In Reply: Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

2019 ◽  
Vol 17 (2) ◽  
pp. E92-E92
Author(s):  
Fawaz Al-Mufti ◽  
Krishna Amuluru ◽  
Eric Cohen ◽  
Vikas Patel ◽  
Mohammad El-Ghanem ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Cerebral Aneurysms ◽  
Procedural Complications

scholarly journals Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms

2018 ◽  
Vol 15 (6) ◽  
pp. 624-633 ◽  
Author(s):  
Fawaz Al-Mufti ◽  
Krishna Amuluru ◽  
Eric R Cohen ◽  
Vikas Patel ◽  
Mohammad El-Ghanem ◽  
...  
Keyword(s):  
Rescue Therapy ◽  
Significant Risk ◽  
Cerebral Aneurysms ◽  
Flow Diverter ◽  
Side Branch ◽  
Parent Vessel ◽  
Vessel Injury ◽  
Procedural Complications ◽  
Background Material ◽  
Device Deployment

Abstract Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary. Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators “AND” and “OR” for the following terms in different combinations: “aneurysm,” “endovascular,” “flow diverter,” “intracranial,” and “pipeline.” A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusion Periprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.

Stent-assisted coiling of cerebral aneurysms: multi-center analysis of radiographic and clinical outcomes in 659 patients

2019 ◽  
Vol 12 (3) ◽  
pp. 289-297 ◽  
Author(s):  
Maxim Mokin ◽  
Christopher T Primiani ◽  
Zeguang Ren ◽  
Keaton Piper ◽  
David J Fiorella ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Patient Characteristics ◽  
Aneurysm Rupture ◽  
Endovascular Coiling ◽  
Complete Occlusion ◽  
Stent Type ◽  
Low Profile ◽  
Grade Scale ◽  
Procedural Complications ◽  
The Difference

IntroductionThe endovascular stent-assisted coiling approach for the treatment of cerebral aneurysms is evolving rapidly with the availability of new stent devices. It remains unknown how each type of stent affects the safety and efficacy of the stent-coiling procedure.MethodsThis study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS) stents. Patient characteristics, treatment details and angiographic results using the Raymond–Roy grade scale (RRGS), and procedural complications were analyzed in our study.ResultsOur study included 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n=182; EP, n=158; LVIS, n=330) that were retrospectively collected from six academic centers. Patient characteristics included mean age 56.3±12.1 years old, female prevalence 73.9%, and aneurysm rupture on initial presentation of 18.8%. We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64.4%, 210/326; NEU 56.2%, 95/169; EP 47.6%, 68/143; P=0.008. The difference of complete occlusion on 10.5 months (mean) and 8 months (median) angiographic follow-up remained significant: LVIS 84%, 251/299; NEU 78%, 117/150; EP 67%, 83/123; P=0.004. There were 7% (47/670) intra-procedural complications and 11.5% (73/632) post-procedural-related complications in our cohort. Furthermore, procedure-related complications were higher in the braided-stents vs laser-cut, P=0.002.ConclusionsThere was a great variability in techniques and choice of stent type for stent-assisted coiling among the participating centers. The type of stent was associated with immediate and long-term angiographic outcomes. Randomized prospective trials comparing the different types of stents are warranted.

Abstract TMP6: Peri-procedural Complications of Endovascular Treatment for Acute Stroke in SWIFT Trial

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Paul Akins ◽  
Arun P Amar ◽  
Sean Pakbaz ◽  
Jeremy Fields
Keyword(s):  
Endovascular Treatment ◽  
Rescue Therapy ◽  
Detailed Knowledge ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Procedural Complications ◽  
Symptomatic Intracranial Hemorrhage ◽  
Technical Factors ◽  
Vessel Dissection ◽  
Retrieval Device

Background: Management of patients with ischemic stroke after endovascular treatment requires knowledge of peri-procedural complications. The SWIFT trial compared two devices (Merci and SOLITAIRE) in a randomized, prospective study. We reviewed peri-procedural complications of endovascular treatment and related clinical and technical factors. Methods: The SWIFT database was searched for major peri-procedural complications defined as: symptomatic intracranial hemorrhage (sICH) within 36 hours, symptomatic subarachnoid hemorrhage (SAH), air emboli, vessel dissection, major groin complications, and emboli to new vascular territories. Results: Major peri-procedural complications occurred in 18/144 patients (12.5%) at the following rates: sICH (4.9%); SAH (3.5%), air emboli (1.4%), vessel dissection (4.2%), major groin complications (2.8%), and emboli to new vascular territories (0.7%). We did not observe any statistically significant associations of complications with: age (<65 y 13.8% vs. >65 y 11.6%); type of center (academic 9.3% vs non-academic 13.9%); duration of stroke symptoms (<6h 11.1% vs 14.7% >6 h), NIH stroke scale score (NIHSS<20 12% vs. NIHSS >20,13.9%), iv thrombolytics (no iv tPA 10.5% vs iv tPA15.2%), atrial fibrillation (absent 10.1% vs present 14.7%), site of vessel occlusion (ICA 19.2%; MCA 11.5%); rescue therapy administered after endovascular treatment (no rescue 11.9% vs rescue 14.9%); or device (Merci 14.5%; Solitaire 11.2%). Comparing the Merci to the Solitaire retrieval device, we observed the following peri-procedural events: Conclusion: Detailed knowledge of peri-procedural complications is important for managing stroke patients after endovascular treatment. Fewer endovascular complications were observed after with SOLITAIRE device treatment compared to Merci device treatment, particularly symptomatic cerebral hemorrhage. Device registries will be helpful to gain deeper understanding of rare events.

scholarly journals Comaneci-Assisted Coiling as a Treatment Option for Acutely Ruptured Wide Neck Cerebral Aneurysm: Case Series of 118 Patients

Neurosurgery ◽  
2020 ◽  
Author(s):  
Alexander Sirakov ◽  
Krasimir Minkin ◽  
Marin Penkov ◽  
Kristian Ninov ◽  
Vasil Karakostov ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Coil Embolization ◽  
Case Series ◽  
Cerebral Aneurysms ◽  
Morbidity Rate ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Simultaneous Application ◽  
Procedural Complications

Abstract Background Wide-necked cerebral aneurysms in the setting of acute subarachnoid hemorrhage (SAH) remain difficult to treat with endovascular methods despite recent progress in the neuroendovascular field. Objective To evaluate the effectiveness and safety of the Comaneci device (Rapid Medical, Israel) in endovascular coil embolization of acutely ruptured, wide-necked sidewall, or bifurcation cerebral aneurysms. Methods We retrospectively reviewed 45 anterior communicating artery, 24 internal carotid artery, 21 middle cerebral artery bifurcation, 15 anterior cerebral artery, and 13 posterior circulation aneurysms, which were treated using Comaneci-assisted coil embolization from August 2017 to January 2019. We evaluated procedural complications, clinical outcomes, and mid-term angiographic follow-up. Immediate and 90 d-clinical outcome and radiological follow-up were obtained in all patients. Results Comaneci-assisted coil embolization was performed in 118 acutely ruptured aneurysms. The technique was carried out successfully in all cases. Simultaneous application of 2 separated Comaneci devices was performed in 8/118 cases (6.77%). Periprocedural thromboembolic complications related to the device were seen in 7/118 cases (5.93%) and severe vasospasm of the parent artery after manipulation of the Comaneci device occurred in 5/118 cases (4.2%). The procedural-related morbidity rate was 2.54%, and there was no procedural related mortality. Among the available survivors, angiographic follow-ups were obtained at 3 and 6 mo, and complete aneurysmal obliteration was confirmed in 81/112 (72.3%) and 75/112 (66.9%) cases, respectively. Mid-term follow-up reviewed total recanalization rate of 14.28%. Conclusion Comaneci-assisted embolization of wide-necked intracranial aneurysms in patients presenting with acute SAH is associated with high procedural safety and adequate occlusion rates. Furthermore, dual antiplatelet therapy can be safely avoided in this patient group.

Endovascular Treatment of Incidental Cerebral Aneurysms

1999 ◽  
Vol 5 (1_suppl) ◽  
pp. 79-81 ◽  
Author(s):  
Y. Murayama ◽  
F. Viñuela ◽  
G.R. Duckwiler ◽  
Y.P. Gobin ◽  
G. Guglielmi
Keyword(s):  
Average Length ◽  
Medical Center ◽  
Clinical Status ◽  
Cerebral Aneurysms ◽  
Clinical Complications ◽  
Incidental Aneurysms ◽  
Procedural Complications ◽  
Aneurysm Occlusion ◽  
Incomplete Occlusion ◽  
Neurologically Intact

One hundred and fifteen patients with 120 intracranial incidental aneurysms were embodied using the GDC endovascular technique at UCLA Medical Center. Angiographic results showed complete or near complete aneurysm occlusion in 109 aneurysms (91%) and an incomplete occlusion in five aneurysms (4%). An unsuccessful GDC embolization was attempted in six aneurysms (5%). One hundred and nine patients (94.8%) remained neurologically intact or unchanged from initial clinical status. Five patients (43%) deteriorated due to immediate procedural complications. All these complications occurred in the first 50 patients. No clinical complications were observed in the last 65 patients. In Groups 1 and 3, the average length of hospitalization was 3.3 days. The technical evolution of the GDC technology has proved to be safe for the treatment of incidental aneurysms (0% morbidity in the last 65 patients). The topography of the aneurysm/s and the clinical condition of the patient did not influence final anatomical or clinical outcomes. GDC technology also brings a positive economical impact by decreasing hospitalization time and eliminating postembolization ICU care.

scholarly journals Treatment of Recurrent Intracranial Aneurysms After Neck Clipping: Novel Classification Scheme and Management Strategies

2017 ◽  
Vol 13 (6) ◽  
pp. 670-678 ◽  
Author(s):  
Shinya Kobayashi ◽  
Junta Moroi ◽  
Kentaro Hikichi ◽  
Shotaro Yoshioka ◽  
Hiroshi Saito ◽  
...  
Keyword(s):  
Classification Scheme ◽  
Management Strategies ◽  
Cerebral Aneurysms ◽  
The Novel ◽  
Conceptual Clarity ◽  
Procedural Complications ◽  
Complex Surgical Procedures ◽  
Type 3

Abstract BACKGROUND Recurrent aneurysms after initial clipping have been discussed as an important issue in the surgical management of aneurysm. OBJECTIVE To report our experience with recurrent cerebral aneurysms after neck clipping and to discuss classification and recommended management. METHODS Aneurysm treatments from a single institution over a 20-year period were retrospectively reviewed. Twenty-three recurrent aneurysms in 23 patients were managed during the study period. Recurrent aneurysms were classified using the concepts of closure line and closure plane, as follows. Type 1: neck situated in an almost different site from the previous clip. Type 2: existing closure plane and reconstructive closure plane are almost the same. Type 3: existing closure plane and reconstructive closure plane cross (type 3a); in rare cases, the existing closure line is sufficiently distant from the neck (type 3b). Type 4: no reconstructive closure line is identifiable. RESULTS Nine patients presented with subarachnoid hemorrhage at recurrence. The mean interval to recurrence was 15.0 years. Management comprised clipping with elective subsequent old-clip removal (n = 7), clipping with preceding old-clip removal (n = 2), bypass occlusion (n = 1), coating (n = 1), combined surgery (n = 1), endovascular surgery (n = 4), and observation (n = 3). Therapeutic intervention was not indicated in 4 patients. Types 3a and 4 required more complex surgical procedures or coil embolization. Procedural complications were observed in 2 patients. CONCLUSION A small but definite propensity toward recurrence after neck clipping exists, and most recurrent aneurysms require some form of retreatment. The novel classification scheme may provide conceptual clarity and therapeutic guidance for decision making.

Analysis of endovascular treatment of ruptured microaneurysms compared with ruptured larger aneurysms

2015 ◽  
Vol 8 (6) ◽  
pp. 586-590
Author(s):  
Eduardo Murias Quintana ◽  
Pedro Vega ◽  
Edison Morales ◽  
Alberto Gil ◽  
Hugo Cuellar ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Clinical Outcomes ◽  
Cerebral Aneurysms ◽  
Imaging Studies ◽  
Endovascular Techniques ◽  
Operator Experience ◽  
Time Period ◽  
Procedural Complications ◽  
Patient Prognosis ◽  
Epidemiologic Characteristics

ObjectiveTo retrospectively analyze the complications and outcome of the endovascular treatment of ruptured microaneurysms compared with the treatment of ruptured larger aneurysms.Methods40 ruptured cerebral microaneurysms treated by endovascular techniques were selected retrospectively and compared with 207 larger ruptured cerebral aneurysms treated by endovascular techniques during the same time period. Medical charts and imaging studies were reviewed to analyze baseline clinical and epidemiologic characteristics, procedural complications, and clinical outcomesResultsCerebral microaneurysms had a higher incidence of intraoperative technical ruptures (13.5% vs 2.9%, p<0.005). The number of thromboembolic complications was not increased. Patient prognosis was similar for the two groups (mean modified Rankin Scale score 1.81 vs 2.09, p>0.1).ConclusionsCoiling of cerebral microaneurysms has a reasonable safety profile with good clinical outcomes, similar to coiling of larger aneurysms. In our experience, the systematic use of remodeling balloons, operator experience, and the ability to manage complications are the reasons for the satisfactory results.

Reasons for failed endovascular recanalization attempts in stroke patients

2018 ◽  
Vol 11 (5) ◽  
pp. 439-442 ◽  
Author(s):  
Hannes Leischner ◽  
Fabian Flottmann ◽  
Uta Hanning ◽  
Gabriel Broocks ◽  
Tobias Djamsched Faizy ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Rescue Therapy ◽  
Minor Role ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Recanalization ◽  
Atherosclerotic Stenosis ◽  
Significant Prolongation ◽  
Procedural Complications ◽  
A Minor

PurposeMechanical thrombectomy (MT) is a highly effective therapy in patients with acute ischemic stroke due to large vessel occlusion (LVO). However, complete recanalization of the occluded vessel cannot be achieved in all patients, leading to poor clinical outcome. We analyzed the reasons for failed recanalization to help direct future improvements in therapy.Methods648 consecutive stroke patients with LVO and an MT attempt were retrospectively analyzed for none or minimal recanalization, assessed according to the Thrombolysis in Cerebral Infarction (TICI) score (0/1). Procedural parameters were evaluated in a standardized approach. Among other variables, number of retrieval attempts, devices, duration of the intervention, and rescue methods were analyzed.ResultsTICI 0/1 was observed in 72/648 patients (11%). In these patients, the thrombus could not be reached in 21% (n=15/72), was reached but not passed in 21% (n=15/72), and was reached and passed in 58% (n=42/72). Only a minor degree of initial recanalization was achieved in 19% (n=8/42) of patients with a reached occlusion during the course of the intervention. Furthermore, a higher number of passes with a single retriever device led to significant prolongation of the intervention. Therefore, major reasons for failed endovascular recanalization were difficult anatomical access and hard or resistant occlusions that might reflect hard thrombi or pre-existing atherosclerotic stenosis. Procedural complications such as dissection or perforation played a minor role.ConclusionIn stroke patients with failed MT attempts, approximately 60% of occlusions can be passed. In such cases, rescue therapy might be considered to improve recanalization and clinical outcome. Further development of access devices might help in the remaining cases where the microcatheter could not be manipulated to or through the occlusion.

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