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Zhang YB, Yao PS, Wang HJ, Xie BS, Wang JY, Zhu M, Wang DL, Yu LH, Lin YX, Gao B, Zheng SF, Kang DZ. Treatment with a flow diverter-assisted coil embolization for ruptured blood blister-like aneurysms of the internal carotid artery: a technical note and analysis of single-center experience with pooled data. Neurosurg Rev 2023; 46:305. [PMID: 37982900 DOI: 10.1007/s10143-023-02216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/25/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
Treatment of blood blister-like aneurysms (BBAs) of the supraclinoid internal carotid artery (ICA) with flow diverters (FDs) has become widespread in recent years. However, ruptured blood blister-like aneurysm (BBA) of ICA treatment with flow diverter-assisted coil embolization (FDAC) remains controversial. Moreover, limited direct comparative studies have been conducted between the two treatment modalities, FDs and FDAC, for BBAs. The purpose of this study was to document our experience and evaluate the effectiveness and safety of FDAC. We conducted a retrospective analysis of clinical and radiological information from ten patients who experienced ruptured BBAs of the supraclinoid ICA at our center from January 2021 to February 2023. The technical details of FDAC for ruptured BBAs were described, and the technical steps were named "pipeline embolization device (PED)-Individualized shaping(microcatheter)-Semi deploying-Rivet(coils)-Massage(microwire)" as the PEISSERM technique. Clinical outcomes were assessed using the modified Rankin Scale (mRS), whereas radiological results were determined through angiography. A pooled analysis was implemented, incorporating data from literature sources that reported perioperative and long-term clinical and angiographic outcomes of ruptured BBAs treated with FD and FDAC strategies, along with our data. Data in our analysis pool were categorized into FD and FDAC strategy groups to explore the preferred treatment modalities for BBAs. The PEISSERM technique was utilized to treat ten patients, seven males, and three females, with an average age of 41.7 years. A single PED was deployed in conjunction with coils in all ten patients. All PEDs were documented to have good wall apposition. The immediate postoperative angiograms demonstrated Raymond grade I in ten aneurysms. Angiographic follow-up of nine patients at 4-25 months showed total occlusion of the aneurysms. At the most recent follow-up, the mRS scores of nine patients hinted at a good prognosis. Pooled analysis of 233 ICA-BBA cases of FD revealed a technical success rate of 91% [95% confidence interval (CI), 0.88 to 0.95], a rate of complete occlusion of 79% (95% CI, 0.73 to 0.84), a recurrence rate of 2% (95% CI, 0.00 to 0.04), a rebleed rate of 2% (95% CI, 0.00 to 0.04), and the perioperative stroke rate was 8% (95% CI, 0.04 to 0.11). The perioperative mortality was 4% (95% CI, 0.01 to 0.07). The long-term good clinical outcome rate was 85% (95% CI, 0.80 to 0.90). The mortality rate was 6% (95% CI, 0.03 to 0.09). Results from the subgroup analysis illustrated that the FDAC strategy for BBAs had a significantly higher immediate postoperative complete occlusion rate (P < 0.001), total occlusion rate (P = 0.016), and a good outcome rate (P = 0.041) compared with the FD strategy. The FDAC strategy can yield a higher rate of good outcomes than the FD strategy. The PEISSERM technique employed by the FDAC is a reliable and effective treatment approach as it can minimize the hemodynamic burden of BBA's fragile dome, thereby achieving an excellent occlusion rate. The PEISSERM technique in the FDAC strategy contributes to understanding the BBA's treatment and offers a potentially optimal treatment for BBA.
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Affiliation(s)
- Yi-Bin Zhang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Pei-Sen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Hao-Jie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Bing-Sen Xie
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Jia-Yin Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, 362000, China
| | - Mei Zhu
- Department of Neurosurgery, The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, 350005, China
| | - Deng-Liang Wang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Liang-Hong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
| | - Yuan-Xiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Bin Gao
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China
| | - Shu-Fa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350212, China.
- Fujian Provincial Clinical Research Center for Neurological Diseases, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Fujian Provincial Institutes of Brain Disorders and Brain Sciences, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
- Clinical Research and Translation Center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, China.
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Field NC, Custozzo A, Gajjar AA, Dalfino JC, Boulos AS, Paul AR. Comparison of pipeline embolization device, flow re-direction endoluminal device and surpass flow diverters in the treatment of intracerebral aneurysms. Interv Neuroradiol 2023:15910199231196621. [PMID: 37635329 DOI: 10.1177/15910199231196621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
OBJECTIVES The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution. METHODS A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution. RESULTS The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01). CONCLUSIONS Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.
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Affiliation(s)
- Nicholas C Field
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Amanda Custozzo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Avi A Gajjar
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alan S Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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Gonzalez SM, Iordanou J, Adams W, Tsiang J, Frazzetta J, Kim M, Rezaii E, Pecoraro N, Zsigray B, Simon JE, Zakaria J, Jusue-Torres I, Li D, Heiferman DM, Serrone JC. Effect of Stent Porosity, Platelet Function Test Usage, and Dual Antiplatelet Therapy Duration on Clinical and Radiographic Outcomes After Stenting for Cerebral Aneurysms: A Meta-Analysis. World Neurosurg 2023; 171:159-166.e13. [PMID: 36529432 DOI: 10.1016/j.wneu.2022.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The use of stents with various porosities for treating cerebral aneurysms requires dual antiplatelet therapy (DAPT) without clear guidelines on the utility of platelet function tests (PFTs) and the duration of DAPT. We sought to determine the effects of stent porosity, PFT usage, and DAPT duration on the radiographic and clinical outcomes after stenting of cerebral aneurysms. METHODS PubMed was searched on March 29, 2021 for studies of cerebral aneurysm stenting that had specified the stent type and DAPT duration. A random effects meta-analysis was used to measure the prevalence of nonprocedural thrombotic and hemorrhagic events, clinical outcomes, aneurysm occlusion, and in-stent stenosis stratified by stent porosity, PFT usage, and DAPT duration. RESULTS The review yielded 105 studies (89 retrospective and 16 prospective) with 117 stenting cohorts (50 high porosity, 17 intermediate porosity, and 50 low porosity). In the high-, intermediate-, and low-porosity stenting cohorts, PFT usage was 26.0%, 47.1%, and 62.0% and the mean DAPT duration was 3.51 ± 2.33, 3.97 ± 1.92, and 5.18 ± 2.27 months, respectively. The intermediate-porosity stents showed a reduced incidence of hemorrhagic events (π = 0.32%) compared with low-porosity stents (π = 1.36%; P = 0.01) and improved aneurysm occlusion (π = 6.18%) compared with high-porosity stents (π = 14.42%; P = 0.001) and low-porosity stents (π = 11.71%; P = 0.04). The prevalence of in-stent stenosis was lower for the intermediate-porosity (π = 0.57%) and high-porosity (π = 1.51%) stents than for the low-porosity stents (π = 3.30%; P < 0.05). PFT use had resulted in fewer poor clinical outcomes (π = 3.54%) compared with those without PFT use (π = 5.94%; P = 0.04). The DAPT duration had no effect on the outcomes. CONCLUSIONS In the present meta-analysis, which had selected for studies of cerebral aneurysm stenting that had reported the DAPT duration, intermediate-porosity stents and PFT use had resulted significantly improved outcomes. No effect of DAPT duration could be detected.
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Affiliation(s)
| | - Jordan Iordanou
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - William Adams
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Illinois, USA
| | - John Tsiang
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Joseph Frazzetta
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Miri Kim
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Elhaum Rezaii
- Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Nathan Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Brandon Zsigray
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Joshua E Simon
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jehad Zakaria
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - Daphne Li
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | - Daniel M Heiferman
- Department of Neurological Surgery, Edward-Elmhurst Health, Naperville, Illinois, USA
| | - Joseph C Serrone
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA; Department of Neurological Surgery, Edward Hines Jr Veterans Affairs Hospital, Hines, Illinois, USA.
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4
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El Naamani K, Saad H, Chen CJ, Abbas R, Sioutas GS, Amllay A, Yudkoff CJ, Carreras A, Sambangi A, Hunt A, Jain P, Dougherty J, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms. Neurosurgery 2023; 92:118-124. [PMID: 36170173 DOI: 10.1227/neu.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/14/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce. OBJECTIVE To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms. METHODS This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication. RESULTS The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172). CONCLUSION Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Angeleah Carreras
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abhijeet Sambangi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jaime Dougherty
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Stent-assisted Coiling vs. Flow Diverter for Treating Blood Blister-like Aneurysms : A Proportion Meta-analysis. Clin Neuroradiol 2022; 32:889-902. [PMID: 35403855 DOI: 10.1007/s00062-022-01160-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/09/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Blood blister-like aneurysms (BBAs) are rare vascular lesions and a therapeutic challenge. Although endovascular treatment of BBA is a promising approach, the optimal treatment remains controversial. The purpose of this study was to compare the safety and efficacy of stent-assisted coiling (SAC) and flow diverter (FD) in the management of BBAs. METHODS A proportion meta-analysis including a published series of BBAs treated with endovascular approaches from 2009 to 2020 including SAC and FD was performed by searching English language studies via MEDLINE and EMBASE. RESULTS The 32 studies included 16 based on SAC and 16 involving FD. The long-term complete occlusion rate was higher in FD (89.26%, 95% confidence interval, CI 82.93-94.26%, I2 = 14.42%) than in SAC (70.26%, 95% CI 56.79-82.13%, I2 = 70.60%). The rate of aneurysm recanalization was lower in FD (4.54%, 95% CI 1.72-8.16%, I2 = 0%) than in SAC (25.38%, 95% CI 14.44-38.19%, I2 = 67.31%). Rates of mortality, favorable functional outcome, procedural complications, and rebleeding showed no differences between the two procedures. CONCLUSION In a proportion meta-analysis comparing FD with SAC, the FD was associated with more favorable angiographic outcomes but similar complications and clinical outcomes.
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Tsukagoshi E, Sato H, Kohyama S. Delayed aneurysm rupture in a patient treated with flow redirection endoluminal device: A case report and literature review. Surg Neurol Int 2022; 13:506. [DOI: 10.25259/sni_783_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background:
Delayed aneurysm rupture after flow-redirection endoluminal device (FRED) implantation is rare. We report a case of internal carotid-cavernous fistula (CCF) caused by a delayed aneurysm rupture of the cavernous portion of the internal carotid artery (ICA) after FRED implantation.
Case Description:
A 75-year-old woman had a gradually enlarging aneurysm at the C4 portion of the left ICA. We performed FRED implantation for the same. The FRED implantation procedure was smooth and the FRED expanded well and attached to the vessel wall. Five days after surgery, the patient developed a strong headache, hyperemia of the left eye, and disturbance of the left eye movement. Magnetic resonance imaging and angiography revealed a left CCF with cortical venous reflux. We performed transarterial aneurysmal and transvenous cavernous sinus embolization. Postoperatively, angiography showed no fistula and complete occlusion of the aneurysm; however, minor eye movement disorder persisted.
Conclusion:
To prevent the development of delayed aneurysm rupture in patients treated with FRED, preoperative consideration of whether to add coil embolization is important, even if the aneurysm is located in the C4 portion of the ICA and there is no risk of subarachnoid hemorrhage, including the size of aneurysm. In this report, we have tried to alert surgeons regarding the risk of delayed aneurysm rupture due to FRED implantation.
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Manzato LB, Santos RB, Filho PMM, Miotto G, Bastos AM, Vanzin JR. Brazilian FRED Registry: A Prospective Multicenter Study for Brain Aneurysm Treatment-The BRED Study. AJNR Am J Neuroradiol 2021; 42:1822-1826. [PMID: 34413065 DOI: 10.3174/ajnr.a7258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/01/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The development of flow diverters has changed the endovascular approach to intracranial aneurysms. On the basis of good results, the indications for flow diverters have expanded to include aneurysms of different shapes, locations, and sizes. The objective of the study was to report on the performance of the Flow Re-Direction Endoluminal Device (FRED) in intracranial aneurysm treatment at early and medium-term follow-up. MATERIALS AND METHODS This single-arm, multicentric, prospective, observational study assessed aneurysm treatment with the FRED. The primary outcome was complete aneurysm occlusion at 6 and 12 months, and the secondary outcome was to evaluate the safety of the FRED with respect to stroke and death rates. RESULTS Between June 2016 and August 2018, a total of 100 consecutive patients with 131 aneurysms were treated in 107 procedures. Total occlusion rates were 91% and 95% at 6 and 12 months. There was 1 death, and the total final morbidity rate was 1.8%. The complication rate was 4.6%. CONCLUSIONS As reported previously, the FRED has proved to be a safe and effective tool, with high occlusion rates. The design of the stent makes it more difficult to perform balloon angioplasty compared with similar devices. A branch arising from the aneurysm sac was found to be a predictor of nonocclusion at 12 months, though larger series are needed to estimate the magnitude of the association.
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Affiliation(s)
- L B Manzato
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil .,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
| | - R B Santos
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil.,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
| | - P M M Filho
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil.,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
| | - G Miotto
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil.,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
| | - A M Bastos
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil.,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
| | - J R Vanzin
- From the Department of Interventional Neuroradiology (L.B.M., P.M.M.F., G.M., J.R.V.), Neurology and Neurosurgery Service, Clinicas Hospital of Passo Fundo, Passo Fundo, Rio Grande do Sul, Brazil.,Department of Interventional Neuroradiology (R.B.S., A.M.B.), Beneficente Portuguesa Hospital, Belém, Brazil
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Pumar JM, Mosqueira A, Olier J, Rodriguez-Fernandez C, Vega P, Gonzalez-Diaz E. Treatment of Intracranial Aneurysms Using the New Silk Vista Flow Diverter: Safety Outcomes at Short-Term Follow-Up. Front Neurol 2021; 12:713389. [PMID: 34305807 PMCID: PMC8299702 DOI: 10.3389/fneur.2021.713389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Flow diverters are widely used as the first endovascular treatment option for complex brain aneurysms due to their high percentage of occlusion and low morbi-mortality. The Silk Vista device is a new generation of flow diverters designed to facilitate full visibility, improve apposition to the vessel wall, and enhance navigability. Indeed, its greatest advantage is that it enables the easier navigation of stents between 3.5 and 4.75 mm through a 0.021 microcatheter. The objective of this study was to evaluate the safety and effectiveness of Silk Vista systems for treating cerebral aneurysms. Methods: This prospective observational study included 25 consecutive patients with 27 wide-necked unruptured aneurysms treated with SILK Vista who were retrospectively analyzed for safety and efficacy. Results: Endovascular treatment was successfully performed in all patients. The final morbidity and mortality rates were both 0.0%. Short-term (3–5 months) angiographic follow-up revealed 21 complete occlusions and 6 near-complete occlusions. No significant parent artery stenosis was observed. Conclusions: This report demonstrates the efficacy of Silk Vista in treating brain aneurysms, although longer experiences should be carried out to confirm our results.
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Affiliation(s)
- José M Pumar
- Neuroradiology Department, Catedra de Neurorradiología Intervencionista, Universidad de Santiago de Compostela, Santiago, Spain
| | - Antonio Mosqueira
- Neuroradiology Department, Catedra de Neurorradiología Intervencionista, Universidad de Santiago de Compostela, Santiago, Spain
| | - Jorge Olier
- Neuroradiology Department, Hospital Clinico Universitario de Navarra, Pamplona, Spain
| | | | - Pedro Vega
- Neuroradiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Eva Gonzalez-Diaz
- Neuroradiology Department, Hospital Universitario de Cruces, Barakaldo, Spain
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Waqas M, Dossani RH, Alkhaldi M, Neveu J, Cappuzzo JM, Lim J, Khan A, Lazarov V, Monteiro A, Davies JM, Siddiqui AH, Levy EI. Flow redirection endoluminal device (FRED) for treatment of intracranial aneurysms: A systematic review. Interv Neuroradiol 2021; 28:347-357. [PMID: 34192977 DOI: 10.1177/15910199211027991] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The Flow Redirection Endoluminal Device (FRED; MicroVention) is a dual-layered flow diverter used for the treatment of intracranial aneurysms. The objective of this systematic review was to compile device-related safety and effectiveness data. METHODS The literature from January 1, 2013 to April 30, 2021 was searched for studies describing use of the FRED for intracranial aneurysm treatment irrespective of aneurysm location and morphology. The review included anterior and posterior circulation ruptured and unruptured saccular, fusiform or dissection, and blister aneurysms. MeSH terms related to "flow re-direction endoluminal device" and "FRED for aneurysms" were used. Data related to indication, complications, and rates of aneurysm occlusion were retrieved and analyzed. RESULTS Twenty-two studies with 1729 intracranial aneurysms were included in this review. Overall reported morbidity was 3.9% (range 0-20%). Overall procedure-related mortality was 1.4% (range 0-6%). Complication rates fell into 5 categories: technical (3.6%), ischemic (3.8%), thrombotic or stenotic (6%), hemorrhagic (1.5%), and non-neurological (0.8%). The aneurysm occlusion rate between 0 and 3 months (reported in 11 studies) was 47.8%. The occlusion rate between 4 and 6 months (reported in 14 studies) was 73.8%. Occlusion rates continued to increase to 75.1% at 7-12 months (reported in 10 studies) and 86.6% for follow-up beyond 1 year (reported in 10 studies). CONCLUSION This review indicated that the FRED is a safe and effective for the treatment of intracranial aneurysms. Future studies should directly compare the FRED with other flow diverters for a better understanding of comparative safety and effectiveness among the different devices.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Modhi Alkhaldi
- Depratment of Neurology, Abdulrhman Bin Faisal University, Imam, Saudi Arabia
| | - Jocelyn Neveu
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Victoria Lazarov
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA.,Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA.,Jacobs Institute, Buffalo, NY, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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10
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Burkhardt JK, McGuire LS, Griessenauer CJ. Flared non-flow diverting ends of the FRED flow diverter for cerebral aneurysms facilitate device anchoring at the arterial bifurcation. Neuroradiol J 2021; 34:521-524. [PMID: 33942661 DOI: 10.1177/19714009211013508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The Flow Redirection Intraluminal Device (FRED) flow diverter has a unique bilayer design, with the outer scaffolding stent extending beyond the inner flow diverting component by about 3 mm at each end. Here, we describe a technique to utilize these unrestrained flared ends for precise flow diverter placement in cases where the aneurysm and an adjacent branch are in close proximity and branch jailing is not desired, such as in posterior communicating artery aneurysms.Technical note: The distal end of the FRED device is pushed out of the microcatheter at the carotid terminus. Once the distal flared ends are fully open and well situated in the terminus, ideally with at least one of the limbs in the A1 segment of the anterior cerebral artery, the device is unsheathed under gentle forward pressure. This technique stabilizes the device at the distal landing zone and prevents unintended foreshortening at the distal end. This is particularly important for aneurysms located adjacent to the carotid terminus in order to assure adequate neck coverage, as well as avoiding jailing one of the branching parent arteries. An illustrative case is provided. CONCLUSIONS The non-flow diverting unrestrained flared ends of the FRED stabilize the distal end of the device when deployed directly into the branches at the arterial bifurcation. The technique is useful to provide adequate neck coverage of cerebral aneurysm located directly adjacent to the bifurcation as is frequently the case with posterior communicating artery aneurysms.
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Affiliation(s)
| | | | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Austria
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11
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Piano M, Lozupone E, Sgoifo A, Nuzzi NP, Asteggiano F, Pero G, Quilici L, Iannucci G, Cerini P, Comelli C, Peschillo S, Princiotta C, Pedicelli A, Limbucci N, Ganci G, Trasimeni G, Ciceri E, Faragò G, Giorgianni A, DE Nicola M, Remida P, Lafe E, Mardighian D, Ruggiero M, Lazzarotti GA, Cavasin N, Castellan L, Chiumarulo L, Burdi N, Paolucci A, Briganti F, Natrella M, Florio FP, Pavia M, Gallesio I, Lucente G, Gozzoli L, Caputo N, Vagnarelli S, Boccardi E, Valvassori L. Long-term follow-up of the Derivo® Embolization Device (DED®) for intracranial aneurysms: the Italian Multicentric Registry. J Neurosurg Sci 2021; 65:361-368. [PMID: 33879762 DOI: 10.23736/s0390-5616.21.05300-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The flow-diverter devices (FDDs) safety and effectiveness have been demonstrated by large series and meta-analyses. Due to the high occlusion rates and the acceptable morbidity rates of FDDs, the indications for their use are continuously expanding. We presented our Italian multicentric experience using the second generation of DERIVO® Embolization Device (DED®; Acandis, Pforzheim, Germany) to cure cerebral aneurysms, evaluating both middle and long-term safety and efficacy of this device. METHODS Between July 2016 and September 2017 we collected 109 consecutive aneurysms in 108 patients treated using DED® during 109 endovascular procedures in 34 Italian centers (100/109 aneurysms were unruptured, 9/109 were ruptured). The collected data included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and post-treatment modified Rankin Scale scores. Midterm and long-term clinical, angiographic and cross-sectional CT/MR follow-up were recorded and collected until December 2018. RESULTS In 2/109 cases, DED® placement was classified as technical failures. The overall mortality and morbidity rates were respectively 6.5% and 5.5%. Overall DERIVO® related mortality and morbidity rates were respectively 0% and 4.6% (5 out of 108 patients). Midterm neuroimaging follow-up showed the complete or nearly complete occlusion of the aneurysm in 90% cases, which became 93% at long-term follow-up. Aneurysmal sac shrinking was observed in 65% of assessable aneurysms. CONCLUSIONS Our multicentric experience using DED® for endovascular treatment of unruptured and ruptured aneurysms showed a high safety and efficacy profile, substantially equivalent or better compared to the other FDDs.
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Affiliation(s)
| | | | | | | | | | - Guglielmo Pero
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Quilici
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Paolo Cerini
- Maggiore della Carità University Hospital, Novara, Italy
| | | | | | | | | | | | | | | | - Elisa Ciceri
- Azienda Ospedaliera Universitaria Integrata di Verona (AOUI-Vr), Verona, Italy
| | - Giuseppe Faragò
- IRCCS Neurologic Institute C. Besta Foundation, Milan, Italy
| | | | | | - Paolo Remida
- ASST San Gerardo Hospital, Monza, Monza-Brianza, Italy
| | - Elvis Lafe
- IRCCS Polyclinic San Matteo Foundation, Pavia, Italy
| | | | | | | | | | | | | | | | | | | | | | - Francesco P Florio
- Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Foggia, Italy
| | | | - Ivan Gallesio
- AON SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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12
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Pavlov O, Shrivastava A, Moscote-Salazar LR, Mishra R, Gupta A, Agrawal A. The new generation double layered flow diverters for endovascular treatment of intracranial aneurysms: current status of ongoing clinical uses. Expert Rev Med Devices 2021; 18:139-144. [PMID: 33476247 DOI: 10.1080/17434440.2021.1879636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The treatment of intracranial aneurysms has significantly evolved over the last decade with the advancement in endovascular techniques and devices. Flow diverters are the latest in the armamentarium for vascular reconstruction, aneurysm exclusion, and preservation of branch vessels. The possibility of treating various types of intracranial aneurysms, including those previously considered untreatable, has represented a new paradigm in the neurovascular era. AREAS COVERED This paper describes in detail the current status in the use of new generation double-layered Flow Redirection Endoluminal Device (FRED; MicroVention Terumo, Tustin, California). For this report, we reviewed the published literature for properties of the currently available FRED devices regarding safety, efficacy, and potential risks and complications associated with their use. EXPERT OPINION FRED and FRED Jr are the new flow diverter devices for which the existing data suggest that they are safe and efficient in addressing the treatment issues with giant, wide-necked saccular and fusiform aneurysms and those with perforators and branch vessels at high risk of occlusion with surgical clipping. Evidence is mounting on their long-term durability which increases the confidence of both the endovascular surgeon in prescribing and the patient side in accepting these FDs as treatment option for intracranial aneurysms.
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Affiliation(s)
- Orlin Pavlov
- Fulda Clinic, Clinic for Neurosurgery, Fulda, Germany
| | - Adesh Shrivastava
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Rakesh Mishra
- Senior Resident Neurological Surgery, Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Ashish Gupta
- Department of TEM (Neurosurgery), All India Institute of Medical Sciences, Bhopal, India
| | - Amit Agrawal
- Professor of Neurosurgery, Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
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13
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Dinc H, Saatci I, Oguz S, Baltacioglu F, Yildiz A, Donmez H, Belet U, Onal B, Andic C, Koc O, Kocak O, Koroglu M, Cetin M, Cekirge HS. Long-term clinical and angiographic follow-up results of the dual-layer flow diverter device (FRED) for the treatment of intracranial aneurysms in a multicenter study. Neuroradiology 2021; 63:943-952. [PMID: 33392735 DOI: 10.1007/s00234-020-02627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Our aim was to determine the long-term safety and efficacy of the Flow Re-Direction Endoluminal Device (FRED) in this multicenter study with prospective design. MATERIALS-METHOD This study included 136 consecutive patients with 155 aneurysms treated between March 2013 and June 2016 in 10 centers. Twenty-two (16.2%) patients presented with rupture of the index aneurysm. Large/giant aneurysms comprised 1/3 of the cohort. Adjuvant coil use during the treatment was 15.5%. The effectiveness measure in the study was the percentage of aneurysms with stable occlusion at follow-up. RESULTS Vascular imaging follow-up was performed at least once in 131/136 (96.3%) patients with 148/155 (95.5%) aneurysms up to 75 months (mean: 37.3 months; median: 36 months according to latest follow-up), and 102/155(65.8%) aneurysms in 90/136 (66.2%) patients had ≥ 24-month control. According to the latest controls, the overall stable occlusion rate was 91.9% (95% CI, 87.5 to 96.3%). Three out of 148 aneurysms with follow-up were retreated (2%, 95% CI 0.0 to 4.3%). Adverse events were noted in 19/136 (14%, 95% CI, 9 to 21%) patients with a morbidity of 1.5% (95% CI, 0.0 to 3.5%). Mortality was 1/136 (0.7%, 95% CI, 0.02 to 2.2%) and was unrelated to aneurysm treatment. In-stent stenosis (ISS) was detected in 10/131 of the patients with follow-up (7.6%, 95% CI; 3.1 to 12.2%), only one being symptomatic. No adverse events have occurred in any of the patients with follow-up after 24 months, except the one resulting from ISS. CONCLUSION In the treatment of cerebral aneurysms which were candidates for flow diversion technique, this study showed long-term efficacy of FRED with good safety and occlusion rates.
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Affiliation(s)
- Hasan Dinc
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Isil Saatci
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey.
| | - Sukru Oguz
- Radiology Department, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Feyyaz Baltacioglu
- Radiology Department, School of Medicine, Marmara University, Istanbul, Turkey
| | - Altan Yildiz
- Radiology Department, School of Medicine, Mersin University, Mersin, Turkey
| | - Halil Donmez
- Radiology Department, School of Medicine, Erciyes University, Kayseri, Turkey
| | - Umit Belet
- Radiology Department, University of Health Sciences, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Baran Onal
- Radiology Department, School of Medicine, Gazi University, Ankara, Turkey
| | - Cagatay Andic
- Radiology Department, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Osman Koc
- Radiology Department, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Omer Kocak
- Radiology Department, Koru Hospitals, Ankara, Turkey
| | - Mert Koroglu
- Interventional Radiology Clinic, Medical Park VM Hospital, Samsun, Turkey
| | - Mustafa Cetin
- Radiology Department, University of Health Sciences Antalya Training and Research Hospital, Antalya, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Section, Koru Hospitals, Kizilirmak mah, 1450 sokak 9/19 Cukurambar, 06510, Ankara, Turkey
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14
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Gan CL, Yang Z, Salahia G, Halpin S, Nair S. A single-centre experience and literature review of Flow Re-Directional Endoluminal Device (FRED) in endovascular treatment of intracranial aneurysms. Clin Radiol 2020; 76:238.e1-238.e8. [PMID: 33317786 DOI: 10.1016/j.crad.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
AIM To present initial single-centre experience with the Flow Re-Direction Endoluminal Device, FRED. MATERIALS AND METHODS This was a retrospective study. All patients treated with FRED from October 2015 to April 2017 were included in the study. Details of the aneurysms, complications as well as follow-up results were recorded. A PubMed search was performed using the keywords "Flow Re-Direction Endoluminal Device", "FRED", "flow diverter", "FD", "FD Stent", "flow re-direction" and "flow redirection" and the results were reviewed and compared to the present authors. RESULTS A total of 21 patients with 25 aneurysms were analysed. No patient was lost to follow-up. At 6 months follow-up, 17 aneurysms (68%) were completely occluded, five had reduced flow, two had persistent flow and the remaining one showed increased flow. Two aneurysms from the reduced flow at 6 months had achieved complete occlusion at 1 year, raising the complete occlusion rate to 76%. Overall, 22/25 (88%) aneurysms were either occluded completely or had reduced flow at 1 year. The appearances of the other aneurysms were stable in subsequent follow-ups. Three complications were recorded (one haemorrhagic, two occlusive/thromboembolic). There was no mortality in the present study. The occlusion rate at University Hospital of Wales as well as the complication rate was comparable to other centres on published data. CONCLUSION FRED is a safe and effective flow diverter, which can be used to treat complex aneurysms that would have been of higher risk and for which for conventional coiling would be ineffective or unsuitable.
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Affiliation(s)
- C L Gan
- Neuroradiology Department, University Hospital of Wales, Cardiff, UK; Directorate Neurosciences, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
| | - Z Yang
- Neuroradiology Department, University Hospital of Wales, Cardiff, UK
| | - G Salahia
- Neuroradiology Department, University Hospital of Wales, Cardiff, UK
| | - S Halpin
- Neuroradiology Department, University Hospital of Wales, Cardiff, UK; Radiology Department, Royal Glamorgan Hospital, Llantrisant, UK
| | - S Nair
- Neuroradiology Department, University Hospital of Wales, Cardiff, UK; Neuroradiology Department, Queen's Medical Centre, Nottingham, UK
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Maragkos GA, Dmytriw AA, Salem MM, Tutino VM, Meng H, Cognard C, Machi P, Krings T, Mendes Pereira V. Overview of Different Flow Diverters and Flow Dynamics. Neurosurgery 2020; 86:S21-S34. [PMID: 31838536 DOI: 10.1093/neuros/nyz323] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 04/30/2019] [Indexed: 12/16/2022] Open
Abstract
Over the past decade, flow diverter technology for endocranial aneurysms has seen rapid evolution, with the development of new devices quickly outpacing the clinical evidence base. However, flow diversion has not yet been directly compared to surgical aneurysm clipping or other endovascular procedures. The oldest and most well-studied device is the Pipeline Embolization Device (PED; Medtronic), recently transitioned to the Pipeline Flex (Medtronic), which still has sparse data regarding outcomes. To date, other flow diverting devices have not been shown to outperform the PED, although information comes primarily from retrospective studies with short follow-up, which are not always comparable. Because of this lack of high-quality outcome data, no reliable recommendations can be made for choosing among flow diversion devices yet. Moreover, the decision to proceed with flow diversion should be individualized to each patient. In this work, we wish to provide a comprehensive overview of the technical specifications of all flow diverter devices currently available, accompanied by a succinct description of the evidence base surrounding each device.
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Affiliation(s)
- Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam A Dmytriw
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Hui Meng
- Canon Stroke and Vascular Research Center, University at Buffalo, Clinical and Translational Research Center, New York
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hopitalier de Toulouse, Toulouse, France
| | - Paolo Machi
- Department of Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Timo Krings
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Vitor Mendes Pereira
- Department of Medical Imaging, Toronto Western Hospital and St. Michael's Hospital, University of Toronto, Toronto, Canada
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16
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Yeomans J, Sandu L, Sastry A. Pipeline Flex embolisation device with Shield Technology for the treatment of patients with intracranial aneurysms: periprocedural and 6 month outcomes. Neuroradiol J 2020; 33:471-478. [PMID: 33092461 DOI: 10.1177/1971400920966749] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND PURPOSE The Pipeline Flex embolisation device with Shield Technology (Pipeline Shield) is a novel flow diverter which reduces intra-vessel thrombogenicity. This study summarises periprocedural outcomes and 6-month follow-up results following its introduction in a tertiary interventional neuroradiology centre. MATERIALS AND METHODS This prospective, single-arm study assessed 32 aneurysms treated over a 21-month time period from the time of procedure to 6 months post-procedure. Data collected included patient demographics, aneurysm features and intraprocedural and 6-month post-procedural complications. RESULTS The mean age of the cohort was 58.8 ± Standard Deviation 8.5 years. Twenty-eight aneurysms were treated electively and four acutely. The elective cases received dual antiplatelet therapy post-procedure. The acute cases received single antiplatelet therapy post-procedure. Of the target aneurysms, 16/32 (50%) were small (<10 mm), 13/32 (41%) were large (10-25 mm) and 3/32 (9%) were giant (≥25 mm). There was no mortality in the series. There were two periprocedural complications (2/32, 6.2%): a stroke and a dissection. There were no post-procedural complications. At 6 months post-procedure, satisfactory occlusion (defined as Raymond-Roy 1 or 2) was achieved in 90.6% and 93.8% by way of magnetic resonance angiography and digital subtraction angiography assessment, respectively. There was no implant migration, no significant intraluminal hyperplasia or in-stent stenosis and no cases of aneurysm recurrence. CONCLUSION The Pipeline Shield has an excellent 6- month safety profile with an acceptable rate of intraprocedural complications, no post-procedure complications and no mortality in this case series of 32 acute and elective cases.
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17
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De Beule T, Boulanger T, Heye S, van Rooij WJ, van Zwam WH, Stockx L. p64 flow diverter: Results in 108 patients from a single center. Interv Neuroradiol 2020; 27:51-59. [PMID: 32506988 DOI: 10.1177/1591019920932048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. MATERIALS AND METHODS We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. RESULTS Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1-6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. CONCLUSION The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.
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Affiliation(s)
- Tom De Beule
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - T Boulanger
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - S Heye
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - W J van Rooij
- Department of Radiology, 70515Algemeen Ziekenhuis Turnhout, Rubensstraat, Turnhout, Belgium
| | - W H van Zwam
- Department of Radiology, Maastricht Universiteit, Medisch Centrum, Maastricht, the Netherlands
| | - L Stockx
- Department of Radiology, Ziekenhuis Oost-Limburg, Genk, Belgium
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Stent-Assisted Coiling Using Leo+ Baby Stent : Immediate and Mid-Term Results. Clin Neuroradiol 2020; 31:409-416. [PMID: 32385517 PMCID: PMC8211599 DOI: 10.1007/s00062-020-00904-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/01/2020] [Indexed: 11/22/2022]
Abstract
Background Stent-assisted coiling is well-established for treatment of cerebral aneurysms. The technique enables treatment of wide-neck, bifurcation and recurrent aneurysms with high packing rates. While described in extenso for laser cut stents, the results of patients treated with the Leo+ Baby (Balt, Montmorency, France) braided microstent are presented. Material and Methods Patients were included if treated with a Leo+ Baby and with digital subtraction angiography (DSA) follow-up available of at least 6 months. Data were evaluated for successful deployment, aneurysm occlusion according to the modified Raymond-Roy classification (MRRC), stent patency and procedure-related morbidity and mortality. Results A total of 81 patients were included and Leo+ Baby deployment was successful in all cases. Coils were used in 80 cases. In 1 case 2 stents were used stent-in-stent without additional coiling. Initial aneurysm occlusion rates were MRRCi1 51.9%, MRRCi2 11.1%, MRRCi3a 24.7% and MRRCi3b 12.3%. Occlusion rates after 6 months were MRRC6m1 78.9%, MRRC6m2 3.9%, MRRC6m3a 6.6% and MRRC6m3b 10.5%. Procedure-related morbidity was 1 case of acute stent thrombosis successfully treated with tirofiban and 1 case with transient hemiparesis due to stent thrombosis after 4 months. There was 1 case of coil-associated subarachnoid hemorrhage (SAH) which caused prolonged hospitalization. No procedure-related mortality was observed. Conclusion The results confirm that stent-assisted coiling with the Leo+ Baby stent is safe and efficient for treatment of wide neck or recurrent cerebral aneurysms. Spontaneous progressive aneurysm occlusion over 6 months supports the theory of considerable flow-modulating effects of Leo+ Baby.
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Luecking H, Doerfler A, Goelitz P, Hoelter P, Engelhorn T, Lang S. Two- to five-year follow-up of 78 patients after treatment with the Flow Redirection Endoluminal Device. Interv Neuroradiol 2019; 26:38-44. [PMID: 31594435 DOI: 10.1177/1591019919878551] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow-diverter stents are well-established for the treatment of cerebral aneurysms. Flow Redirection Endoluminal Device differs from other flow-diverter stents by its dual-layer design and has proved equality to other devices in numerous short-term surveys. However, follow-up data covering substantially more than one year are still limited for this device. We present our long-term experience with Flow Redirection Endoluminal Device. MATERIALS AND METHODS Seventy-eight patients harboring distal internal carotid artery (91%) or vertebrobasilar (9%) cerebral aneurysms treated with Flow Redirection Endoluminal Device with or without adjunctive coiling met the inclusion criteria. All cases were evaluated for aneurysm occlusion (according to Modified Raymond Roy Classification, MRRC), for flow-diverter stents patency and configuration and for procedure- and device-related morbidity and mortality. RESULTS Mean follow-up interval was 36.9 ± 9.5 months (<30 months: n = 18; 31-42 months: n = 31; >42 months: n = 24). Total and subtotal aneurysm occlusion after six months was assessed in 92.0% (MRRC1 = 77.3%, MRRC2 = 14.7%, MRRC3a =2.7%, MRRC3b = 4.1%) and increased to 95.9% (MRRC1 = 90.5%, MRRC2 = 5.4%, MRRC3a = 2.7%). There was one case of aneurysm growth requiring early re-treatment. Procedure-related morbidity was observed in three cases (3.8%; one transient hemiparesis, one suspected foreign-body reaction, and one micro-wire perforation). There was no procedure- or device-related mortality. In-stent stenosis due to intimal hyperplasia was observed in two cases and fish-mouthing in three cases. CONCLUSIONS Our long-term data covering two to five years after flow diversion confirm that Flow Redirection Endoluminal Device is a safe and effective device for the treatment of cerebral aneurysms with progressive high aneurysm occlusion rates; recurrence rates were very low. Overall device-related morbidity was low and was not observed later than six months after intervention.
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Affiliation(s)
- Hannes Luecking
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Philipp Goelitz
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Philip Hoelter
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
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Sivasankar R, Shrivastava M, Limaye US. Experience with FRED junior flow diverter in treatment of cerebral aneurysms at or distal to the circle of Willis. J Clin Neurosci 2019; 69:166-169. [PMID: 31451376 DOI: 10.1016/j.jocn.2019.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 06/14/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
Abstract
This retrospective study was aimed at assessing our results of endovascular management using the FRED junior flow diverter in cerebral aneurysms at or distal to the circle of Willis. 12 patients with 15 small cerebral vessel aneurysms at or distal to the circle of Willis underwent endovascular treatment using the FRED junior flow diverter at two tertiary care centres in Mumbai, India. 12 of the 15 aneurysms were unruptured, one was treated in an acutely ruptured setting, while two, which had presented with SAH were initially treated with balloon assisted coiling and later treated in a staged manner with a flow diverter. Technical success was 100% in all 15 deployments. Deployments were made across angles ranging from 45° to 180°. There was no stroke/TIA/death in any of the cases, which were unruptured. The O'Kelly-Marotta (OKM) staging was used to analyze angiographic follow up (at least one post procedure angiogram) which was available in 8 patients (10 aneurysms). OKM D & C was seen in 80% of the aneurysms on follow up angiograms. The treatment of small vessel cerebral aneurysms at or distal to the Circle of Willis using a dedicated flow diverter (FRED Jr.) is both technically feasible and highly efficacious.
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Affiliation(s)
- Rajeev Sivasankar
- Dept of Imaging & Interventional Radiology, INHS Asvini, Colaba, Mumbai, India.
| | - Manish Shrivastava
- Consultant Interventional Neuroradiology, Department of Imaging & Interventional Radiology, Kokilaben Dhirubai Ambani Hospital, Mumbai, India
| | - Uday S Limaye
- Consultant Interventional Neuroradiology, Department of Imaging & Interventional Radiology, Lilavati Hospital, Mumbai, India
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Bender MT, Colby GP, Coon AL. Commentary: Comparison of Pipeline Embolization Device and Flow Re-Direction Endoluminal Device Flow Diverters for Internal Carotid Artery Aneurysms: A Propensity-Score Matched Cohort Study. Neurosurgery 2019; 85:E256-E257. [PMID: 30544139 DOI: 10.1093/neuros/nyy613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/23/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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22
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Bhogal P, Udani S, Cognard C, Piotin M, Brouwer P, Sourour NA, Andersson T, Makalanda L, Wong K, Fiorella D, Arthur AS, Yeo LLL, Soderman M, Henkes H, Pierot L. Endosaccular flow disruption: where are we now? J Neurointerv Surg 2019; 11:1024-1025. [DOI: 10.1136/neurintsurg-2018-014623] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 11/03/2022]
Abstract
Endosaccular flow disruption is an innovative method of treating wide-necked complex aneurysms. Currently four types of devices have obtained the CE mark for use within Europe. These are the Woven EndoBridge device (WEB), the Luna Aneurysm Embolization System, the Medina Embolic Device (Medtronic), and the Contour Neurovascular System. The aim of this article is to provide an overview of these devices and to summarize the evidence in the literature pertaining to the treatment of intracranial aneurysms with them.
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23
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Piano M, Valvassori L, Lozupone E, Pero G, Quilici L, Boccardi E. FRED Italian Registry: a multicenter experience with the flow re-direction endoluminal device for intracranial aneurysms. J Neurosurg 2019; 133:174-181. [PMID: 31075778 DOI: 10.3171/2019.1.jns183005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The introduction of flow-diverter devices (FDDs) has revolutionized the endovascular treatment of intracranial aneurysms. Here the authors present their Italian multicenter experience using the flow re-direction endoluminal device (FRED) in the treatment of cerebral aneurysms, evaluating both short- and long-term safety and efficacy of this device. METHODS Between February 2013 and December 2014, 169 consecutive aneurysms treated using FRED in 166 patients were entered into this study across 30 Italian centers. Data collected included patient demographics, aneurysm location and characteristics, baseline angiography, adverse event and serious adverse event information, morbidity and mortality rates, and pre- and posttreatment modified Rankin Scale scores, as well as angiographic and cross-sectional CT/MRI follow-up at 3-6 months and/or 12-24 months per institutional standard of care. All images were reviewed and adjudicated by an independent core lab. RESULTS Of the 169 lesions initially entered into the study, 4 were later determined to be extracranial or nonaneurysmal by the core lab and were excluded, leaving 165 aneurysms in 162 patients treated in 163 procedures. Ninety-one (56.2%) patients were asymptomatic with aneurysms found incidentally. Of the 165 aneurysms, 150 (90.9%) were unruptured. One hundred thirty-four (81.2%) were saccular, 27 (16.4%) were fusiform/dissecting, and the remaining 4 (2.4%) were blister-like. One hundred thirty-seven (83.0%) arose from the anterior circulation.FRED deployment was impossible in 2/163 (1.2%) cases, and in an additional 4 cases (2.5%) the device was misdeployed. Overall mortality and morbidity rates were 4.3% and 7.3%, respectively, with rates of mortality and morbidity potentially related to FRED of up to 2.4% and 6.2%, respectively. Neuroimaging follow-up at 3-6 months showed complete or nearly complete occlusion of the aneurysm in 94% of cases, increasing to 96% at 12-24 months' follow-up. Aneurysmal sac shrinkage was observed in 78% of assessable aneurysms. CONCLUSIONS This preliminary experience using FRED for endovascular treatment of complex unruptured and ruptured aneurysms showed a high safety and efficacy profile that is comparable to those of other FDDs currently in use.
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Affiliation(s)
| | | | - Emilio Lozupone
- 2UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guglielmo Pero
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
| | - Luca Quilici
- 1ASST Grande Ospedale Metropolitano Niguarda, Milan; and
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Ocal O, Arat A. Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance. Jpn J Radiol 2019; 37:549-554. [PMID: 31062213 DOI: 10.1007/s11604-019-00842-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe the rate and characteristics of air bubble retention (ABR) within cerebral aneurysms treated by flow diversion. METHODS Procedural flat detector CT (FDCT) studies were scrutinized for the presence of air bubbles (density < - 200 HU) in patients treated by flow diversion. Patients with intrasaccular treatment or previous clipping were excluded. Clinical outcomes, procedural angiograms, aneurysm characteristics and imaging features of air within the aneurysm were evaluated. RESULTS Bubbles were noted in 17.1% of 105 aneurysms in 85 FDCTs. Aneurysms with ABR were significantly larger (mean diameter: 18.9 versus 7.5 mm, P < 0.0001). There was a trend for the use of multiple devices during the treatment of these aneurysms (72.2% vs 49.4%, P = 0.071). All of the bubbles were located rostrally in the aneurysm sac and were smaller than 6 mm (mean diameter: 2.1 ± 1.3 mm). None of the patients had post-procedural neurological deterioration. The air had spontaneously disappeared on follow-up CT images (available in 12 patients) obtained at a mean follow-up duration of 48 h. CONCLUSIONS ABR is not infrequent in cerebral flow diversion procedures. It is a clinically silent and self-limited technical complication. We propose air entrapment or filtration through the flow diverter as causative factors.
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Affiliation(s)
- Osman Ocal
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Anıl Arat
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey.
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Kaschner MG, Petridis A, Turowski B. Single-center experience with the new-generation Derivo embolization device for ruptured and unruptured intracranial aneurysms. J Neurosurg Sci 2019; 64:353-363. [PMID: 31079436 DOI: 10.23736/s0390-5616.19.04678-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study is to evaluate safety and efficacy of the new-generation Derivo embolization device in complex ruptured (RIA) and unruptured (UIA) intracranial aneurysms. METHODS Retrospective analysis of 32 patients with complex RIAs and UIAs treated with Derivo at our hospital from November 2015 to December 2018. Clinical safety was defined as absence of death, transient attack, absence of minor and major stroke, and Derivo associated hemorrhage. Treatment efficacy was assessed angiographically (DSA) immediately after treatment and at 6-month follow-up according to the O'Kelly-Marotta (OKM) Grading Scale (from A=total filling to D=no filling; prolongation of stasis 1=arterial to 3=venous phase). RESULTS Thirty-two patients with 39 aneurysms were treated with 42 Derivos. In five aneurysms, additional coiling was performed. Deployment was technically successful in all cases. Two patients developed a procedure related minor stroke (one transient). In one patient bleeding due to an inflammatory aneurysmatic wall process occurred 20 days after retreatment and in one patient a stroke due to in-stent thrombosis occurred when dual platelet inhibition (PI) was switched to permanent single PI 12 month after FD treatment. No treatment related deaths were observed. Initial DSA revealed three OKM D, six OKM C, five OKM B, and 25 OKM A. Six-month follow-up for DSA and clinical evaluation was available in 20/32 patients (62.5%), 26 of 39 aneurysms (66.7%) and revealed 73.1% complete and 3.8% subtotal occlusion (OKM D: 19 of 26, OKM C3: one of 26). CONCLUSIONS Treatment of complex RIAs and UIAs with the new-generation Derivo appeared to be safe and effective in this single-center case series for ruptured and unruptured intracranial aneurysms. Immediate DSA revealed a significant flow modulation; and 6-month follow-up showed a high occlusion rate.
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Affiliation(s)
- Marius G Kaschner
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany -
| | - Athanasios Petridis
- Department of Neurosurgery, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University of Duesseldorf, Duesseldorf, Germany
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26
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Oishi H, Fujii T, Suzuki M, Takano N, Teranishi K, Yatomi K, Kitamura T, Yamamoto M, Aoki S, Arai H. Usefulness of Silent MR Angiography for Intracranial Aneurysms Treated with a Flow-Diverter Device. AJNR Am J Neuroradiol 2019; 40:808-814. [PMID: 31048297 DOI: 10.3174/ajnr.a6047] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/25/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The flow-diverter device has been established as a treatment procedure for large unruptured intracranial aneurysms. The purpose of this study was to compare the usefulness of Silent MR angiography and time-of-flight MRA to assess the parent artery and the embolization state of the aneurysm after a flow-diverter placement. MATERIALS AND METHODS Seventy-eight large, unruptured internal carotid aneurysms in 78 patients were the subjects of this study. After 6 months of treatment, they underwent follow-up digital subtraction angiography, Silent MRA, and TOF-MRA, performed simultaneously. All images were independently reviewed by 2 neurosurgeons and 1 radiologist and rated on a 4-point scale from 1 (not visible) to 4 (excellent) to evaluate the parent artery. The aneurysmal embolization status was assessed with 2 ratings: complete or incomplete occlusion. RESULTS The mean scores of Silent MRA and TOF-MRA regarding the parent artery were 3.18 ± 0.72 and 2.31 ± 0.86, respectively, showing a significantly better score with Silent MRA (P < .01). In the assessment of the embolization of aneurysms on Silent MRA and TOF-MRA compared with DSA, the percentages of agreement were 91.0% and 80.8%, respectively. CONCLUSIONS Silent MRA is superior for visualizing blood flow images inside flow-diverter devices compared with TOF-MRA. Furthermore, Silent MRA enables the assessment of aneurysmal embolization status. Silent MRA is useful for assessing the status of large and giant unruptured internal carotid aneurysms after flow-diverter placement.
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Affiliation(s)
- H Oishi
- From the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
- Neurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
| | - T Fujii
- From the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
| | - M Suzuki
- Radiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan
| | - N Takano
- Radiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan
| | | | - K Yatomi
- Neurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
| | - T Kitamura
- From the Departments of Neuroendovascular Therapy (H.O., T.F., T.K.)
| | - M Yamamoto
- Neurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
| | - S Aoki
- Radiology (M.S., N.T., S.A.), Juntendo University Faculty of Medicine, Tokyo, Japan
| | - H Arai
- Neurosurgery (H.O., K.T., K.Y., M.Y., H.A.)
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27
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Dmytriw AA, Phan K, Moore JM, Pereira VM, Krings T, Thomas AJ. On Flow Diversion: The Changing Landscape of Intracerebral Aneurysm Management. AJNR Am J Neuroradiol 2019; 40:591-600. [PMID: 30894358 DOI: 10.3174/ajnr.a6006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/25/2019] [Indexed: 12/15/2022]
Abstract
Uptake of flow-diverting technology is rapidly outpacing the availability of clinical evidence. Most current usage is off-label, and the endovascular community is nearer the beginning than the end of the learning curve, given the number of devices in development. A comprehensive overview of technical specifications alongside key outcome data is essential both for clinical decision-making and to direct further investigations. Most-studied has been the Pipeline Embolization Device, which has undergone a transition to the Pipeline Flex for which outcome data are sparse or heterogeneous. Alternative endoluminal devices do not appear to be outperforming the Pipeline Embolization Device to date, though prospective studies and long-term data mostly are lacking, and between-study comparisons must be treated with caution. Nominal technical specifications may be unrelated to in situ performance, emphasizing the importance of correct radiologic sizing and device placement. Devices designed specifically for bifurcation aneurysms also lack long-term outcome data or have only recently become available for clinical use. There are no major studies directly comparing a flow-diverting device with standard coiling or microsurgical clipping. Data on flow-diverting stents are too limited in terms of long-term outcomes to reliably inform clinical decision-making. The best available evidence supports using a single endoluminal device for most indications. Recommendations on the suitability and choice of a device for bifurcation or ruptured aneurysms or for anatomically complex lesions cannot be made on the basis of current evidence. The appropriateness of flow-diverting treatment must be decided on a case-by-case basis, considering experience and the relative risks against standard approaches or observation.
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Affiliation(s)
- A A Dmytriw
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada .,Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - K Phan
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,NeuroSpine Surgery Research Group (K.P.), Prince of Wales Private Hospital, Sydney, Australia
| | - J M Moore
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - V M Pereira
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - T Krings
- From the Department of Medical Imaging (A.A.D., V.M.P., T.K.), Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A J Thomas
- Neurosurgical Service (A.A.D., K.P., J.M.M., A.J.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Zhu Y, Zhang H, Zhang Y, Wu H, Wei L, Zhou G, Zhang Y, Deng L, Cheng Y, Li M, Santos HA, Cui W. Endovascular Metal Devices for the Treatment of Cerebrovascular Diseases. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2019; 31:e1805452. [PMID: 30589125 DOI: 10.1002/adma.201805452] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/20/2018] [Indexed: 06/09/2023]
Abstract
Cerebrovascular disease involves various medical disorders that obstruct brain blood vessels or deteriorate cerebral circulation, resulting in ischemic or hemorrhagic stroke. Nowadays, platinum coils with or without biological modification have become routine embolization devices to reduce the risk of cerebral aneurysm bleeding. Additionally, many intracranial stents, flow diverters, and stent retrievers have been invented with uniquely designed structures. To accelerate the translation of these devices into clinical usage, an in-depth understanding of the mechanical and material performance of these metal-based devices is critical. However, considering the more distal location and tortuous anatomic characteristics of cerebral arteries, present devices still risk failing to arrive at target lesions. Consequently, more flexible endovascular devices and novel designs are under urgent demand to overcome the deficiencies of existing devices. Herein, the pros and cons of the current structural designs are discussed when these devices are applied to the treatment of diseases ranging broadly from hemorrhages to ischemic strokes, in order to encourage further development of such kind of devices and investigation of their use in the clinic. Moreover, novel biodegradable materials and drug elution techniques, and the design, safety, and efficacy of personalized devices for further clinical applications in cerebral vasculature are discussed.
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Affiliation(s)
- Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hongbo Zhang
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Huayin Wu
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA, 02138, USA
| | - Liming Wei
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Gen Zhou
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Yuezhou Zhang
- Department of Pharmaceutical Sciences Laboratory, Åbo Akademi University, Turku, FI-20520, Finland
- Turku Center for Biotechnology, University of Turku and Åbo Akademi University, Turku, FI-20520, Finland
| | - Lianfu Deng
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai, 200233, P. R. China
| | - Hélder A Santos
- Drug Research Program, Division of Pharmaceutical Chemistry and Technology, Faculty of Pharmacy, University of Helsinki, FI-00014, Helsinki, Finland
- Helsinki Institute of Life Science, University of Helsinki, FI-00014, Helsinki, Finland
| | - Wenguo Cui
- Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025, P. R. China
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Delayed Treatment (≥5 Days) by Flow Diversion of Ruptured Blister-Like Cerebral Aneurysms. Clin Neuroradiol 2019; 30:287-296. [DOI: 10.1007/s00062-019-00758-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 01/08/2019] [Indexed: 11/26/2022]
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30
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Pierot L, Spelle L, Berge J, Januel AC, Herbreteau D, Aggour M, Piotin M, Biondi A, Barreau X, Mounayer C, Papagiannaki C, Lejeune JP, Gauvrit JY, Derelle AL, Chabert E, Costalat V. SAFE study (Safety and efficacy Analysis of FRED Embolic device in aneurysm treatment): 1-year clinical and anatomical results. J Neurointerv Surg 2018; 11:184-189. [PMID: 30297539 PMCID: PMC6582717 DOI: 10.1136/neurintsurg-2018-014261] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 11/06/2022]
Abstract
Background and purpose Flow diversion is an innovative and increasingly used endovascular treatment for intracranial aneurysms. Its initial evaluation with the first devices available showed good efficacy of this treatment with variable safety results. The Flow Direction Endoluminal Device (FRED) has a specific design and was evaluated in a single-arm, multicenter, prospective, Good Clinical Practice study: SAFE (Safety and efficacy Analysis of FRED Embolic device in aneurysm treatment). This analysis reports clinical results at 1 year and anatomical results at 6 months and 1 year. Methods Patients with unruptured and recanalized aneurysms located in the anterior circulation treated with FRED and FRED Jr were prospectively included. A Clinical Event Committee and a Core Laboratory independently evaluated clinical outcome and anatomical results. Results Thirteen interventional neuroradiology centers included 103 patients/aneurysms. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 71 (68.9%), cavernous ICA in 15 (14.6%), anterior cerebral or anterior communicating artery in 9 (8.7%), and middle cerebral artery in 8 (7.8%). Most aneurysms were small (<10 mm) in 71 patients (68.9%). Cumulative 1-year mortality and morbidity rates were 2/103 (1.9%) and 3/103 (2.9%), respectively, one death being related to cancer. At 1 year, anatomical results were: complete occlusion in 66/90 patients (73.3%), neck remnant in 7/90 patients (7.8%), and aneurysm remnant in 17/90 patients (18.9%). Conclusions SAFE study analysis at 1 year confirms the excellent safety profile of the FRED device for aneurysm treatment, with low morbidity and mortality rates (2.9% and 1.9%, respectively) and demonstrates its efficacy (adequate occlusion in 73/90 (81.1%)). Clinical trial registration Unique identifier: NCT02921698; Results.
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Affiliation(s)
- Laurent Pierot
- Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Laurent Spelle
- Paris-Saclay University, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | | | | | - Michel Piotin
- Fondation Ophtalmologique A. de Rothschild, Paris, France
| | | | | | | | | | | | | | | | | | - Vincent Costalat
- Hôpital Gui de Chauliac, Université de Montpellier, Montpellier, France
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Zhu D, Yan Y, Zhao P, Duan G, Zhao R, Liu J, Huang Q. Safety and Efficacy of Flow Diverter Treatment for Blood Blister–Like Aneurysm: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 118:e79-e86. [DOI: 10.1016/j.wneu.2018.06.123] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
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Mahajan A, Das B, Narang KS, Jha AN, Singh VP, Sapra H, Goel G. Surpass Flow Diverter in the Treatment of Ruptured Intracranial Aneurysms-A Single-Center Experience. World Neurosurg 2018; 120:e1061-e1070. [PMID: 30213677 DOI: 10.1016/j.wneu.2018.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/30/2018] [Accepted: 09/02/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Use of a Surpass flow diverter (FD) device in the treatment of acutely ruptured aneurysm has not been well studied and reported in the literature. METHODS We retrospectively reviewed patients with subarachnoid hemorrhage who were treated by Surpass FD placement at our hospital between June 2016 and March 2018. Detailed analysis of medical records was performed to obtain patient age, gender, clinical history, Hunt and Hess grade, Fisher grade, results of radiographic and procedural details including technical success and complication, clinical outcome, and follow-up angiographic results. RESULTS Our search identified 16 patients with 16 aneurysms who were treated with Surpass FD, of which 13 aneurysms (81%) were in the anterior circulation and 3 (19%) were in the posterior circulation. Aneurysm size ranged from 1.1 to 16 mm, with a mean of 4 mm. The mean delay between subarachnoid hemorrhage and endovascular treatment was 5 days (range, 3-20 days). Only 1 Surpass FD was used in each patient, ranging in size from 3 × 25 mm to 4 × 50 mm. Fifteen patients (94%) achieved favorable clinical outcome (modified Rankin Scale score 0-1) at 3 months. One patient died of invasive fungal infection. Angiographic follow-up results were assessed by O'Kelly-Marotta grading scale in 15 surviving patients and showed a grade D result (no filling) in 13/15 aneurysms (87%) at 3 and 6 months. CONCLUSIONS A Surpass FD device is a feasible option for the treatment of ruptured intracranial aneurysms that are difficult to treat by conventional clipping and coiling; however, larger and comparative studies with long-term follow-up are needed to confirm its safety and efficacy.
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Affiliation(s)
- Anshu Mahajan
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Biplab Das
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Karanjit Singh Narang
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Ajaya Nand Jha
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Varindera Paul Singh
- Department of Neurosurgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Harsh Sapra
- Department of Neuroanaesthesia and Critical Care, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India
| | - Gaurav Goel
- Department of Neurointerventional surgery, Institute of Neuroscience, Medanta The Medicity, Gurgaon, Haryana, India.
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Initial Experience with a Flow Redirection Endoluminal Device Stent—A Brazilian Multicenter Study. J Stroke Cerebrovasc Dis 2018; 27:e158-e164. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 10/17/2022] Open
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Laukka D, Rautio R, Rahi M, Rinne J. Acute Treatment of Ruptured Fusiform Posterior Circulation Posterior Cerebral, Superior Cerebellar, and Posterior Inferior Cerebellar Artery Aneurysms With FRED Flow Diverter: Report of 5 Cases. Oper Neurosurg (Hagerstown) 2018; 16:549-556. [DOI: 10.1093/ons/opy194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/01/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Flow diverter (FD) treatment of ruptured fusiform posterior cerebral artery (PCA), posterior inferior cerebellar artery (PICA), and superior cerebellar artery (SCA) aneurysms are limited to single reports.
OBJECTIVE
To study the safety and efficacy of FD treatment for ruptured fusiform aneurysms of the PCA, SCA, and PICA.
METHODS
Five patients with ruptured posterior circulation fusiform aneurysms and treated with a Flow-Redirection Endoluminal Device (FRED/FRED Jr; Microvention, Tustin, California) stent in the acute phase of subarachnoid hemorrhage between 2013 and 2016 were included and reviewed retrospectively.
RESULTS
Two aneurysms located on the PICA, 2 on PCA, and 1 on the SCA. Mean treatment time with FD was 5.8 d (range, 0-11 d) from ictus. The technical success rate was 100%. On admission 2 patients were Hunt and Hess grade 1, 2 patients grade 3, and 1 patient grade 4. At discharge, 4 patients (80%) were independent (modified Ranking Scale (mRS) ≤2) and 1 patient had severe disability (mRS 4). None of the patients had aneurysmal rebleeding. All 5 aneurysms were completely occluded on angiographic follow-up (range, 3-22 mo). One patient had permanent intraprocedural in stent thrombosis and brain infarction. One patient had spontaneous nonaneurysmal intracerebral hemorrhage 1 mo after FD treatment. External ventricular drainage was inserted in 3 patients and ventriculoperitoneal shunt in 2 patients without hemorrhagic complications despite dual antiplatelet therapy.
CONCLUSION
FD could be considered as a treatment option for ruptured fusiform aneurysms located on PCA, PICA, or SCA when other treatment options are challenging.
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Affiliation(s)
- Dan Laukka
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Riitta Rautio
- Department of Radiology and Interventional Radiology, Turku University Hospital, Turku, Finland
| | - Melissa Rahi
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Jaakko Rinne
- Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
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35
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Killer-Oberpfalzer M, Kocer N, Griessenauer CJ, Janssen H, Engelhorn T, Holtmannspötter M, Buhk JH, Finkenzeller T, Fesl G, Trenkler J, Reith W, Berlis A, Hausegger K, Augustin M, Islak C, Minnich B, Möhlenbruch M. European Multicenter Study for the Evaluation of a Dual-Layer Flow-Diverting Stent for Treatment of Wide-Neck Intracranial Aneurysms: The European Flow-Redirection Intraluminal Device Study. AJNR Am J Neuroradiol 2018; 39:841-847. [PMID: 29545252 DOI: 10.3174/ajnr.a5592] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/12/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Endoluminal reconstruction with flow-diverting stents represents a widely accepted technique for the treatment of complex intracranial aneurysms. This European registry study analyzed the initial experience of 15 neurovascular centers with the Flow-Redirection Intraluminal Device (FRED) system. MATERIALS AND METHODS Consecutive patients with intracranial aneurysms treated with the FRED between February 2012 and March 2015 were retrospectively reviewed. Complications and adverse events, transient and permanent morbidity, mortality, and occlusion rates were evaluated. RESULTS During the defined study period, 579 aneurysms in 531 patients (median age, 54 years; range, 13-86 years) were treated with the FRED. Seven percent of patients were treated in the acute phase (≤3 days) of aneurysm rupture. The median aneurysm size was 7.6 mm (range, 1-36.6 mm), and the median neck size 4.5 mm (range, 1-30 mm). Angiographic follow-up of >3 months was available for 516 (89.1%) aneurysms. There was progressive occlusion witnessed with time, with complete occlusion in 18 (20%) aneurysms followed for up to 90 ± 14 days, 141 (82.5%) for 180 ± 20 days, 116 (91.3%) for 1 year ± 24 days, and 122 (95.3%) aneurysms followed for >1 year. Transient and permanent morbidity occurred in 3.2% and 0.8% of procedures, respectively. The overall mortality rate was 1.5%. CONCLUSIONS This retrospective study in real-world patients demonstrated the safety and efficacy of the FRED for the treatment of intracranial aneurysms. In most cases, treatment with a single FRED resulted in complete angiographic occlusion at 1 year.
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Affiliation(s)
- M Killer-Oberpfalzer
- From the Research Institute of Neurointervention/Department of Neurology (M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria
| | - N Kocer
- Department of Neuroradiology (N.K., C.I.), Cerrahpasa Medical School, Istanbul University, Turkey
| | - C J Griessenauer
- From the Research Institute of Neurointervention/Department of Neurology (M.K.-O., C.J.G.), Paracelsus Medical University, Salzburg, Austria.,Department of Neurosurgery (C.J.G.), Geisinger Health, Danville, Pennsylvania
| | - H Janssen
- Institute of Radiology and Neuroradiology (H.J., T.F.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - T Engelhorn
- Department of Neuroradiology (T.E.), University Hospital, Erlangen, Germany
| | - M Holtmannspötter
- Department of Diagnostic Radiology (M.H.), Rigshospitalet, Copenhagen, Denmark
| | - J H Buhk
- Department of Neuroradiology (J.H.B.), University Hospital Hamburg, Eppendorf, Germany
| | - T Finkenzeller
- Institute of Radiology and Neuroradiology (H.J., T.F.), Klinikum Nuernberg Sued, Paracelsus Medical University, Nuernberg, Germany
| | - G Fesl
- Department of Neuroradiology (G.F.), Klinikum Grosshadern, University of Munich, Munich, Germany
| | - J Trenkler
- Department of Neuroradiology (J.T.), Kepler Universitätsklinikum, Linz, Austria
| | - W Reith
- Klinik für Diagnostische und Interventionelle Neuroradiologie (W.R.), Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - A Berlis
- Klinik für Diagnostische Radiologie und Neuroradiologie (A.B.), Klinikum Augsburg, Augsburg, Germany
| | - K Hausegger
- Department of Diagnostic and Interventional Radiology (K.H.), Klinikum Klagenfurt, Klagenfurt, Austria
| | - M Augustin
- Department of Radiology (M.A.), University Hospital, Graz, Austria
| | - C Islak
- Department of Neuroradiology (N.K., C.I.), Cerrahpasa Medical School, Istanbul University, Turkey
| | - B Minnich
- Department of Cell Biology and Physiology (B.M.), Universität Salzburg, Salzburg, Austria
| | - M Möhlenbruch
- Department of Neuroradiology (M.M.), Universitätsklinikum Heidelberg, Heidelberg, Germany
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Jia ZY, Shi HB, Miyachi S, Hwang SM, Sheen JJ, Song YS, Kim JG, Lee DH, Suh DC. Development of New Endovascular Devices for Aneurysm Treatment. J Stroke 2018; 20:46-56. [PMID: 29402066 PMCID: PMC5836571 DOI: 10.5853/jos.2017.02229] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/28/2017] [Accepted: 01/01/2018] [Indexed: 12/28/2022] Open
Abstract
Since the first use of the Guglielmi detachable coil system for cerebral aneurysm embolization in 1990, various endovascular methods have been developed to treat large numbers of aneurysms. The main strategic and technical modifications introduced to date include balloon-assisted coil embolization, stent-assisted coil embolization, flow diverters, and flow disrupters. The development and introduction of such devices have been so persistent and rapid that new devices are being approved worldwide even before the earlier ones become available in some countries. However, even if some patient populations may possibly benefit from earlier introduction of new devices, the approval authorities should balance the available evidence of the safety and effectiveness of novel devices. This review aims to provide an overview of the recent innovations in endovascular treatment of cerebral aneurysms and a brief review of market access policies and regulations for importing high-risk medical devices, such as those used for endovascular aneurysm management, which correspond to class III devices, as defined by the U.S. Food and Drug Administration. We focus on the current situation in Korea and compare it with that in other Asian countries, such as China and Japan.
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Affiliation(s)
- Zhen Yu Jia
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hai Bin Shi
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shigeru Miyachi
- Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Sun Moon Hwang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Jon Sheen
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yun Sun Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong Goo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok Hee Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Chul Suh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Pierot L, Spelle L, Berge J, Januel AC, Herbreteau D, Aggour M, Piotin M, Biondi A, Barreau X, Mounayer C, Papagiannaki C, Lejeune JP, Gauvrit JY, Costalat V. Feasibility, complications, morbidity, and mortality results at 6 months for aneurysm treatment with the Flow Re-Direction Endoluminal Device: report of SAFE study. J Neurointerv Surg 2018; 10:765-770. [PMID: 29352057 PMCID: PMC6204937 DOI: 10.1136/neurintsurg-2017-013559] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 11/16/2022]
Abstract
Background and purpose Flow diverters are increasingly used for the treatment of intracranial aneurysms. Evaluation of the first devices available for clinical use showed high efficacy of this treatment although safety results were worse compared with coiling or balloon-assisted coiling. The Safety and Efficacy Analysis of FRED Embolic Device in Aneurysm Treatment (SAFE) trial is a single-arm, multicenter, prospective study conducted to precisely analyze the safety and efficacy of the FRED and FRED Jr devices. Methods Unruptured and recanalized aneurysms located in the anterior circulation treated with FRED and FRED Jr were prospectively included. Adverse events were independently evaluated by a Clinical Event Committee with a vascular neurosurgeon and an interventional neuroradiologist. Primary safety outcome measures were morbidity and mortality rates at 6 months after treatment. Results A total of 103 patients/aneurysms were included in 13 interventional neuroradiology (INR) centers. Aneurysm locations were supraclinoid internal carotid artery (ICA) in 71 (68.9%), cavernous ICA in 15 (14.6%), anterior cerebral artery or anterior communicating artery in nine (8.7%), and middle cerebral artery in eight (7.8%). Aneurysms were small (<10 mm) in 71 patients (68.9%). Treatment was successfully performed in 98/103 patients (95.1%). Thromboembolic (TE) complications occurred in 5/103 patients (4.9%), intraoperative rupture in 2/103 patients (1.9%), delayed aneurysm rupture in 1/103 patient (1.0%), and delayed hematoma occurred in 1/103 patient (1.0%). Six-months' mortality and morbidity rates were 1/102 (1.0%) and 2/102 (2.0%), respectively. Conclusions Aneurysm treatment with the FRED device is safe with low mortality (1.0%) and morbidity (2.0%). Clinical trial registration NCT02921698.
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Affiliation(s)
- Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Laurent Spelle
- Department of Neuroradiology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicetre, France
| | - Jérôme Berge
- Department of Neuroradiology, CHU Pellegrin, Bordeaux, France
| | | | - Denis Herbreteau
- Department of Neuroradiology, Hôpital Bretonneau, Université François Rabelais, Tours, France
| | - Mohamed Aggour
- Department of Neuroradiology, CHU Saint-Etienne, Saint-Etienne, France
| | - Michel Piotin
- Department of Neuroradiology, Fondation Ophtalmologique A. de Rothschild, Paris, France
| | - Alessandra Biondi
- Department of Neuroradiology, Hôpital Jean-Minjoz, CHRU de Besançon, Besançon, France
| | - Xavier Barreau
- Department of Neuroradiology, CHU Pellegrin, Bordeaux, France
| | | | | | | | | | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Université de Montpellier, Montpellier, France
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Management of Blood Blister–Like Aneurysms of the Internal Carotid Artery: Lessons Learned from Direct Clipping in 22 Cases. World Neurosurg 2017; 108:618-626. [DOI: 10.1016/j.wneu.2017.09.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 11/23/2022]
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Voigt P, Schob S, Jantschke R, Nestler U, Krause M, Weise D, Lobsien D, Hoffmann KT, Quäschling U. Stent-Assisted Coiling of Ruptured and Incidental Aneurysms of the Intracranial Circulation Using Moderately Flow-Redirecting, Braided Leo Stents-Initial Experience in 39 Patients. Front Neurol 2017; 8:602. [PMID: 29184531 PMCID: PMC5694479 DOI: 10.3389/fneur.2017.00602] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 10/30/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Flow diversion (FD)-a young technique using stents with highly increased surface coverage-was introduced to treat complex aneurysms without intra-aneurysmal material placement and has amended the spectrum of endovascular techniques such as stent-assisted coil occlusion considerably. However, ischemic complications, a common side effect in FD, occur more frequently compared with the conventional endovascular approaches and certainly limit the indication of this technique. Our study aimed to investigate the feasibility and efficacy of stent-assisted coiling using low profile self-expandable stents, which exhibit only moderate flow-redirecting properties and therefore represent a combination of hemodynamic endovascular and occlusive endosaccular therapy. MATERIALS AND METHODS 39 Patients were included in our retrospective study. Occlusion rates were assessed 6 months after the procedure in a total of 27 cases using the Raymond scale. RESULTS Complete occlusion (Raymond I) was achieved in 24/27 aneurysms. Small neck remnants (Raymond II) were evident in 3/27 aneurysms. There were no cases with sac remnant or complete persistence of aneurysmal filling (Raymond III and IV). CONCLUSION Our study demonstrates interventional treatment of intracranial aneurysms using flow-redirecting stent-assisted coiling to be technically feasible and highly effective in aneurysmal occlusion. We believe that this approach is outstanding in the prevention of long-term aneurysmal reperfusion and exhibits a more acceptable risk profile than highly efficient FD techniques.
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Affiliation(s)
- Peter Voigt
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Stefan Schob
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Robert Jantschke
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Ulf Nestler
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - Matthias Krause
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - David Weise
- Department of Neurology, Leipzig University Hospital, Leipzig, Germany
| | - Donald Lobsien
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | | | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
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40
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Möhlenbruch MA, Kizilkilic O, Killer-Oberpfalzer M, Baltacioglu F, Islak C, Bendszus M, Cekirge S, Saatci I, Kocer N. Multicenter Experience with FRED Jr Flow Re-Direction Endoluminal Device for Intracranial Aneurysms in Small Arteries. AJNR Am J Neuroradiol 2017; 38:1959-1965. [PMID: 28798217 DOI: 10.3174/ajnr.a5332] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters are emerging as an endovascular treatment alternative for proximally located intracranial aneurysms. However, treatment of aneurysms at and beyond the circle of Willis is not well-established. We assessed the clinical safety and efficacy of the Flow Re-Direction Endoluminal Device Jr (FRED Jr) dedicated to small-vessel diameters between 2.0 and 3.0 mm. MATERIALS AND METHODS This was a multicenter observational clinical study of 42 patients with 47 aneurysms treated by a flow-direction technique with the FRED Jr. The primary end point for clinical safety was the absence of death, major or minor stroke, and TIA. The primary end point for treatment efficacy was complete and near-complete occlusion according to the O'Kelly-Marotta grading scale at follow-up after 1, 6, and 12 months. RESULTS The FRED Jr deployment was technically successful in all cases. In 39/42 (93%) patients, the primary safety end point was reached; in the 3 remaining patients, 1 disabling ischemic stroke, 1 minor stroke with complete recovery at discharge, and 1 TIA were observed. Two asymptomatic, completely reversible side-branch occlusions occurred. Angiographic (DSA or flat panel CT) and clinical follow-up were available after 1 month in 41/47 (87%), 6 months in 27/47 (57%), and 12 months in 11/47 (23%) aneurysms. The primary efficacy end point was reached at 1 month in 27/41 (66%), at 6 months in 21/27 (78%), and at 12 months in 11/11 (100%) aneurysms. CONCLUSIONS Deployment of the FRED Jr is safe and effective in the treatment of intracranial aneurysms located in small vessels.
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Affiliation(s)
- M A Möhlenbruch
- From the Department of Neuroradiology (M.A.M., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - O Kizilkilic
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - M Killer-Oberpfalzer
- Department of Neurology/Research Institute of Neurointervention (M.K.-O.), Paracelsus Medical University, Salzburg, Austria
| | - F Baltacioglu
- Department of Radiology (F.B.), Marmara University School of Medicine, Istanbul, Turkey
| | - C Islak
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - M Bendszus
- From the Department of Neuroradiology (M.A.M., M.B.), Heidelberg University Hospital, Heidelberg, Germany
| | - S Cekirge
- Department of Radiology (S.C.), Koru and Bayindir Hospital, Ankara, Turkey.,Department of Radiology (S.C., I.S.), Yüksek Ihtisas University, Koru Hospital, Ankara, Turkey
| | - I Saatci
- Department of Radiology (S.C., I.S.), Yüksek Ihtisas University, Koru Hospital, Ankara, Turkey
| | - N Kocer
- Department of Neuroradiology (O.K., C.I., N.K.), Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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