Treatment of intracranial broad-neck aneurysms with a new self-expanding stent and coil embolization

BACKGROUND AND PURPOSE: Endovascular treatment of broad-neck intracranial aneurysms with detachable coils requires special techniques. Placement of a stent over the aneurysm neck and secondary coil embolization prevents coil migration and allows attenuated packing of the coils. However, access for the stent-delivery system can be technically limited in tortuous anatomy. We present six cases of broad-neck aneurysms treated with a new self-expanding stent and coil embolization. METHODS: Three aneurysms of the supraophthalmic internal carotid artery and three aneurysms of the basilar tip with extension to the origin of a posterior cerebral artery were treated. The stent was a new self-expanding stent with a 3F over-the-wire microcatheter delivery system. Coil embolization was performed with electrolytically detachable coils. Time-of-flight MR angiography was performed after treatment in five cases. Three other patients could not be treated with the stent because deployment was not possible after correct positioning of the delivery system. RESULTS: Access with the stent-delivery system was easy, and the aneurysm neck was covered sufficiently. After stent placement, total coil embolization was achieved in four and subtotal coil embolization was achieved in two. Parent arteries remained open, and no secondary coil migration was seen. On follow-up MR imaging, the stent was clearly visible and patency of the parent vessel and emerging branches was assessable. CONCLUSION: This new stent is a safe and efficient tool for the endovascular treatment of intracranial broad-neck aneurysms. Access to smaller vessels was easy, but the mechanism of deployment had to be improved. Follow-up MR imaging was sufficient.     

Giant aneurysms of the renal arteries: an unusual manifestation of fibromuscular dysplasia.

Diffuse areas of narrowing and dilatation involving the main renal artery are the most common angiographic findings in fibromuscular dysplasia (FMD), together with the presence of renal artery stenosis. The development of false aneurysms of the renal artery and arteriovenous fistulas are uncommon manifestations. Large, partially thrombosed and calcified renal artery aneurysms are described and their differential diagnosis is stressed.     

Subacute and chronic benign superior vena cava obstructions: endovascular treatment with self-expanding metallic stents.

OBJECTIVE: Our purpose is to report our clinical experience with patients who underwent endovascular treatment with Wallstents for subacute or chronic benign obstruction of the superior vena cava (SVC). SUBJECTS AND METHODS: Twelve patients who were an average of 54 +/- 12 years old were referred for treatment of severe SVC syndrome related to implanted central venous catheters (n = 8), postradiation fibrosis (n = 2), a permanent pacemaker (n = 1), or a benign tumor (n = 1). Symptoms were present for an average of 16 weeks (range, 4-48 weeks) before treatment. Diagnosis of SVC obstruction was confirmed with helical CT and pretherapeutic phlebography. Four patients had Stanford's type II stenosis; two, type III; and six, type IV. The mean clinical and radiologic follow-up intervals were 11 months (range, 1-36 months) and 7 months (range, 1 week to 32 months), respectively. RESULTS: Recanalization was successful in all patients. Fifteen stents were implanted in the 12 patients. Stents were placed after percutaneous balloon angioplasty in nine patients, and primary stent placement was attempted in three patients. We immediately achieved a satisfactory SVC diameter in all patients, whose symptoms were relieved completely within 1 week of stent placement. No technical or clinical complications occurred. SVC syndrome recurred in one patient 2 months after stent placement and was treated by placing a second stent. CONCLUSION: Endovascular treatment with stent placement should be considered relevant and safe for refractory benign SVC syndrome. However, a larger series and a longer follow-up period are needed to define the role of stent placement for this syndrome.     

Circumferential and fusiform intracranial aneurysms: reconstructive endovascular treatment with self-expandable stents

INTRODUCTION: We report our experience with endovascular treatment (EVT) of circumferential and fusiform intracranial aneurysms by a reconstructive approach with self-expandable stents. METHODS: A retrospective review of our prospectively maintained database identified all circumferential and fusiform aneurysms treated by a reconstructive endovascular approach over a 3-year period. Clinical charts, procedural data, and angiographic results were reviewed. RESULTS: From April 2004 to May 2007, 13 patients were identified, of whom 12 were asymptomatic and 1 presented with a subarachnoid hemorrhage. Two patients with an aneurysm 相似文献   

Neuroform3支架辅助弹簧圈栓塞脑宽颈动脉瘤的长期随访疗效

目的评价Neuroform3支架辅助弹簧圈栓塞脑宽颈动脉瘤的长期随访疗效。方法2007年至2011年应用Neuroform3支架辅助弹簧圈栓塞118例脑动脉瘤,其中86例为破裂出血性动脉瘤,32例为未破裂动脉瘤,76例在出血72 h内实施了治疗。术后对患者进行脑血管造影和临床随访。结果支架准确释放115例(97.5%),因为血管扭曲和痉挛失败植入支架1例,支架移位2例。实施单纯支架植入2例,采用微导管经支架网眼技术66例,支架后释放技术49例。术后即刻造影示动脉瘤完全栓塞87例(74.4%),次全栓塞30例(25.6%)。术中无动脉瘤破裂出血事件发生,术后症状性脑梗死3例,无症状性脑梗死5例。术后随访6～60个月,平均26.8个月,共随访到105例,复查1～5次脑血管造影,完全栓塞99例(84.6%),次全栓塞病例中11例(36.7%)存在血栓形成;9例(7.7%)瘤体复发,其中5例进行了再次治疗达到完全栓塞,术后所有患者均无再出血,除3例外,所有患者支架内无明显狭窄。结论 Neuroform3支架辅助弹簧圈栓塞脑宽颈动脉瘤安全、有效,仍需更长期的随访和多中心研究。     

Interlocking detachable coil occlusion in the endovascular treatment of intracranial aneurysms: preliminary results.

PURPOSETo present our preliminary experience with the recently developed interlocking detachable coils in the treatment of intracranial aneurysms.METHODSTwo aneurysms of the basilar tip, two of the internal carotid artery, and one of the posterior inferior cerebellar artery were treated by an endovascular technique using interlocking detachable coils. Three of the patients had undergone unsuccessful surgical clipping. Three-month and 1-year control angiograms were obtained.RESULTSIn all patients but one, who had an aneurysm of the internal carotid artery, the aneurysmal sac was occluded with preservation of the parent artery and did not show recanalization on the follow-up control angiograms. In the other patient who had a wide-necked aneurysm of the internal carotid artery, the sac could not be totally obliterated and showed contrast filling in the neck remnant at 3-month angiography. None of the patients experienced neurologic deficit after treatment.CONCLUSIONBecause they are soft and retrievable, interlocking detachable coils, with their immediate coil release design, may provide an alternative to surgery in the future treatment of endovascular aneurysms.     

Idiopathic aneurysms of distal cerebellar arteries: endovascular treatment after rupture

Introduction Idiopathic ruptured aneurysms of distal cerebellar arteries (DCAAs) are rare, and their endovascular therapy (EVT) has as yet not been extensively reported. They are usually assumed to result from local arterial wall disruption rather than infection, unlike distal supratentorial artery aneurysms. This study was performed to audit their frequency, potential aetiology and results of EVT. Patients and methods Using strict inclusion criteria and a database of 1715 EVT patients, we identified ten idiopathic ruptured DCAAs (0.6%) over a 13-year period (1993–2006). The series comprised six males and four females with mean age of 64 years and solitary aneurysms located on posterior inferior cerebellar artery (five patients), anterior inferior cerebellar artery (three patients) and superior cerebellar artery (two patients). Nine aneurysms were fusiform and were treated by endovascular parent artery occlusion, and one was saccular and treated by endosaccular packing. Endovascular therapy was performed with coils in seven cases, n-butyl-2-cyanoacrylate (NBCA) in two cases and with both in one case. Results Primary EVT was successful in eight patients. One patient died following a procedure-related re-bleeding and one patient required re-treatment after failed endosaccular packing. Nine patients made good or excellent clinical recoveries (modified Rankin Scale 2 or less). Focal cerebellar infarctions were seen on computed tomography images after EVT in three patients, only one of whom was symptomatic with transient dysmetria, which resolved completely during follow up. No aneurysm recanalisation was detected on late follow-up imaging up to 24 months. Conclusion Ruptured DCAAs are rare. The majority are fusiform in shape and their aetiology remains uncertain. Endovascular treatment is feasible and effective. It usually requires parent artery occlusion.     

Hemodialysis related venous stenoses: treatment with self-expanding endovascular prostheses.

Seven patients undergoing chronic hemodialysis presented a total of ten venous stenoses which were treated with self-expanding metallic vascular endoprostheses. Four lesions were central (brachiocephalic and subclavian vein). One acute occlusion could be successfully recanalized by PTA. Restenosis prompted seven secondary interventions. Four patients underwent a kidney transplantation between 5 and 8 months after vascular stenting. Definite occlusion occurred in one patient. According to our experience, stenting of large central veins in hemodialysis patients seems less prone to restenosis due to intimal hyperplasia. Despite a high restenosis rate in the peripheral lesions we believe that stenting is a useful tool in the treatment of hemodialysis-related venous stenosis, permitting a significant prolongation of shunt function.     

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38–77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34–125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments. Received: 22 July 1998; Revision received: 30 November 1998; Accepted: 21 December 1998     

Safety of endovascular treatment of intracranial aneurysms with a new,complex shaped Guglielmi detachable coil

Introduction The Guglielmi detachable coil (GDC) 360°, a new complex shaped bare platinum coil, became available in Europe for aneurysm treatment in September 2005. The purpose of this study was to assess the feasibility and safety of selective embolization of intracranial aneurysms with the GDC 360° in 52 consecutive patients. Methods All patients included in this study were registered in a prospectively maintained database. We assessed the patient clinical history, aneurysm shape and dimensions, technical details and complications of the procedures, degree of aneurysm occlusion, and clinical findings upon discharge. In all patients, the first coil deployed was a GDC 360°. Results Over a 6-month period, we intended to treat 52 aneurysms with the GDC 360° in 52 patients. Of these 52 patients, 42 (81%) were treated in the context of subarachnoid haemorrhage. In 51 of 52 patients, the underlying aneurysm was successfully treated by coil embolization. Six procedures (11.5%) were complicated by the formation of thrombus in the parent artery during the intervention. One patient suffered a stroke related to the procedure. Angiograms obtained immediately after the procedure showed complete occlusion of the aneurysmal sac in 38 of 51 procedures (74.5%), a neck remnant in 11 (21.6%), and a residual aneurysm in 2 (3.9%). In 43 of 51 patients (84.3%), clinical assessment demonstrated independent clinical status, whereas 7 patients (13.7%) required assistance in the activities of daily living upon hospital discharge. One patient (2.0%) died after development of a severe vasospasm 10 days after the endovascular procedure. Conclusion The GDC 360° can be safely used for the endovascular occlusion of intracranial aneurysms.     

Onyx联合支架辅助弹簧圈治疗复杂性颅内破裂动脉瘤

目的 探讨应用Onyx联合支架辅助弹簧圈治疗颅内复杂破裂动脉瘤的可行性和疗效.方法 回顾性分析2例应用Onyx联合支架辅助弹簧圈技术方法,进行治疗的颅内复杂破裂动脉瘤.并对Onyx栓塞治疗颅内动脉瘤相关文献进行回顾.结果 应用该技术栓塞治疗2例复杂性颅内动脉瘤(1例为右侧颈内动脉分叉部动脉瘤,1例为颈内动脉前壁复发动脉...     

周围动脉瘤的腔内介入及外科手术治疗的临床探讨

<正>周围动脉瘤是血管外科常见病,可导致危害肢体功能的严重并发症,如瘤体破裂出血、血管损伤、邻近神经组织受压等,需及早治疗。我院自2007年4月～2009年12月共收治12例周围动脉瘤患者,临床诊治效果满意,现报道如下。     

Venous stenoses in dialysis shunts: treatment with self-expanding metallic stents

A flexible, self-expanding metallic endoprosthesis was employed for the treatment of venous outflow stenoses in four patients with a polytetrafluoroethylene shunt and two patients with a Brescia-Cimino shunt. The stenoses had led to shunt occlusion in five patients and to flow impairment in one. In the occluded shunts, thrombectomy and subsequent balloon angioplasty were performed in four patients, and percutaneous recanalization with angioplasty was performed in one. One shunt with decreasing flow was percutaneously dilated. Since the underlying stenoses recurred in four patients after 24 hours and did not respond sufficiently to angioplasty in two patients, up to four stents were placed in the venous segments. Thrombosis of the stents occurred in two patients after 24 hours and in one after 6 weeks and was successfully recanalized with thrombectomy in two. At 2-6 months follow-up, the stents and the shunts were patent in five patients. In three of these patients, intima hyperplasia, associated with narrowing of the stent lumen in two, was noted within 4 months after stent placement.     

Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases

Blood blister-like aneurysms (BBAs) are among the most hazardous cerebrovascular aneurysms to treat; microsurgical treatment of these small, wide-necked, and exceptionally fragile aneurysms place patients at significant risk of morbidity or mortality. We report two cases of ruptured BBAs attempted to be treated for the first time with stent-assisted coil embolization solely and review the current literature on treatment options. Our patients underwent stent-assisted coil embolization of the aneurysms in the acute stage of subarachnoid hemorrhage (SAH). One patient was successfully treated without procedure-related complications. The other patient died after surgical internal carotid artery (ICA) occlusion, carried out after intraoperative rerupture of the aneurysm during the endovascular treatment. In the successful case, 8-month and 19-month follow-up angiograms demonstrated incomplete (>90%) occlusion with residual filling of the aneurysm neck, which did not need additional coil embolization. Even though stent-assisted coil embolization of ruptured BBAs in the acute stage appears to be a technically feasible treatment option, the present stent-related endovascular technology has potentially hazardous drawbacks.     

支架辅助下弹簧圈栓塞颅内宽颈动脉瘤长期随访分析

目的 观察使用支架辅助弹簧圈栓塞治疗颅内宽颈动脉瘤患者术后3年以上的复发率、支架内狭窄率、动脉瘤再破裂发生率.方法 47例支架辅助弹簧圈栓塞颅内宽颈动脉瘤患者,术后3年以上接受DSA下全颈脑血管造影检查.结果 出现不同程度的支架内狭窄3例,其中1例出现载瘤动脉慢性闭塞.复发5例,其中1例为小型前交通动脉瘤,患者动脉瘤体可见部分显影;4例为超过1.5 cm的颈内动脉虹吸段的大型动脉瘤,栓塞后半年随访发现,动脉瘤内弹簧圈压缩,瘤体再度显影,该4例中有3例经过2次栓塞后即时显影消失,但仍有2例3年随访动脉瘤体再度显影,另1例拒绝2次栓塞,继续随访中.3年随访期内无一例患者栓塞后动脉瘤再破裂.结论 支架辅助弹簧圈栓塞颅内宽颈动脉瘤术式有效、可行,复发率低,支架内狭窄发生率不高,长期效果良好.     

Long-term follow-up in the endovascular treatment of intracranial aneurysms with flow-diverter stents: update of a single-centre experience

Introduction

Flow-diverter stents are becoming a useful tool in treating patients with intracranial aneurysms with suitable anatomical feature. Purpose of this study was to evaluate effectiveness and safety of endovascular treatment with flow-diverting stents (FD) in unruptured intracranial aneurysms.

Methods

From May 2009 and May 2014, we treated 49 patients with a total of 58 aneurysms, with FD technique. All patients were treated electively, under general anesthesia and were administered single antiplatelet drug 5 days before the procedure and double antiplatelet therapy for 3 months afterwards. Fifteen of the patients were asymptomatic, eight had headache, thirteen patients presented symptoms due to mass effect of the aneurysm on CNS structures, twelve were treated due to a post-surgical relapse and one patient presented relapsing TIAs due to distal embolization from the aneurysm dome. Choice of FD treatment was done according to aneurysm anatomy (fusiform over saccular, dome/neck ratio < 2) and whenever conventional treatment (coil embolization) appeared difficult (eg. Large aneurysm neck, fusiform aneurysms or difficult sac catheterization). We considered a dome/neck ratio > 2 as the only exclusion criteria.

Results

Successful stent deployment was achieved in 50 procedures out of 52 (94.34%) while overall mortality was 2% (1/49). Forty-eight patients were evaluated at long-term follow-up for a total of 56 treated aneurysms. At 3 months, follow-up 75% (42/56) of the aneurysms were excluded from intracranial circulation, at 6 months 80.35% (45/56) and at 12 months 84% (47/56). Stent patency was observed in 100% of patients at short and long-term follow-up, with only two cases of intimal hyperplasia at 3 months, without any further complications.

Conclusions

According to our study FD repair of unruptured intracranial aneurysms appeared to be a safe and effective technique, especially in selected patients with hostile anatomy for traditional embolization.

     

Single-center experience of surgical and endovascular treatment of ruptured intracranial aneurysms

BACKGROUND AND PURPOSE:ISAT provided valuable data on patient outcome after endovascular coiling and surgical clipping of ruptured aneurysms. The purpose of this study was to retrospectively review the ≥1-year outcome (in terms of survival, independence, and rebleeding) of patients who were treated in a routine clinical setting.MATERIALS AND METHODS:Records of patients presenting with an SAH from a ruptured aneurysm between 2000 and 2008 were reviewed. The 403 patients who met the inclusion criteria harbored 443 treated aneurysms; 173 were managed surgically and 230 by endovascular means. Mean clinical follow-up was 33.9 months (range, 12–106 months).RESULTS:The pretreatment clinical condition according to the HH was significantly better in the surgically treated patients (P = .018). Death occurred in 11.6% after surgery and in 17.4% after endovascular treatment (P = .104). Of the surviving patients in the surgical and endovascular groups, 80.3% and 87.2%, respectively, were able to live independently with grades 0–2 on the mRS (P = .084). Complete aneurysm occlusion was achieved significantly more often after surgical treatment (P < .001). Rebleeding occurred in 3.1% and 2.3% of the patients after surgical treatment and endovascular coiling, respectively. The occurrence of a residual aneurysm at the end of a coiling procedure was significantly related to the frequency of rebleeding (P = .007).CONCLUSIONS:The management of patients with intracranial aneurysms in a routine clinical setting shows good and comparable rates of mortality and independence. Coiling results in lower rates of complete aneurysm occlusion. Postcoiling angiography showing a residual aneurysm is a good predictor of the risk of rebleeding.

Intracranial aneurysms are an important health problem worldwide, affecting about 2% of the population.¹ Treatment consists of the exclusion of the malformation from the intracranial circulation to eliminate the risk of bleeding or rebleeding. Intracranial aneurysms can be treated by endovascular coiling or by surgical clipping. Since the introduction of GDCs,^1,2 endovascular treatment of intracranial aneurysms has evolved rapidly as an alternative to microsurgical clipping. Coiling has become the preferential treatment since the ISAT demonstrated its clinical superiority over clipping in patients with a ruptured aneurysm who were eligible for both treatments.^3–6 However, many patients are preferentially treated by either neurosurgery (eg, MCA aneurysms) or by endovascular treatment (eg, posterior circulation aneurysms).⁷ Moreover, coiling achieves lower rates of complete occlusion compared with microsurgical clipping, which may affect the long-term stability and rates of rebleeding.^8–11The results of ISAT were based on a selected patient population suitable for both endovascular and surgical treatment in a trial setting. Little data are available on the outcome of patients who are either endovascularly or surgically treated in a routine clinical practice. In our center, intracranial aneurysms are treated either by surgical or by endovascular means, according to a decision reached by a multidisciplinary team that includes a neurologist, neurosurgeon, and interventional radiologist. Therefore, the purpose of the present study was to review the outcome of a consecutive cohort of patients who were either endovascularly or surgically treated for a ruptured intracranial aneurysm in a routine clinical setting. The outcome was determined by rates of survival, independence, retreatment, and rebleeding after ≥1 year of clinical follow-up.     

Cortical blindness, transient and otherwise, associated with detachable coil embolization of intracranial aneurysms

BACKGROUND AND PURPOSE: Cortical visual loss is a rare complication of cerebral angiography without a definitive pathophysiology. Given the rapid increase in endovascular procedures used to treat cerebral aneurysms, we explored the prevalence of this complication and whether we could add to the understanding of this disorder.Materials and METHODS: We performed a retrospective review of all procedures performed with the same contrast agent and detachable coils for treatment of posterior circulation aneurysms by 1 endovascular surgery service from 1996 to 2006. All patients were evaluated before and after each procedure by a team that included a neuro-ophthalmologist.RESULTS: Of 137 intra-arterial treatment procedures performed for posterior circulation aneurysms, we identified 4 patients with cerebral vision loss complications. During the same time period, >500 aneurysms of the anterior cerebral circulation were treated without this complication. The visual field loss was unilateral in 2 and bilateral in 2 patients. Recovery was complete in 3 and almost normal in the fourth patient. The amount of contrast used and the duration of the procedure were similar among all patients. The 4 patients had no identified specific risk factors for developing procedure-associated occipital dysfunction, all 4 had undergone prior angiography, and 1 patient had undergone repeat coiling, without complication.CONCLUSION: The 2.9% prevalence of cerebral visual loss with endovascular coil treatment of posterior circulation aneurysms is higher than that for angiography alone. Our patients recovered well with corticosteroid and intravenous hydration treatment. Recognizing the self-limiting nature of this problem might prevent an unneeded intervention.

Endosaccular occlusion procedures with detachable coils are used with increasing frequency in the treatment of intracranial aneurysms because of clinical effectiveness, good clinical outcome, and low complication rates.^1,2 Endovascular procedures necessitate repeated intra-arterial contrast injections to evaluate therapeutic progress and to avoid or reverse complications such as emboli or unplanned arterial occlusion. Transient cortical blindness is a rare but known complication after administration of angiographic contrast agent,³ which has been reported in 0.3%–1% of patients undergoing vertebral angiography.^4,5 The prevalence could be higher in patients with vasculopathy, even with carotid artery injections,⁶ or with older techniques.^7,8 The exact mechanism for this problem has not been proved. We encountered this complication in 4 patients who had endovascular treatment of posterior circulation aneurysms, which has been reported twice.^9,10