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Ma L, Hoz SS, Al-Bayati AR, Nogueira RG, Lang MJ, Gross BA. Flow Diverters with Surface Modification in Patients with Intracranial Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:320-326.e17. [PMID: 38160909 DOI: 10.1016/j.wneu.2023.12.132] [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: 11/17/2023] [Revised: 12/24/2023] [Accepted: 12/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Flow diverters with surface modification (FDSM) are increasingly being used in the treatment of intracranial aneurysms (ANs). We aimed to evaluate the effectiveness and safety across different devices and antiplatelet therapies using a systematic review and meta-analysis. METHODS A systematic review was performed to identify original studies of ≥10 patients with intracranial ANs treated with FDSM from database inception through August 2023. Primary effectiveness outcome was the rate of complete AN occlusion at follow-up ≥6 months. Safety outcomes included ischemic stroke, hemorrhage, and in-stent thrombosis, and were stratified by FDSM devices and antiplatelet therapies. Certainty of evidence was evaluated following the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS Twenty-seven studies were included, yielding 2161 patients with 2373 ANs. A total of 70.5% of the ANs were located on the internal carotid artery (ICA). Total 10.3% were acutely ruptured. The complete AN occlusion rate was 72.3% at follow-up ≥6 months. Sensitivity analysis in the ICA AN cohort yielded comparable occlusion rates between Pipeline Flex Embolization Device-Shield (80.4%) and Phenox-hydrophilic polymer-coated (77.5%, P = 0.54), but a lower 66.2% rate for Flow Redirection Endoluminal Device-X (P = 0.02). The rate of in-stent thrombosis and stenosis tended to be higher in Phenox-hydrophilic polymer-coated (3.4%) and Flow Redirection Endoluminal Device-X (4.3%) versus Pipeline Flex Embolization Device-Shield (0.8%, P = 0.05). CONCLUSIONS FDSM were safe with satisfactory effectiveness for intracranial ANs. More specific investigations are warranted to explore their performance in ANs beyond the ICA and optimal antiplatelet therapy.
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Affiliation(s)
- Li Ma
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samer S Hoz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Ernst M, Jamous A, Bartl M, Riedel CH, Holtmannspötter M, Voit-Höhne H, Grieb D, Schlunz-Hendann M, Fiebig T, Fiorella D, Klisch J, Lobsien D. Multicenter study of the safety and effectiveness of intracranial aneurysm treatment with the p64MW-HPC flow modulation device. Interv Neuroradiol 2023:15910199231220964. [PMID: 38105527 DOI: 10.1177/15910199231220964] [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: 12/19/2023] Open
Abstract
BACKGROUND AND PURPOSE The new p64 flow diverter with hydrophilic polymer coating (HPC) was designed to reduce thrombogenicity. To date, it is unclear how antithrombogenic surface modifications affect neoendothelialization and thrombus formation in patients with unruptured intracranial aneurysms. The purpose of this study was to evaluate the safety and effectiveness of the p64MW-HPC in the treatment of unruptured aneurysms of small to giant size and of both the anterior and posterior circulation. MATERIALS AND METHODS Between March 2020 and October 2022 all patients with unruptured intracranial aneurysms treated with the p64MW-HPC were included at five neurovascular centers. Demographic data, aneurysm characteristics, antiplatelet therapy, procedural complications, and clinical and angiographic outcomes were recorded. RESULTS A total of 100 patients with 100 unruptured intracranial aneurysms met the inclusion criteria. Eighty-three aneurysms were classified as saccular, 12 aneurysms were fusiform, 4 aneurysms dissecting, and 1 aneurysm was blister-like. Dual antiplatelet therapy with Clopidogrel and Aspirin was given in 68 cases, and with Ticagrelor and Aspirin in 24 cases. Technical issues with deployment were encountered in 14 cases (torsion (n = 3), foreshortening (n = 8), and incomplete opening (n = 3)). Ischemic stroke occurred in a total of seven cases. In one patient a wire perforation and subsequent severe ICH occurred. Complete aneurysm occlusion at angiographic follow-up (mean time = 7 months) was seen in 73% and adequate occlusion in 93%. CONCLUSION This study is the largest multicenter study to date documenting the safety and effectiveness of the new antithrombogenic p64MW-HPC in the treatment of unruptured intracranial aneurysms of the anterior and posterior circulation.
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Affiliation(s)
- M Ernst
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Jamous
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - M Bartl
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - C H Riedel
- Institute of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - M Holtmannspötter
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg, Germany
| | - H Voit-Höhne
- Institute of Radiology und Neuroradiology, Paracelsus Medical University, Nuremberg, Germany
| | - D Grieb
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Duisburg, Germany
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | - M Schlunz-Hendann
- Department of Radiology and Neuroradiology, Klinikum Duisburg-Sana Kliniken, Duisburg, Germany
| | - T Fiebig
- Department of Radiology, Helios Klinikum Meiningen, Meiningen, Germany
| | - D Fiorella
- Cerebovascular Center, Stony Brook University, Stony Brook, NY, USA
| | - J Klisch
- Institute of Diagnostic and Interventional Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - D Lobsien
- Institute of Diagnostic and Interventional Neuroradiology, Helios Klinikum Erfurt, Erfurt, Germany
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Bilgin C, Senol YC, Kobeissi H, Orscelik A, Ghozy S, Oliver AA, Kadirvel R, Brinjikji W, Kallmes DF. Phenox HPC and Phenox flow modulation devices for the endovascular treatment of intracranial aneurysms: a systematic review and meta-analysis. J Neurointerv Surg 2023:jnis-2023-020514. [PMID: 37536930 DOI: 10.1136/jnis-2023-020514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/12/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Surface-modified flow diverters are increasingly used in clinical settings. However, their safety profiles and additional benefits over non-coated devices still need to be explored. In this meta-analysis, we aimed to investigate and compare the clinical outcomes of the uncoated Phenox and coated Phenox HPC flow diverters. METHODS A systematic literature review was performed using PubMed, Scopus, Embase, and Web of Science databases. Collected data were pooled and corresponding 95% confidence intervals (CI) were calculated. Outcomes of interest included aneurysm occlusion (>6 months) and complication rates. Additionally, the safety outcomes of prophylactic single (SAPT) and dual antiplatelet treatment (DAPT) approaches were compared for patients treated with coated Phenox HPC flow diverters. RESULTS We included 17 studies with 1238 patients. The overall complete occlusion rates were 80% (95% CI 74.01% to 86.56%) for Phenox HPC and 71.3% (95% CI 59.71% to 85.20%) for non-coated Phenox flow diverters (p=0.24). Ischemic complication rates were 7.3% (95% CI 4.6% to 11.39%) with the Phenox HPC and 5.3% (95% CI 4.07% to 6.91%) with the Phenox (p=0.24). For patients treated with Phenox HPC, the SAPT (5.5%; 95% CI 2.83% to 10.85%) and DAPT (7.1%; 95% CI 1.23% to 41.45%) approaches resulted in comparable ischemic complication rates (p=0.79). The DAPT group (4.8%; 95% CI 1.46% to 16.24%) had higher hemorrhagic complication rates than the SAPT group (1.7%; 95% CI 0.52% to 6.09%), but the difference was not statistically significant for patients treated with Phenox HPC (p=0.25). CONCLUSIONS Our findings indicate that Phenox HPC is equally as safe and effective as non-coated Phenox devices. Additionally, our results suggest that prasugrel monotherapy might effectively prevent ischemic complications in patients treated with Phenox HPC flow diverters.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Atakan Orscelik
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Li L, Xu GQ, Gao HL, Gao BL, Zhang K, Wang ZL, Li TX. Endovascular treatment of intracranial vertebral artery unruptured dissecting aneurysms: Comparison of flow diversion and stent-assisted coiling or stenting alone. Front Neurol 2022; 13:919866. [PMID: 36081876 PMCID: PMC9445568 DOI: 10.3389/fneur.2022.919866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose To investigate the effect and safety of flow diverters in the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery in comparison with stent-assisted coiling or stenting alone. Materials and methods Patients with unruptured dissecting intracranial aneurysms of the vertebral artery treated with the flow diverter, stent-assisted coiling, or stenting alone were retrospectively enrolled. The clinical data were analyzed and compared. Results Twenty-five patients were enrolled in the flow diversion group and 42 patients in the stenting group. Twenty-six flow diverters were deployed in the flow diversion group. Immediate angiography revealed contrast agent retention within the aneurysm cavity in all patients. In the stenting group, 48 stents were deployed, and immediate angiographic outcome showed O'Kelly-Marotta (OKM) grade D in 18 (42.9%) aneurysms, grade C in 16 (38.1%), and grade B in 8 (19.0%). Periprocedural ischemic complications of thrombosis occurred in two (4.8%) patients and were treated with thrombolysis. In the flow diversion group, 19 (76%) patients underwent angiographic follow-up 3–46 (median 24) months after the procedure, with the OKM grade D in 11 (57.9%) patients, C in two (10.5%), and B in six (31.6%). The aneurysm recurrence rate was zero, and all diverters remained patent. Asymptomatic instent stenosis occurred in two (10.5%) patients. In seven of the ten patients with mild or moderate parent artery stenosis before the procedure who experienced angiographic follow-up, the stenosis was improved in five (71.4%) patients. In the stenting group, angiographic follow-up was carried out in 33 (78.6%) patients 6–58 months (median 34) after the procedure, with OKM grade D in 22 (66.7%) patients, grade C in five (15.2%), grade B in three (9.1%), and aneurysm recurrence (grade B, with increased contrast agent into the aneurysm cavity) in three (9.1%). Five (16.7%) patients experienced asymptomatic instent stenosis, and six of the 12 patients (50%) with parent artery stenosis were improved. Conclusion Flow diverters with or without selective adjunctive coiling for the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery may be safe and effective with good occlusion effects not inferior to those of stent-assisted coiling and stenting alone even though the long-term effect still warrants confirmation.
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Schob S, Brill R, Siebert E, Sponza M, Schüngel MS, Wohlgemuth WA, Götz N, Mucha D, Gopinathan A, Scheer M, Prell J, Bohner G, Gavrilovic V, Skalej M. Indirect Flow Diversion for Off-Centered Bifurcation Aneurysms and Distant Small-Vessel Aneurysms, a Retrospective Proof of Concept Study From Five Neurovascular Centers. Front Neurol 2022; 12:801470. [PMID: 35069430 PMCID: PMC8770821 DOI: 10.3389/fneur.2021.801470] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Treatment of cerebral aneurysms using hemodynamic implants such as endosaccular flow disruptors and endoluminal flow diverters has gained significant momentum during recent years. The intended target zone of those devices is the immediate interface between aneurysm and parent vessel. The therapeutic success is based on the reduction of aneurysmal perfusion and the subsequent formation of a neointima along the surface of the implant. However, a subset of aneurysms-off-centered bifurcation aneurysms involving the origin of efferent branches and aneurysms arising from peripheral segments of small cerebral vessels-oftentimes cannot be treated via coiling or implanting a hemodynamic implant at the neck level for technical reasons. In those cases, indirect flow diversion-a flow diverter deployed in the main artery proximal to the parent vessel of the aneurysm-can be a viable treatment strategy, but clinical evidence is lacking in this regard. Materials and Methods: Five neurovascular centers contributed to this retrospective analysis of patients who were treated with indirect flow diversion. Clinical data, aneurysm characteristics, anti-platelet medication, and follow-up results, including procedural and post-procedural complications, were recorded. Results: Seventeen patients (mean age: 60.5 years, range: 35-77 years) with 17 target aneurysms (vertebrobasilar: n = 9) were treated with indirect flow diversion. The average distance between the flow-diverting stent and the aneurysm was 1.65 mm (range: 0.4-2.4 mm). In 15/17 patients (88.2%), perfusion of the aneurysm was reduced immediately after implantation. Follow-ups were available for 12 cases. Delayed opacification (OKM A3: 11.8%), reduction in size (OKM B1-3: 29.4%) and occlusion (D1: 47.1%) were observable at the latest investigation. Clinically relevant procedural complications and adverse events in the early phase and in the late subacute phase were not observed in any case. Conclusion: Our preliminary data suggest that indirect flow diversion is a safe, feasible, and effective approach to off-centered bifurcation aneurysms and distant small-vessel aneurysms. However, validation with larger studies, including long-term outcomes and optimized imaging, is warranted.
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Affiliation(s)
- Stefan Schob
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Richard Brill
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Eberhard Siebert
- Institut für Neuroradiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Massimo Sponza
- Angiography and Interventional Radiology Unit, Department of Radiology, Azienda Sanitari Universitaria Friuli Centrale, Udine, Italy
| | - Marie-Sophie Schüngel
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Walter Alexander Wohlgemuth
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Nico Götz
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Dirk Mucha
- Institut für Radiologie und Neuroradiologie, Heinrich-Braun-Klinikum, Zwickau, Germany
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Maximilian Scheer
- Klinik & Poliklinik für Neurochirurgie, Universitätsklinikum Halle, Halle (Saale), Germany
| | - Julian Prell
- Klinik & Poliklinik für Neurochirurgie, Universitätsklinikum Halle, Halle (Saale), Germany
| | - Georg Bohner
- Institut für Neuroradiologie, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vladimir Gavrilovic
- Angiography and Interventional Radiology Unit, Department of Radiology, Azienda Sanitari Universitaria Friuli Centrale, Udine, Italy
| | - Martin Skalej
- Abteilung für Neuroradiologie, Klinik & Poliklinik für Radiologie, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
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