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Hohenstatt S, Saatci I, Jesser J, Çekirge HS, Koçer N, Islak C, Lücking H, DuPlessis J, Rautio R, Bendszus M, Vollherbst DF, Möhlenbruch MA. Prasugrel Single Antiplatelet Therapy versus Aspirin and Clopidogrel Dual Antiplatelet Therapy for Flow Diverter Treatment for Cerebral Aneurysms: A Retrospective Multicenter Study. AJNR Am J Neuroradiol 2024; 45:592-598. [PMID: 38453414 DOI: 10.3174/ajnr.a8163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/07/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE The optimal antiplatelet regimen after flow diverter treatment of cerebral aneurysms is still a matter of debate. A single antiplatelet therapy might be advantageous in determined clinical scenarios. This study evaluated the efficacy and safety of prasugrel single antiplatelet therapy versus aspirin and clopidogrel dual antiplatelet therapy. MATERIALS AND METHODS We performed a post hoc analysis of 4 retrospective multicenter studies including ruptured and unruptured aneurysms treated with flow diversion using either prasugrel single antiplatelet therapy or dual antiplatelet therapy. Primary end points were the occurrence of any kind of procedure- or device-related thromboembolic complications and complete aneurysm occlusion at the latest radiologic follow-up (mean, 18 months). Dichotomized comparisons of outcomes were performed between single antiplatelet therapy and dual antiplatelet therapy. Additionally, the influence of various patient- and aneurysm-related variables on the occurrence of thromboembolic complications was investigated using multivariable backward logistic regression. RESULTS A total of 222 patients with 251 aneurysms were included, 90 (40.5%) in the single antiplatelet therapy and 132 (59.5%) in the dual antiplatelet therapy group. The primary outcome-procedure- or device-related thromboembolic complications-occurred in 6 patients (6.6%) of the single antiplatelet therapy and in 12 patients (9.0%) of the dual antiplatelet therapy group (P = .62; OR, 0.712; 95% CI, 0.260-1.930). The primary treatment efficacy end point was reached in 82 patients (80.4%) of the single antiplatelet therapy and in 115 patients (78.2%) of the dual antiplatelet therapy group (P = .752; OR, 1.141; 95% CI, 0.599-2.101). Logistic regression showed that non-surface-modified flow diverters (P = .014) and fusiform aneurysm morphology (P = .004) significantly increased the probability of thromboembolic complications. CONCLUSIONS Prasugrel single antiplatelet therapy after flow diverter treatment may be as safe and effective as dual antiplatelet therapy and could, therefore, be a valid alternative in selected patients. Further prospective comparative studies are required to validate our findings.
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Affiliation(s)
- Sophia Hohenstatt
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Işıl Saatci
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Jessica Jesser
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - H Saruhan Çekirge
- Interventional Neuroradiology Section (I.S., H.S.C.), Koru and Bayindir Private Hospitals, Ankara, Turkey
| | - Naci Koçer
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Civan Islak
- Department of Neuroradiology (N.K., CI.), Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Hannes Lücking
- Department of Neuroradiology (H.L.), University of Erlangen-Nuremberg, Erlangen, Germany
| | - Johannes DuPlessis
- Department of Clinical Neurosciences (J.D.), Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Riitta Rautio
- Department of Interventional Radiology (R.R.), Turku University Hospital, Turku, Finland
| | - Martin Bendszus
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Dominik F Vollherbst
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- From the Department of Neuroradiology (S.H., J.J., M.B., D.F.V., M.A.M.), Heidelberg University Hospital, Heidelberg, Germany
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Hohenstatt S, Ulfert C, Herweh C, Hilgenfeld T, Schmitt N, Schönenberger S, Chen M, Bendszus M, Möhlenbruch MA, Vollherbst DF. Long-term Follow-up After Aneurysm Treatment with the Flow Redirection Endoluminal Device (FRED) Flow Diverter. Clin Neuroradiol 2024; 34:181-188. [PMID: 37833546 PMCID: PMC10881684 DOI: 10.1007/s00062-023-01346-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/22/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION This study focuses on long-term outcomes after aneurysm treatment with either the Flow Re-Direction Endoluminal Device (FRED) or the FRED Jr. to investigate the durability of treatment effect and long-term complications. METHODS This study is based on a retrospective analysis of a prospectively maintained patient data base. Patients treated with either FRED or FRED Jr. between 2013 and 2017 at our institution, and thus a possibility for ≥ 5 years of follow-up, were included. Aneurysm occlusion rates, recurrence rates, modified Rankin scale score shifts to baseline, and delayed complications were assessed. RESULTS In this study 68 patients with 84 aneurysms had long-term follow-up with a mean duration of 57.3 months and 44 patients harboring 52 aneurysms had a follow-up ≥ 5 years with a mean follow-up period of 69.2 months. Complete occlusion was reached in 77.4% at 2 years and increased to 84.9% when the latest available imaging result was considered. Younger age and the absence of branch involvement were predictors for aneurysm occlusion in linear regression analysis. After the 2‑year threshold, there were 3 reported symptomatic non-serious adverse events. Of these, one patient had a minor stroke, one a transitory ischemic attack and one had persistent mass effect symptoms due to a giant aneurysm, none of these resulted in subsequent neurological disability. CONCLUSION This long-term follow-up study demonstrates that the FRED and FRED Jr. are safe and effective for the treatment of cerebral aneurysms in the long term, with high rates of complete occlusion and low rates of delayed adverse events.
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Affiliation(s)
- Sophia Hohenstatt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Tim Hilgenfeld
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | | | - Min Chen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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Hanel RA, Cortez GM, Benalia VHC, Sheffels E, Sutphin DJ, Pederson JM, Pereira VM. Patient outcomes after treatment of brain aneurysm in small diameter vessels with the silk vista baby flow diverter: A systematic review. Interv Neuroradiol 2024; 30:5-13. [PMID: 35392703 PMCID: PMC10956459 DOI: 10.1177/15910199221091645] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Silk Vista Baby (SVB, BALT) is a first-in-class flow-diverter device delivered using a 0.017" microcatheter, designed for the treatment of intracranial aneurysms, including those in small diameter vessels. This study reports a systematic literature review (SLR) to evaluate the safety and efficacy of using SVB to treat intracranial aneurysms in vessels less than 3.5 mm in diameter. METHODS We performed a PRISMA-compliant SLR to evaluate the outcomes of SVB in the treatment of aneurysms in small intracranial vessels. Primary outcomes were occlusion status and major stroke, and secondary outcomes included all-cause mortality, procedure-related neurologic death, and post-operative aneurysm rupture. Data were expressed as descriptive statistics only. RESULTS A total of four studies, including 163 patients with 173 intracranial aneurysms, were included. The most common aneurysm locations were the anterior cerebral artery (24.9% [43/173]), the middle cerebral artery (24.3% [42/173]), and the anterior communicating artery (23.1% [40/173]). Parent artery diameter ranged from 0.9 mm to 3.6 mm, and 29% were acutely or previously ruptured aneurysms. Overall, complete or near-complete occlusion was 72.1% on early-term follow-up. Mortality rate among the studies was 2.5%, with 3 instances adjudicated as neurologic deaths (1.8%). Major stroke was noted in 1.2% of cases, and branch occlusion or stent thrombus formation in 5.5%. CONCLUSION Our review suggests that SVB is a safe and effective treatment for intracranial aneurysms in small vessels. Further prospective and comparative studies with patient outcome data specific to aneurysm location are needed to confirm the safety and efficacy of SVB.
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Affiliation(s)
- Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | - Victor H C Benalia
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, Jacksonville University, Jacksonville, FL, USA
| | | | | | | | - Vitor M Pereira
- Departments of Surgery and Medical Imaging, Division of Neurosurgery, St Michaels Hospital, University of Toronto, Ontario, Canada
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Solis F, Plasencia A, Wahlster S, Walker M, Levitt MR, Ecos R. Flow Diversion for the Treatment of Intracranial Aneurysms in a Peruvian Cohort: Experiences from a Limited-Resource Setting and Barriers to Implementation. World Neurosurg 2023; 180:79-85. [PMID: 37742718 DOI: 10.1016/j.wneu.2023.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Stenting with flow diverter devices (FDDs) has increasingly emerged as a treatment for intracranial aneurysms. The use of FDDs in the developing world has not been described. METHODS A retrospective review was performed of a cohort of patients who underwent flow diversion at 4 tertiary-care centers in Lima, Peru between January 2017 and June 2021. Demographics, clinical features, and aneurysm morphology were evaluated. Clinical outcomes were observed 3 months after discharge and occlusion rates were assessed 12 months after treatment. RESULTS Sixty-nine patients (mean age, 46 ±14.5 years; 17% female) were treated with FDDs; 4% (n = 3) of the treated aneurysms were ruptured. Most aneurysms were saccular (n = 65; 94%), <10 mm in maximum size (n = 60; 87%), and located in the anterior circulation (n = 67; 97%). Minor complications, such as groin hematoma, occurred in 7 cases. No serious complications or deaths occurred. Patients' functional status was excellent (modified Rankin Scale score 0-1) in 99% (n = 66) at discharge and 100% (n = 67) at 3 months. Although some patients were lost to follow-up, complete occlusion was seen in 76% (n = 31) of 41 treated patients at 12 months. CONCLUSIONS We report the largest multicenter experience of FDDs for cerebral aneurysm treatment in Peru, with reasonable outcomes that are comparable to other settings despite various challenges, suboptimal circumstances, and lack of resources.
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Affiliation(s)
- Frank Solis
- Neurological Surgery and Endovascular Neurosurgery, Clínica Internacional San Borja, Lima, Peru; Endovascular Neurosurgery Unit, Instituto Nacional de Ciencias Neurológicas, Lima, Peru.
| | - Andres Plasencia
- Neurological Surgery and Endovascular Neurosurgery, Clínica Internacional San Borja, Lima, Peru
| | - Sarah Wahlster
- Neurology, Neurosurgery, and Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Melanie Walker
- Neurological Surgery and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Rosa Ecos
- Vascular Neurology, Instituto Nacional de Ciencias Neurológicas, Lima, Peru; Medicine Faculty, Universidad Nacional Federico Villarreal, Lima, Peru
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Flow Diverting Stents in Cerebral Small Caliber Vessels (< 2 mm) for Aneurysm Treatment : A Three Center Retrospective Study. Clin Neuroradiol 2023; 33:99-105. [PMID: 35768696 DOI: 10.1007/s00062-022-01187-6] [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: 04/12/2022] [Accepted: 06/08/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The off-label use of flow diverting stents (FDS) for treating cerebral aneurysms in small distal vessels is increasing in clinical practice with encouraging results; however, data directly addressing the parent vessel size are still scarce. Our aim was to evaluate the safety and efficacy of FDS placement in anterior and posterior circulation aneurysms with parent arteries ≤ 2 mm in a real-world representative setting. METHODS We retrospectively reviewed patients treated with FDS at the three participating university hospitals between 2009 and 2021. The inclusion criteria were the placement of at least one FDS in a parent vessel with a maximum diameter of 2 mm or less. The primary clinical safety endpoint was the absence of death, major or minor symptomatic stroke, transient ischemic attack and procedure-related intracranial hemorrhage. Clinical outcome was assessed using the modified Rankin Scale (mRS) score at the follow-up visit at 1 year. The primary efficacy endpoint was defined as complete and near-complete occlusion at the 1‑year follow-up. RESULTS We identified 55 patients harboring 56 aneurysms. The primary clinical safety endpoint was obtained in 93% of cases. The hemorrhagic and thromboembolic complication rates were 4% and 9%, respectively. No patient died or had a relevant discrepancy (> 1 point) at the pre-mRS and post-mRS. The primary efficacy endpoint was reached in 80% of cases. CONCLUSION The use of FDS in vessels < 2 mm is technically feasible with good aneurysm occlusion rates and an acceptable safety profile. Nevertheless, it is essential to be aware of the of the main complications associated when operating in small diameter vessels.
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Endovascular treatment of challenging aneurysms with FRED Jr flow diverter stents: a single-center experience. Jpn J Radiol 2023; 41:322-334. [PMID: 36315360 PMCID: PMC9619020 DOI: 10.1007/s11604-022-01354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 10/20/2022] [Indexed: 01/24/2023]
Abstract
PURPOSE To analyze clinical safety and efficacy of flow re-direction endoluminal device (FRED) Jr flow diverter for treatment of unruptured, ruptured, or recanalyzed aneurysms. MATERIALS AND METHODS Between October 2019 and February 2022, 25 patients with 31 aneurysms treated with FRED Jr were included in the study. Clinical and radiological records, procedural details, and follow-up outcomes were retrospectively evaluated. Eighteen (72%) patients were female. Median age was 48.8 (age range 9-85). Mean follow-up was 21 months (6-28 months). Location of the aneurysms were as follows; 13 in middle cerebral artery (MCA), 7 in anterior cerebral artery (ACA), 4 in posterior cerebral artery (PCA), 3 in true posterior communicating artery (PCom), 2 in anterior communicating artery (ACom), 1 in superior cerebellar artery (SCA), 1 in true ophthalmic artery. Five patients (20%) presented with acute subarachnoid hemorrhage (aSAH). RESULTS In all procedures, FRED Jr was successfully deployed. Three true Pcom aneurysms and a true ophthalmic aneurysm were treated with FRED Jr. Three patients with two adjacent aneurysms were treated with a single FRED Jr. In two (8%) patients in-stent thrombosis occurred intraoperatively, they were treated with iv tirofiban and thrombectomy without any sequelae. Post-discharge 2 weeks later, intraparenchymal hemorrhage occurred in a patient. He was treated with surgical drainage, the clinical course was modified Rankin score (mRS) 2. Digital subtraction angiography (DSA) was performed on 16 (64%) patients with 21 (67%) aneurysms. Near complete-complete occlusion (O'Kelly-Morata grading scale (OKM C-D) was documented in 15/16 (93.7%) patients, 20/21 (95.2%) aneurysms. In nine (36%) patients, no residual filling was observed in the magnetic resonance angiography (MRA). Good clinical outcome (mRS 0-1) was achieved in 24/25 (96%) of patients. CONCLUSION Endovascular treatment of small cerebral aneurysms with FRED Jr is safe and effective even in complex and challenging morphologies allowing high rates of aneurysm occlusion with low periprocedural complications. Our cohort, consisting of a rate 20% acute ruptured aneurysms, is the major additive data to the published literature.
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El Naamani K, Saiegh FA, Chen CJ, Abbas R, Sioutas GS, Amllay A, Shehabeldine M, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Treatment of cerebral aneurysms with the FRED Jr flow-diverting stent: A case series and meta-analysis. Clin Neurol Neurosurg 2022; 223:107483. [DOI: 10.1016/j.clineuro.2022.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/29/2022] [Accepted: 10/18/2022] [Indexed: 11/30/2022]
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