective device for treatment of bifurcation aneurysms, allowing good conformability, a high level of navigability, and easy mesh crossing to perform Y/X stenting procedures. The rate of procedural complications remains non-negligible, and an indication for a double stenting procedure should be carefully discussed in a multidisciplinary meeting.

Comparison of endovascular treatment for middle cerebral artery aneurysm with a low-profile visualized intraluminal support stent or pipeline embolization device

The aim of the present study was to evaluate the safety and effectiveness of low-profile visualized intraluminal support (LVIS) stent and the pipeline embolization device (PED) for middle cerebral artery (MCA) aneurysm treatment. Data of patients with MCA aneurysms who received endovascular treatment with LVIS stent or PED added to the hospital's database between August 2016 and March 2018 were retrospectively collected, and the clinical results and angiographic outcomes were evaluated. A total of 43 patients were included in the study, of whom 23 received LVIS stents and 20 received PED. The rate of complete occlusion was similar in the two groups at 6 months post-treatment (90.9 vs. 88.9%; P=0.832). Peri-operative complications were more frequent in the PED group; however, the LVIS group had more ischemic symptoms during the long-term follow-up. A larger aneurysm size (P=0.032) was associated with recanalization in the two groups. In conclusion, the LVIS stent and PED had acceptable rates of complete occlusion and aneurysm size was an independent predictor for recanalization. LVIS is more effective during the peri-operative period, while PED appears to have higher long-term safety.

Dissecting distal cerebellar artery aneurysms: options beyond a parent vessel sacrifice

Parent vessel occlusion (PVO) is the conventional endovascular treatment (EVT) for dissecting distal cerebellar artery aneurysms (DCAA). The associated ischemic sequelae are often well-tolerated. However, at the outset, the magnitude of this risk is uncertain. Meanwhile, non-PVO endovascular treatments (EVT) are deemed to provide incomplete protection from a rebleed. This study reviews our experience in the management of dissecting DCAA with emphasis on the effectiveness of parent vessel-preserving endovascular strategies as compared to PVO. Our institutional database was reviewed for all the dissecting DCAA aneurysms treated by endovascular means between Nov 2015 and Oct 2018. Their clinical presentations, imaging findings, EVT techniques, and clinical outcomes were retrospectively evaluated. Eighteen dissecting DCAA were identified: 13 in the posterior-inferior cerebellar artery (PICA), 3 in anterior-inferior cerebellar artery (AICA), and 2 in superior cerebellar artery (SCA). Median patient age was 61 years (range 40-86; average 60.7 years) with a 5:1 female predominance. Nine (6 in the PICA and 3 in the AICA) patients were managed by parent vessel-preserving strategies (6 with isolated endosaccular coiling and 3 with telescoping stents) while the remaining 9 (7 in the PICA and 2 in the SCA) were treated by PVO.The frequency of early rebleed was the same (11%) in both the treatment arms. One patient from the PVO arm suffered an extensive cerebellar infarct that mandated decompressive craniectomy and adversely affected her recovery. There were no such complications in patients treated with parent vessel-preserving strategies. No recurrence/rebleed was encountered in the 3 aneurysms secured using telescoping stents. Overall, excellent clinical outcomes (mRS of 0 and 1) were sparsely seen in the patients who had PVO (89 vs 23%). In dissecting DCAA, aforedescribed, parent vessel-preserving strategies are as effective as the more frequently used option of PVO in preventing an early rebleed. However, these are technically challenging, may be feasible in a smaller proportion of patients, and would need meticulous imaging follow-up in the acute period. When successfully implemented, these strategies can deliver excellent clinical outcomes and eliminate the uncertain risk of ischemic complications associated with PVO.

Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis

BACKGROUND

Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms.

METHODS

A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I² statistics.

RESULTS

The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001).

CONCLUSIONS

Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.

Initial and Long-Term Outcomes of Complex Bifurcation Aneurysms Treated by Y-Stent-Assisted Coiling with Low-Profile Braided Stents

BACKGROUND AND PURPOSE

Coiling complex intracranial bifurcation aneurysms often necessitates the implantation of double stents in various configurations, such as Y-stent placement. Low-profile braided stents have been introduced recently to facilitate the endovascular treatment of wide-neck aneurysms. We aimed to investigate the feasibility, safety, efficacy, and durability of Y-stent-assisted coiling with double low-profile braided stents for the treatment of complex bifurcation aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated using Y-stent-assisted coiling with low-profile braided stents. Technical success was assessed, as were initial and follow-up clinical and angiographic outcomes. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed using the modified Rankin Scale.

RESULTS

Forty patients with 40 intracranial aneurysms were included in the study. Y-stent placement was successfully performed in all cases. Immediate postprocedural digital subtraction angiography images revealed total aneurysm occlusion in 72.5% of cases. The mean angiographic follow-up time was 24.8 months. The last follow-up angiograms showed complete occlusion in 85% of patients. During follow-up, only 1 patient showed an increase in the filling status of the aneurysm and that patient did not require retreatment. There was no mortality in this study. The overall procedure-related complication rate, including asymptomatic complications, was 17.5%. A permanent morbidity developed in 1 patient (2.5%).

CONCLUSIONS

The long-term angiographic and clinical outcomes of this retrospective study demonstrate that Y-stent-assisted coiling using low-profile braided stents is an effective, relatively safe, and durable endovascular treatment for wide-neck and complex bifurcation aneurysms.

Treatment of Intracranial Aneurysms with Self-Expandable Braided Stents: A Systematic Review and Meta-Analysis

BACKGROUND

The safety and efficacy of treatment with self-expandable braided stents (LEO and LVIS) required further investigation.

PURPOSE

Our aim was to analyze the outcomes after treatment with braided stents.

DATA SOURCES

A systematic search of 3 databases was performed for studies published from 2006 to 2017.

STUDY SELECTION

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting patients treated with LEO or LVIS stents.

DATA ANALYSIS

Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and neurologic outcomes.

DATA SYNTHESIS

Thirty-five studies evaluating 1426 patients treated with braided stents were included in this meta-analysis. Successful stent delivery and complete aneurysm occlusion were 97% (1041/1095; 95% CI, 95%-98%) (I² = 44%) and 88.3% (1097/1256; 95% CI, 85%-91%) (I² = 72%), respectively. Overall, treatment-related complications were 7.4% (107/1317; 95% CI, 5%-9%) (I² = 44%). Ischemic/thromboembolic events (48/1324 = 2.4%; 95% CI, 1.5%-3.4%) (I² = 27%) and in-stent thrombosis (35/1324 = 1.5%; 95% CI, 0.6%-1.7%) (I² = 0%) were the most common complications. Treatment-related morbidity was 1.5% (30/1324; 95% CI, 0.9%-2%) and was comparable between the LEO and LVIS groups. Complication rates between the anterior (29/322 = 8.8%; 95% CI, 3.4%-12%) (I² = 41%) versus posterior circulation (10/84 = 10.5%; 95% CI, 4%-16%) (I² = 0%) and distal (30/303 = 8%; 95% CI, 4.5%-12%) (I² = 48%) versus proximal aneurysms (14/153 = 9%; 95% CI, 3%-13%) (I² = 46%) were comparable (P > .05).

LIMITATIONS

Limitations were selection and publication biases.

CONCLUSIONS

In this analysis, treatment with the LEO and LVIS stents was relatively safe and effective. The most common complications were periprocedural thromboembolisms and in-stent thrombosis. The rate of complications was comparable among anterior and posterior circulation aneurysms, as well as for proximal and distally located lesions.

Usefulness of contrast-enhanced and TOF MR angiography for follow-up after low-profile stent-assisted coil embolization of intracranial aneurysms

BACKGROUND

Low-profile, self-expandable stents are used to treat wide-neck aneurysms located on the smaller distal intracranial arteries. This study aimed to assess the usefulness of time-of-flight (TOF) and contrast-enhanced (CE) magnetic resonance angiography (MRA) for follow-up after LEO Baby stent (LBS)-assisted coil embolization.

METHODS

Twenty-four aneurysms treated with LBS-assisted coil embolization were evaluated. Researchers reviewed TOF MRA and CE MRA images in terms of occlusion and stent patency. Aneurysm occlusion was graded according to Raymond-Roy classification as follows: total occlusion (grade 1), residual neck (grade 2), and residual aneurysm (grade 3). Stent patency was scored as follows: occlusion (1), stenosis (2), and normal (3). Interobserver and intermodality agreement values were determined by weighted kappa (κ) statistics.

RESULTS

Intermodality and interobserver values of TOF MRA and CE MRA with digital subtraction angiography (DSA) were perfect (κ = 1.00, p < 0.001) in terms of aneurysm occlusion. Rate of stent occlusion and stenosis in DSA, TOF, and MRA, respectively, were as follows: 0 and 12.5%, 16.6 and 70.8%, and 0 and 62.5%. Intermodality agreement values of TOF MRA and CE MRA with DSA were insignificant in terms of stent patency (κ = 0.065, p = 0.27; κ = 0.158, p = 0.15, respectively). Interobserver agreement was substantial in both TOF MRA (κ = 0.71, p < 0.001) and CE MRA (κ = 0.64, p = 0.001).

CONCLUSIONS

Both TOF and CE MRA techniques have strong concordance with DSA for the detection of aneurysm occlusion status. CE MRA can be used as a first-line noninvasive imaging modality due to its superiority to TOF MRA with respect to the visualization of in-stent signals.

LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience

Background and Purpose

Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms.

Methods

Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed.

Results

Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases.

Conclusions

In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.

Evaluation of ischemic lesion prevalence after endovascular treatment of intracranial aneurysms, as documented by 3-T diffusion-weighted imaging: a 2-year, single-center cohort study

OBJECTIVE

Even though published data exist concerning the prevalence of ischemic lesions detected by diffusion-weighted imaging (DWI) following endovascular treatment of intracranial aneurysms, a single-center cross-evaluation of the different endovascular techniques has been lacking. The authors sought to prospectively evaluate the prevalence and clinical significance of ischemic lesions occurring after endovascular treatment of intracranial aneurysms and to compare the safety and effectiveness of a broad spectrum of currently accepted endovascular techniques in a single-center setting.

METHODS

This was a prospective cohort study involving consecutive patients treated for intracranial aneurysms exclusively by endovascular means, excluding treatments in the acute rupture phase, in a center featuring an endovascular-only treatment policy for intracranial aneurysms. All patients underwent MRI, including a 3-directional DWI sequence, before treatment, 24 hours postprocedure, and 6 months following endovascular embolization. Selective angiography was performed at 6 months’ follow-up.

RESULTS

From January 2012 through December 2013, 164 aneurysms were treated in 128 consecutive patients. Endovascular techniques included coiling (14.6%), balloon-assisted coiling (20.1%), stent-assisted coiling (3.7%), low-profile stent-assisted coiling, flow diversion (38.4%), and very complex treatments (6.1%) involving 2 stents in Y or T configurations. On postprocedure MRI, the rates of occurrence of new DWI-positive lesions were 64.3% for coiling, 54.5% for remodeling, 61.1% for stent-assisted coiling, 53.7% for flow-diverting stents, and 75% for very complex treatments (p = 0.4962). The 6-month procedure-related morbidity and mortality rates were 6.25% and 0%, respectively. At 6 months’ follow-up, 93% of the patients had modified Rankin Scale (mRS) scores of 0–2. Very complex treatments offered a higher complete occlusion rate (100%) than all other techniques (66.7%–88.9%). Age and length of procedure were independent factors for DWI lesion occurrence. The diameter of DWI lesions on 24-hour postprocedure MRI was positively correlated with mRS score at discharge. Among the DWI-positive lesions measuring less than 2 mm in diameter on the 24-hour MRI, 44.12% had regressed at 6 months.

CONCLUSIONS

Procedure-related DWI lesions are far more often encountered in silent forms than they are clinically evident. They do not seem to be significantly correlated with procedure-related complications, nor do they seem to impair clinical outcome, regardless of the endovascular technique. Small lesions (< 2 mm in diameter) may regress within 6 months. The use of the most adapted technique, in terms of aneurysm configuration, results in significant total occlusion rates, with acceptable safety.

Stent-assisted coiling of cerebral aneurysms with the Neuroform Atlas stent

Objectives The Neuroform Atlas stent (AS) is the smallest intracranial stent with an open-cell design. This study reports the first clinical experience with AS. Methods All intracranial aneurysms treated by stent-assisted coiling using a single AS in a single institution were retrospectively evaluated. Patient demographics, aneurysm characteristics, angles between the parent artery and stented branch, technical success, and clinical and angiographic follow-up were analyzed. Results Fifty-five consecutive aneurysms treated with AS-assisted coiling were included. Of these, 69.1% were located distal to the circle of Willis. Technical success rate was 100%. The mean diameters of proximal and distal parent arteries were 2.62 mm (range 1.5-4.4) and 1.8 mm (range 0.8-3.5), respectively. Except for a minor stroke in a patient who completely discontinued antiplatelet therapy on postoperative day 4, there were no clinical events with permanent sequelae, and 94.1% of patients had Raymond-Roy score of 1 or 2 aneurysmal occlusion at a mean follow-up duration of 7.9 months. Although the angle between the parent artery and the stented branch increased significantly ( p < 0.001) with time, the angular change at follow-up was only 16.45 ± 11.03 degrees and was inversely correlated both with preoperative angle and the diameter of the distal parent artery ( r = -0.465 and r = -0.433, respectively, p = 0.004 for both). Conclusion AS-assisted coiling was associated with a favorable early clinical outcome and angiographic results in this series. This stent can be used for distally located aneurysms and results in minimal alteration of the arterial anatomy.

Long-term follow-up of aneurysms treated electively with woven stent-assisted coiling

Background

Preliminary short-term results for stent-assisted coil embolization (SACE) using woven/braided stents have been promising. However, evidence supporting mid- to long-term efficacy and durability is lacking.

Objective

To report the long-term results for the durability of elective intracranial aneurysms treated with woven stents.

Materials and methods

Between May 2012 and May 2015, 98 consecutive patients with 103 aneurysms underwent elective woven SACE across three Australian neurovascular centres. All patients had immediate, 6- and 18-month clinical and radiological follow-up. Radiological assessment was performed with modified Raymond–Roy occlusion scores based on angiography results, while clinical assessment was based on the modified Rankin Scale.

Results

Six-month follow-up was available in 100 aneurysms, and an 18-month follow-up in 97 aneurysms. Total occlusion rates of 82% were achieved at inception, 82% at 6 months, and 90% at 18 months. Satisfactory occlusion with small neck remnants was present in 17% at inception, 16% at 6 months, and 9% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Intraprocedural thromboembolic events were recorded in 3% and delayed events in 1% (all in patients taking clopidogrel). Aneurysm recurrence occurred in one patient (1%). Technical complications occurred in 5%. The total complication rate was 10%.

Conclusions

Woven SACE is safe, efficacious, and durable at long-term 18-month follow-up, with very low recurrence and re-treatment rates. Preliminary results appear better than those for traditional laser-cut stents.

Midterm results of T-stent–assisted coiling of wide-necked and complex intracranial bifurcation aneurysms using low-profile stents

OBJECTIVE

Coiling of wide-necked and complex bifurcation aneurysms frequently requires implantation of double stents in various configurations. T-stent–assisted coiling involves the nonoverlapping implantation of 2 stents to protect the daughter vessels of bifurcation and is followed by coiling of the aneurysm. The authors studied the feasibility, efficacy, and safety of the T-stent–assisted coiling procedure as well as the midterm angiographic/clinical outcomes of patients with wide-necked bifurcation intracranial aneurysms treated using this technique.

METHODS

The authors retrospectively identified patients with wide-necked bifurcation intracranial aneurysms treated using double-stent–assisted coiling with a T-stent configuration.

RESULTS

Twenty-four patients with 24 aneurysms and a mean of age of 51.91 years were identified. The most common locations were the middle cerebral bifurcation (45.8%) and anterior communicating artery (35.7%). T stentings were performed using low-profile stents. The procedures were performed with a technical success rate of 95.8%, and an immediate total occlusion rate of 79.2% was achieved. We observed periprocedural complications in 16.7% of cases and a delayed thromboembolic event in 4.2%. The complications caused permanent morbidity in 1 patient (4.2%). No deaths occurred. The mean angiographic follow-up duration was 9.3 months. The total occlusion rate at the last follow-up was 81.2%. The recanalization rate was 4.5%. Modified Rankin Scale scores of all patients at the last follow-ups were between zero and 2.

CONCLUSIONS

T-stent–assisted coiling using low-profile stents is a feasible, effective, and relatively safe endovascular technique used to treat wide-necked and complex intracranial aneurysms. The midterm angiographic and clinical outcomes are outstanding.

Safety and effectiveness of the Low Profile Visualized Intraluminal Support (LVIS and LVIS Jr) devices in the endovascular treatment of intracranial aneurysms: results of the TRAIL multicenter observational study

Background and purpose

To evaluate the safety and effectiveness of the low-profile braided intracranial stents called the Low Profile Visualized Intraluminal Support (LVIS) devices for stent-assisted coil embolization of wide-necked intracranial aneurysms.

Materials and methods

This was a prospective, multicenter, observational study of unruptured and ruptured intracranial aneurysms treated with the LVIS devices. Imaging and clinical data were independently analyzed respectively by CoreLab and Clinical Event Committee. Primary endpoints were clinical safety, effectiveness, and angiographic stability of the results at 6 and 18 months.

Results

Ten centers participated in the study; 102 patients were included and 90 patients (42.2% men, 57.8% women) were eventually analyzed, among which 27 (30.0%) had multiple aneurysms. Twenty-three (25.6%) were ruptured aneurysms, four of which (4.4%) were treated in the acute phase. One aneurysm was treated per patient; 92 LVIS and LVIS Jr devices were placed overall. The total aneurysm occlusion rate was 91.0% on immediate post-procedure angiograms, which remained unchanged at 6-month follow-up and was 92.4% at 18-month follow-up. One patient (1.1%) underwent retreatment between 6 and 18 months of follow-up. A modified Rankin score of 0 was documented for most cases immediately after the procedure (86.7%) and at 6-month (86.8%) and 18-month (83.3%) follow-up. The overall permanent morbidity rate at 18 months was 5.6% and the overall rate of events with sequelae related to the stent was 2.2%. The 18-month procedure-related mortality rate was 3.3%. No patient was deemed to require retreatment at 18-month follow-up.

Conclusion

The LVIS/LVIS Jr endovascular devices are safe and effective in the treatment of ruptured and unruptured intracranial aneurysms, with acceptable complication rates, very high immediate total occlusion rates, and stable angiographic results.

Long term follow-up of bifurcation aneurysms treated with braided stent assisted coiling and complex T- and Y- stent constructs

Background

Stent assisted coil embolization (SACE) of bifurcation aneurysms is challenging. Heterogeneous results have been achieved to date, but largely for laser cut stents. While braided stents offer multiple technical advantages, their long term efficacy has yet to be validated.

Objective

To report the first long term 18 month results for the durability of bifurcation aneurysms treated with braided stents.

Materials and methods

Over a 4 year period, 59 consecutive patients with 60 bifurcation aneurysms underwent elective braided SACE across three Australian neurovascular centers. 17 of these aneurysms underwent T- or Y-shaped stent constructs. All patients had immediate, 6 month and 18 month clinical and radiological follow-up. Radiological assessment was made on modified Raymond–Roy occlusion scores while clinical assessment was based on the modified Rankin Scale. Subgroup analysis of 17 aneurysms treated with multi-stent constructs was conducted.

Results

6 month follow-up data were available for 59 aneurysms and 18 month follow-up data for 58 aneurysms. Satisfactory aneurysm occlusion was achieved in 97% at inception and at 6 months, and 98% at 18 months. Good neurological outcomes were achieved in 95% at 18 months. Similar satisfactory results were achieved with the multi-stent construct cohort. Intraprocedural thromboembolic events were recorded in 5% and delayed events in 2%. Technical complications were found in 5%. All complication rate was 13%.

Conclusion

Braided SACE was safe, efficacious, and durable at the long term 18 month follow-up, including for multi-stent constructs. Preliminary results indicate favorable clinical and radiological outcomes compared with laser cut stents.

Flow Diversion with Low-Profile Braided Stents for the Treatment of Very Small or Uncoilable Intracranial Aneurysms at or Distal to the Circle of Willis

BACKGROUND AND PURPOSE

The endovascular treatment of aneurysms located at or distal to the circle of Willis and not amenable to coiling remains a challenge. We report our experience with flow-diversion treatment using low-profile braided stents as a stent monotherapy procedure for treating distally located very small or uncoilable aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed our data bases to identify patients with aneurysms located at or distal to the circle of Willis who were treated with stent monotherapy using low-profile braided stents. The immediate and follow-up angiographic findings and clinical status of the patients were assessed.

RESULTS

Twenty aneurysms in 19 patients were included in the study. The mean size of the aneurysms was 4.7 ± 2.4 mm. Patients were treated via telescopic implantation of 2 stents for 11 aneurysms; single-stent placement was used for the remaining aneurysms. The technical success rate was 95%. We observed a technical complication in 1 case (5.3%) and a late ischemic event in another (5.3%). The final angiographies during a mean follow-up of 14.7 months showed complete aneurysm occlusion in 73.7%. The complete occlusion rate of the aneurysms treated with telescopic stent placement was 81.8%. The modified Rankin scale scores of all patients at the last follow-up were between 0 and 2.

CONCLUSIONS

Flow diversion with low-profile braided stents as a stent monotherapy procedure for very small or uncoilable intracranial aneurysms located at or beyond the circle of Willis is a promising, relatively safe, and durable endovascular procedure.

Safety and Efficacy of Low-Profile, Self-Expandable Stents for Treatment of Intracranial Aneurysms: Initial and Midterm Results - A Systematic Review and Meta-Analysis

Low-profile stents seem to be associated with a higher incidence of thromboembolic events compared with preexisting stents. We conducted a systematic review of 11 eligible reports and a meta-analysis of 7 reports with respect to the clinical efficacy and safety of low-profile stents. There were 217 intracranial aneurysms reported; 22% were ruptured aneurysms. In all, 72% were treated using single stenting, 19% were treated using overlapping stenting, and 6% were treated using balloon angioplasty followed by stenting; 3% were used to assess the flow diverter effect in a dissecting aneurysm or were treated using unexpected subtotal coil packing. On immediate postprocedural angiographic results, Raymond class I and II obliteration was obtained in 87% of the aneurysms. On angiographic results at 3-6 months, Raymond class I and II obliteration or stability was obtained in 79% of the aneurysms, and Raymond class III obliteration was obtained in 3% of the aneurysms. The recurrence rate on follow-up of intracranial aneurysms was 6.5% (5.7% with LEO Baby and 1.3% with LVIS Jr). The periprocedural complication rate was 12.4%. Periprocedural thromboembolism occurred in 6.5% of the cases. The rate of in-stent stenosis on follow-up of intracranial aneurysms was 10%. In the midterm result, the recurrence rate with use of low-profile, self-expandable stents was relatively low compared to that with use of other self-expandable stents. In the meta-analysis comparing LEO Baby with LVIS Jr, the obliteration rate at 6 months was not significantly different, but the periprocedural complication rate was relatively low with LVIS Jr.

Leo stent for endovascular treatment of intracranial aneurysms: very long-term results in 50 patients with 52 aneurysms and literature review

INTRODUCTION

The Leo stent was the first retrievable stent for endovascular treatment of intracranial aneurysms (IAs). We report our experience with this device with emphasis on very long-term follow-up.

METHODS

This study was approved by authors' ethical committee. A retrospective review of our prospectively maintained database identified all patients treated for a saccular IA with this stent in our institution. Technical issues and immediate and long-term outcomes (at least 12 months) were evaluated.

RESULTS

Between 2004 and 2015, 50 patients with 52 IAs were identified. In two patients, the stent could not safely be placed (failure rate = 3.8%). Among 48 treated patients with 50 IAs, there were 44 women and 4 men (mean age, 53 years). Mean aneurysm diameter was 7.2 mm. All IAs but six were wide-necked. There was no immediate morbidity or mortality. Anatomical results included 76% complete occlusions, 22% neck remnants, and 2% incomplete occlusions. Mean follow-up was 50.2 months (range, 12-139 months). Two patients had delayed TIAs but long-term morbidity rate remained = 0%. At follow-up, occlusion was stable in 68% IAs, showed thrombosis in 12%, and recanalization in 20% IAs. Complementary treatment was required in 8% IAs. Final results showed 70% complete occlusions, 24% neck remnants, and 6% incomplete occlusions. Asymptomatic stent occlusion and significant stenosis occurred in one and two cases, respectively.

CONCLUSION

The Leo stent is safe and effective for treatment of wide-necked saccular IAs. Very long-term results show high rates of adequate and stable occlusion. Moreover, the stent is well tolerated.

The Barrel stent: new treatment option for stent-assisted coiling of wide-necked bifurcation aneurysms—results of a single-center study

Purpose

The Barrel stent is a laser cut stent designed for stent-assisted coil embolization of wide-necked bifurcation or branch aneurysms with a single device, with the purpose of lowering the metal-to-artery ratio and its inherent risk of thromboembolic complications of multiple stents. We report our early experiences with this device in 17 patients in this retrospective single-center analysis.

Materials and methods

17 consecutive patients who underwent stent-assisted coil embolization of wide-necked bifurcation aneurysms with the Barrel stent were retrospectively identified. We analyzed the feasibility of successful deployment and post-treatment angiographic results. Adverse events, clinical outcome, and angiographic follow-up results were also analyzed.

Results

Aneurysms were located in the internal carotid artery (n=3), the middle cerebral artery (n=9), the anterior communicating artery (n=3), and the basilar artery (n=2). In the immediate post-treatment angiography, adequate occlusion (neck remnant or total occlusion) was observed in 16/17 (94.1%) of aneurysms. One patient experienced a transient ischemic attack. No permanent neurologic deficits were observed. 13/17 (76.5%) patients underwent short-term follow-up angiography after 3 months, all of which showed adequate occlusion of the aneurysm.

Conclusions

In this small retrospective single-center analysis we show that stent-assisted coiling with the Barrel stent is a safe and effective option for the endovascular treatment of intracranial wide-necked bifurcation aneurysms.

Stent-Assisted Endovascular Treatment of Anterior Communicating Artery Aneurysms - Literature Review

The anterior cerebral artery is a common location of intracranial aneurysms. The standard coil embolization technique is limited by its inability to occlude wide-neck aneurysms. Stent deployment across the aneurysm neck supports the coil mass inside the aneurysmal sac, and furthermore, has an effect on local hemodynamic and biologic changes. In this article, various management strategies and techniques as well as angiographic outcomes and complications related to stent-assisted endovascular treatment of anterior communicating artery aneurysms are presented. This treatment method is safe and associated with low morbidity and mortality rates.

Stent-assisted coil embolization of challenging intracranial aneurysms: initial and mid-term results with low-profile ACCLINO devices

BACKGROUND

Stent-assisted coiling using low-profile, self-expandable and retrievable stents is a valid option in endovascular treatment of challenging intracranial aneurysms. This study aims to evaluate the feasibility and efficacy of ACCLINO 1.9 F and ACCLINO Flex stent systems, designed for use as adjunctive products in coil embolization of intracranial aneurysms.

METHODS

Case files of 47 patients, and 52 aneurysms in total, treated with at least one ACCLINO 1.9 F or ACCLINO Flex stent were retrospectively evaluated. Technical success, complications, and angiographic outcomes were assessed based on immediate post-procedural controls along with 6th and 12th month angiograms.

RESULTS

Mechanical untoward event rate, including asymptomatic complications, is 9.6 % (five out of 52 aneurysms). Failed dual-stenting attempt rate is 15.4 % (two out of 13). Overall procedure-related morbidity is 4.2 % with no neurologic sequelae. Initial occlusion rate is 90.4 % (47 aneurysms). One patient had residual filling in the aneurysm neck, which was stable throughout follow-up. The remaining four cases had spontaneous follow-up occlusion. Recanalization rate at 6th month is 2.1 % with one aneurysm requiring retreatment. One patient was lost to follow-up. There is no mortality associated with treatment.

CONCLUSIONS

Stent-assisted coil embolization with ACCLINO stents in single or dual configurations is a feasible treatment option for challenging intracranial aneurysms. Follow-up results are encouraging; techniques were effective in complex cases and there were no clinically significant adverse outcomes.

LEO Baby Stent Use following Balloon-Assisted Coiling: Single- and Dual-Stent Technique--Immediate and Midterm Results of 29 Consecutive Patients

BACKGROUND AND PURPOSE

We report our preliminary results in terms of safety and efficacy in using the low-profile LEO Baby stent for the treatment of large-neck and complex intracranial aneurysms with balloon-then-stent-assisted coiling and single- or dual-stent-assisted coiling.

MATERIALS AND METHODS

Clinical and radiologic data of all consecutive patients treated at our institution from September 2012 to October 2013 for an intracranial aneurysm by using a LEO Baby stent were retrospectively analyzed. Immediate and midterm clinical and anatomic follow-up of each patient is reported.

RESULTS

Twenty-nine patients with 29 aneurysms were treated with LEO Baby stents at our institution. The mean age of patients was 48 years; 20 patients were women (71%). One patient was treated in the acute phase of a subarachnoid hemorrhage. In 8 procedures, a double-lumen-catheter balloon was used for balloon-then-stent-assisted coiling. In 3 cases, a LEO Baby stent was used in a Y-, T-, and telescopic dual-stent configuration. In 18 cases, a single LEO Baby stent was used. In 2 cases, technical failure to deploy the stent resulted in acute parent artery thrombosis. In 3 further cases, thromboembolic complications occurred intraoperatively. MR imaging and angiographic midterm follow-up showed complete aneurysm occlusion for 96% of the followed patients (27/29). Clinical outcome was favorable for all patients followed up.

CONCLUSIONS

Results obtained in our study by using the LEO Baby stent for balloon-then-stent and single- or dual-stent-assisted coiling of complex and distally located intracranial aneurysms are encouraging. Incomplete or inadequate opening of the device is a potential cause of laminar blood flow alteration and thrombus formation.

Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms Using Low-Profile LEO Baby Stents: Initial and Midterm Results

BACKGROUND AND PURPOSE

Low-profile self-expandable stents were recently introduced for the treatment of wide-neck intracranial aneurysms. This study investigated the initial and midterm clinical and angiographic results of LEO Baby stent-assisted coiling in the treatment of wide-neck intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated with LEO Baby stent-assisted coiling. Eighty patients with 80 wide-neck intracranial aneurysms were included in the study. Eleven patients (13.8%) presented with subarachnoid hemorrhage. All patients were treated with LEO Baby stent-assisted coiling. Technical success and immediate postprocedural clinical and angiographic outcomes were evaluated. Seventy-three patients attended angiographic and clinical follow-up for a mean duration of 7.2 ± 3.8 months. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed by using the modified Rankin Scale.

RESULTS

The technical success rate of the procedure was 97.5%. The immediate postprocedural angiography revealed a complete occlusion of the aneurysm in 75% of the 80 patients. The last follow-up angiograms showed complete occlusion in 85.7% of the 77 patients with an angiographic follow-up. Of the 77 patients with a follow-up angiography, 6.5% showed an increase in the filling status of the aneurysm and 5.2% required retreatment. The overall procedure-related complication rate, including asymptomatic complications, was 11.3%. The permanent morbidity rate was 3.8%. There was no mortality in this study.

CONCLUSIONS

This case series demonstrates the relative safety, efficacy, and midterm durability of the LEO Baby stent-assisted coiling procedure for the treatment of wide-neck intracranial aneurysms.