Endovascular coil embolization of unruptured intracranial aneurysms: a Korean multicenter study

Background and objective

Endovascular coil embolization has been a major treatment modality for unruptured intracranial aneurysms (UIAs) in South Korea. However, there are still few reports on the outcomes of this procedure. We performed a retrospective, multicenter study to determine how safe and effective coiling for UIA has been over the most recent 3 years in South Korea.

Materials and methods

We analyzed a total of 2,180 UIAs in 2,035 patients who were treated by coiling from January 2007 to December 2009 at 22 centers in South Korea, with a focus on patient characteristics, the location and size of the aneurysms, procedural complications, and angiographic and clinical outcomes.

Results

Coiling was successful in 98.0 % of the cases (2,137/2,180 aneurysms). Immediate post-procedural angiography demonstrated complete occlusion in 62.6 % (1,337/2,137 aneurysms), residual neck in 32.4 % (692/2,137), and residual sac in 5.0 % (108/2,137) of the cases. The rate of any procedure-related adverse event was 6.9 % (148/2,137 aneurysms). The rates of permanent morbidity and mortality were 1.8 % (39/2,137 aneurysms) and 0.1 % (2/2,137 aneurysms), respectively. Follow-up conventional angiography or MRA at ≥6 months was performed in 85.7 % (1,832/2,137 aneurysms) of cases. Among the eligible aneurysms for follow-up angiographic analysis, major recanalization was noted in 3.9 % (72/1,832 aneurysms, mean follow-up interval, 12 months). Among these, 68 aneurysms (3.7 %) were re-treated. An aneurysm of the middle cerebral artery (MCA) was a risk factor for incomplete occlusion (P?=?0.049) and major recanalization (P?=?0.046). During follow-up, no aneurysmal rupture occurred.

Conclusions

Endovascular coil embolization of UIAs has been an effective preventive modality with low procedure-related morbidity in South Korea.     

Mid-term outcome of intracranial aneurysms treated with HydroSoft coils compared to historical controls treated with bare platinum coils: a single-center experience

Background

HydroSoft (MicroVention, Aliso Viejo, CA), a hydrogel-platinum coil hybrid device, is one of various efforts to overcome recanalization of coiled intracranial aneurysms. The purpose of this study was to evaluate the efficacy and safety of the HydroSoft coils in patients with intracranial aneurysms, and to compare the 12-month outcomes with that of bare platinum coils.

Methods

Four-hundred one patients harboring 430 intracranial aneurysms underwent endovascular embolization with the HydroSoft coils. In the control group, 221 patients harboring 253 aneurysms underwent coil embolization with bare platinum coils. The authors compared the degree of occlusion of the aneurysms, packing attenuations, procedural-related complications, and 12-month follow-up results between the two groups.

Results

There were no significant differences of initial angiographic outcomes and procedure-related complications between the HydroSoft-coil group and the bare-coil group. Mean volumetric packing density of the HydroSoft-coil group was significantly higher than that of the bare platinum coil group (36.0?±?8.50 % versus 32.1?±?8.22 %, p?p?=?0.001, Fischer’s exact test). Multivariate Poisson regression revealed that coil embolization using the HydroSoft coil significantly reduces the retreatment rate of coiled aneurysms at 12-month follow-up (adjusted RR, 0.21; 95 % CI, 0.07-0.64; p?=?0.004).

Conclusion

Coil embolization using HydroSoft coils achieves higher volumetric packing density. Twelve-month follow-up data favors HydroSoft coils, with lower retreatment rates.     

Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms

Background

Despite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms.

Methods

Parent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30 months (mean 14.6 months) after the procedure.

Results

The procedure-related complications were parent artery dissection (n?=?1), parent artery thrombosis (n?=?4), and coil protrusion (n?=?10). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods.

Conclusions

Facing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.     

Flow visualization of recurrent aneurysms after coil embolization by 3D phase-contrast MRI

Background

Flow patterns in cerebral aneurysms are clinically important. Information on inflow patterns into aneurysms is especially helpful in preventing a recurrence after coil embolization. Computational fluid dynamics (CFD) simulations of patient-specific cerebral aneurysms are feasible and provide information on flow patterns. However, flow visualization by CFD simulations is challenging for recurrent aneurysms after coil embolization because coils make it difficult to obtain precise geometry of the recurrent aneurysms. In this study, we assessed the feasibility of flow visualization of recurrent aneurysms using 3D phase-contrast magnetic resonance imaging (PC-MRI).

Method

Time-of-flight magnetic resonance angiography and 3D PC-MRI were performed in eight cases of recurrent aneurysms after coil embolization. We attempted to visualize flow inside the aneurysms using data of 3D PC-MRI and evaluated the visualization. Additionally, CFD simulations were performed in a single case.

Results

Inflow into aneurysms was visualized in all eight cases (100 %). Flow patterns inside aneurysms were visualized in six cases (75 %), and these were associated with a large size of recurrent aneurysms (mean size, 10.3 mm for visualized cases vs. 4.8 mm for unvisualized cases; p?=?0.046, Mann–Whitney test). Flow patterns were similar between PC-MRI and CFD simulations. PC-MRI was faster and easier for observing inflow patterns than CFD simulations.

Conclusions

This is the first study to demonstrate that flow visualization of recurrent aneurysms by 3D PC-MRI is feasible. This technique may be more practical and easier than CFD simulations, and may provide clinically helpful information.     

Endovascular treatment of 404 intracranial aneurysms treated with nexus detachable coils: short-term and mid-term results from a prospective,consecutive, European multicenter study

Background

Aneurysm recanalization remains a limitation of endovascular treatment. A new type of bioactive coil, the polyglycolic/polylactic acid-covered platinum microfilaments Nexus coil (ev3/Covidien, Irvine, CA, USA), has been proposed. The objective is to evaluate the safety and short-term and mid-term efficacy of Nexus coils in the endovascular treatment of intracranial aneurysms.

Methods

The ENDECOR (European Nexus Detachable Coil Registry) is the first prospective, consecutive, multicenter non-randomized registry. After providing informed consent, 390 patients (238 women and 152 men; mean age, 51.6 years) with 404 ruptured or unruptured aneurysms were enrolled at 34 centers. Treatment was performed with at least 75 % of coil length as Nexus coils. Clinical and technical complications were systematically reported. An independent core laboratory evaluated angiographic results by using the Raymond Grading Scale.

Results

Complete occlusion was seen in 181 aneurysms (48 %); neck remnant in 86 aneurysms (22 %) and aneurysm remnant in 111 aneurysms (30 %). Technical and clinical complications related to the procedure occurred in 33 patients (8.5 %). At discharge, overall mortality and permanent-morbidity were 4.1 % (16/390) and 5.6 % (14/251), respectively. Angiographic mean follow-up of 13.3 months was obtained in 233 of 390 patients (64.4 %) harboring 247 aneurysms. Recanalization was observed in 44 aneurysms (17.7 %), and progressive thrombosis was observed in 53 aneurysms (21.6 %).

Conclusions

Endovascular treatment of intracranial aneurysms with Nexus coils was associated with low morbidity and mortality rates. Efficacy of Nexus coils was comparable to published series of intracranial aneurysms treated with bare platinum coils, but their efficacy to prevent aneurysm recanalization was not demonstrated.     

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

Objectives

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms.

Methods

We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients’ demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke.

Results

Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p?=?0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p?<?0.001 and p?=?0.004).

Conclusion

Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.     

Emergence of the white-collar sign after coil embolization of cerebral aneurysms

Background

The white-collar sign (WCS) is represented by the formation of neointimal tissue at the level of the aneurysm neck as the successful outcome on follow-up angiography after coil embolization. WCS has been reported only in aneurysms treated with Matrix® coils. This is the first study to report WCS emergence in aneurysms treated with bare platinum coils, and potential factors associated with WCS emergence were evaluated.

Method

Total 130 unruptured (female: male ratio, 100: 30; mean age, 60 years) cerebral aneurysms were treated with coil embolization. Embolization status was assessed immediately and 1 year after treatment, and emergence of WCS in follow-up angiography was assessed. We evaluated the association between WCS emergence and aneurysm location, dome diameter, neck diameter, dome-neck ratio, and type of coil used (bare platinum or bioactive).

Results

WCS appeared in nine aneurysms (6.9 %), of which six were treated only with bare platinum coils. Neck diameter was significantly smaller in the WCS-positive group than in the WCS-negative group. The proportion of aneurysms treated with bioactive coils was not significantly different between the groups. Immediate embolization status in the WCS-positive group tended to be slightly better than that in the WCS-negative group. No aneurysmal morphological characteristics other than small neck diameter were associated with WCS emergence.

Conclusions

WCS is not specific to bioactive coil usage. Small neck diameter was significantly associated with WCS emergence in our series. Further investigations to clarify the predictors of WCS will contribute to progress of aneurysmal embolization.     

Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography

Background

In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents.

Methods

Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010” coils or a PX Slim microcatheter for 0.020” Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography.

Results

It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41?±?0.18 mm vs 0.69?±?0.20 mm; P?=?0.008). The SL-10 microcatheter was smaller than approximately 80 % of the stent pores of the first stent and 30 % of those of the second stent. The PX Slim microcatheter was smaller than 20 % of the stent pores of the first stent and 0 % of those of the second stent.

Conclusions

It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020” Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.     

Rupture during the endovascular treatment of intracranial aneurysms: outcomes and technical aspects

Object

The purpose of this study was to determine the incidence and outcomes of intraprocedural rupture (IPR) during endovascular coil embolization of intracranial aneurysm at a single center and to explore the technical reasons and put forward corresponding preventive measures for the feared event to serve as references for other endovascular specialists.

Methods

The aneurysm database in our series was retrospectively reviewed. From April 2005 to March 2009, 176 aneurysms were consecutively treated with coils in 161 patients and IPR occurred in 12 patients. The medical records for the 12 patients were seriously examined.

Results

Of the 12 patients (6.8 %), four were men and eight were women with a median age of 56 years. An emergency “rescue clipping” of the lesion was carried out in two patients, parent artery occlusion was performed in two cases, endovascular treatment was terminated in one case and aneurysm coiling was rapidly completed in the remaining seven cases. Complete occlusion was achieved in nine aneurysms and incomplete occlusion in one. One patient died, yielding a mortality rate of 8.3 %. The follow-up duration was 6–30 months (median 14 months) and the mean Glasgow Outcome Scale score at the last follow-up examination was 4.3.

Conclusions

The rate of IPR during endovascular coiling of intracranial aneurysms is quite low and the clinical outcome from this complication need not be catastrophic if managed appropriately. Improved operation skill and practical experience exchange among neuroradiologists are essential to lower the incidence or better patient prognoses.     

Intracranial aneurysms in patients with internal carotid artery occlusion: management and outcome in 22 cases

Background

There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms.

Methods

We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms.

Results

This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57?months (range, 3–203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm.

Conclusion

Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.     

Coil embolization of overwide and undertall small intracranial aneurysms with double microcatheter technique

Background

Overwide and undertall small intracranial aneurysms remain a challenge for coil embolization. The purpose of this study is to evaluate the feasibility and results of intrasaccular double microcatheter endovascular coil embolization of overwide and undertall small intracranial aneurysms.

Methods

Small (<7 mm), overwide (dome-to-neck ratio [DNR] ≤1.2), and undertall (ASPECT ratio ≤1.2) aneurysms which were treated with double microcatheter technique were selected. For the double microcatheter technique, two microcatheters were selected simultaneously into the aneurysm sac and coil insertion was performed alternatingly. The initial results, ASPECT, DNR ratios, complications, and follow-up results were assessed.

Results

Twenty small (mean, 3.8 mm), overwide (mean DNR, 1.1), and undertall (mean ASPECT, 1.0) aneurysms were treated with the double microcatheter technique. Overall, complete or near complete occlusion was achieved in 19/20 cases. This was achieved with only the double microcatheter technique in 16/20 cases (ASPECT mean, 1.0; DNR mean, 1.1). Adjuvant balloon remodeling was performed in 4/20 cases (ASPECT mean, 0.8; DNR mean, 1.1). The ASPECT ratio was significantly lower in the adjuvant balloon remodeling cases (p?=?0.027). Coiling failed in one patient with both DNR and ASPECT ratio <1.0. Overall, one patient developed a focal visual field defect after the procedure. No other patients developed neurologically significant complications.

Conclusions

Double microcatheter technique may be a safe and effective method for the treatment of overwide and undertall small intracranial aneurysms.     

Aneurysm embolization grade: a predictive tool for aneurysm recurrence after coil embolization

Background

Coil embolization has gained importance in the management of intracranial aneurysms over the past decade. However, the recurrence risk after embolization mandates closer follow-up than surgical clip ligation. Currently, there is no reliable system for predicting aneurysm sac thrombosis. An aneurysm embolization grade (AEG) reported previously by the senior author (EMD) has been proposed as a tool for predicting the durability of aneurysm occlusion based on hemodynamic characteristics. Here, we present our internal validity results.

Methods

AEG and Raymond–Roy Occlusion Classification (RROC) scores were prospectively assigned to all aneurysms coiled from June 2008 to June 2011. The prospectively assigned AEG and RROC scores from the cerebral angiograms were collected for data analysis and validity assessment of the AEG system. 110 consecutive patients who had aneurysm coil embolization were included in this study.

Results

The post-coiling AEG significantly predicted follow-up angiographic filling characteristics. Pairwise comparisons revealed that the follow-up AEG for those initially scored ‘A’ (complete obliteration) was significantly better than the contrast-flow groups. Significant differences were also noted between contrast-stasis and contrast-flow groups. A pairwise comparison between RROC scores demonstrated that only the RROC Type 1 could be used to predict follow-up occlusion durability. Stent placement in wide-neck aneurysms had no effect on initial AEG, RROC, or long-term occlusion durability. Packing density significantly predicted initial AEG and RROC, but had no effect on long-term occlusion.

Conclusions

The AEG system is uniquely based on angiographic filling characteristics of the aneurysm, and this study demonstrated its high predictive value for determining aneurysm sac thrombosis. Assigning an AEG to the aneurysm can guide the neurointerventionalist in discussions with the patient regarding the probability of aneurysm recurrence and potential need for retreatment.     

Various techniques of stent-assisted coil embolization of wide-necked or fusiform artherosclerotic and dissecting unruptured vertebrobasilar artery aneurysms for reducing recanalization: mid-term results

Background

Coil embolization of wide-necked or fusiform vertebrobasilar aneurysms is challenging and tends to involve frequent recanalization.

Purpose

The aim of our study was to evaluate complications and mid-term outcomes of complex vertebrobasilar artery aneurysms after stent-assisted coiling with various techniques.

Methods

We retrospectively evaluated 28 cases of unruptured vertebrobasilar aneurysm treated by stent-assisted coiling.

Results

Forty-four of the 45 stents placed in 28 patients were deployed at the desired location (97.8 %). Single stent-assisted coiling was performed in 14 aneurysms, a stent-within-a-stent (SWS) technique was used in 12 aneurysms, and Y-stent-assisted coiling was employed in four basilar tip aneurysms. Two basilar tip aneurysms treated by single stent-assisted coiling recurred and were retreated by SWS and Y-stent-assisted coiling. Complete embolization was achieved in 19 aneurysms (67.8 %), and remnant neck persisted in eight aneurysms (28.6 %) and remnant aneurysm was noted in one aneurysm (3.6 %). Permanent neurologic deficit (Modified Rankin Scale 1 and 4) was noted in two patients (7.1 %). Angiographic follow-up (mean follow-up period: 20.8 months) was performed in 20 patients. Major recanalization occurred in two basilar tip aneurysms (10 %) and minor compaction was noted in one superior cerebellar artery aneurysm. The remaining 17 aneurysms were stable or improved (85 %).

Conclusions

Complex vertebrobasilar aneurysm embolization with stent-assisted techniques was effective and feasible as a method for reducing recanalization during midterm angiographic follow-up. Large and wide-necked basilar tip aneurysms showed frequent major recanalization, and compact packing with single or Y-stent-assisted coiling is needed to prevent recanalization even if coiling will be done without stenting.     

Frequency,risk of hemorrhage and treatment considerations for cerebral arteriovenous malformations with associated aneurysms

Background

Data on arteriovenous malformations (AVMs) of the brain with AVM-associated aneurysms (AAA) are scarce. This study addresses the incidence, rate of hemorrhage, treatment strategies and stability during follow-up in a neurovascular center.

Methods

We retrospectively reviewed patients harboring an AVM with at least one AAA treated at our neurovascular center between 2002 and 2013.

Results

Of 216 patients, 59 (27.3 %) had at least one AAA (n?=?92 aneurysms total). Compared to patients without AAA, hemorrhagic presentation occurred more frequently (61.0 % versus 43.9 %, p?=?0.025), and the rate of infratentorial AVMs was higher (37.3 % versus 16.6 %, p?=?0.001). The aneurysm was the origin of the bleeding in most cases, most often categorized as a feeding artery aneurysm. Overall, the first and recurrent hemorrhage were associated with a high mortality and morbidity (15.3 % and 39 %, respectively). Aneurysms were treated by coiling (n?=?21), surgery (n?=?18), or embolizaton with liquid embolization agents (n?=?11). All aneurysms treated by embolization and surgery remained occluded during follow-up (mean follow-up 39.0?±?45.0 months). However, in incomplete AVM obliteration, significant recurrence of the treated aneurysm was noted after endovascular coiling (37.5 %), which may be related to the persistence of pathological blood flow.

Conclusion

In our series, AAA was a significant risk factor for hemorrhage and was associated with a poor outcome. It seems worthwhile to consider whether the aneurysm itself is a risk factor or only an epiphenomenon of severely altered hemodynamics induced by these special AVMs and therefore only the most common site of rupture. As the complication rate was low for aneurysm occlusion, we recommend treating these aneurysms whenever possible. Furthermore, obliteration of the AVM should be strived for as this subtype may be associated with an increased risk of hemorrhage.     

Unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery: aneurysmal characteristics and outcomes following endovascular treatment

Background

This study was undertaken to evaluate the aneurysmal characteristics and clinico-radiological outcomes of unruptured non-branching site aneurysms located on the anterior (dorsal) wall of the supraclinoid internal carotid artery (ICA).

Methods

The data of 34 patients that underwent endovascular treatment for 36 unruptured ICA anterior wall aneurysms were reviewed. ICA anterior wall aneurysms were defined as aneurysms that projected superiorly from the anterior wall of the ICA ophthalmic (n?=?35) or communicating (n?=?1) segment on lateral angiograms, without any branch vessel relationship. In addition, aneurysmal characteristics and treatment outcomes were compared with those of 60 unruptured aneurysms originating from the posterior (ventral) wall of the ICA ophthalmic segment.

Results

Patients with an ICA anterior wall aneurysm frequently had a mirror aneurysm on the contralateral side (14.7?% versus 3.3?%) or another ICA aneurysm (35.3?% versus 15?%). Two of the 36 ICA anterior wall aneurysms exhibited ICA narrowing suggestive of dissection, and another five had dysplastic ICA dilatation around the neck. Stent-assisted embolization was more frequently performed for ICA anterior wall aneurysms (66.7?% versus 36.7?%) because of unfavorable dome/neck (mean, 1.21) and aspect (mean, 1.15) ratios, and because of microcatheter instability associated with superior aneurysmal projections against the abrupt curvature of the carotid siphon. Procedure-related thromboembolic complications occurred in three patients in the anterior aneurysm group, but no patient deteriorated clinically. Immediate radiological outcomes were more unfavorable for ICA anterior wall aneurysms (residual sac, 36.1?% versus 16.7?%). Nevertheless, rates of recanalization (2.9?% versus 5.2?%) and progressive occlusion (24.7?% versus 8.1?%) during follow-up slightly favored ICA anterior wall aneurysms. Two stent-treated ICA anterior wall aneurysms developed asymptomatic ICA steno-occlusion (8.3?%).

Conclusions

Stent-assisted embolization is safe and effective for the treatment of unruptured ICA anterior wall aneurysms exhibiting unfavorable aneurysmal geometries and projections for coil embolization.     

Aneurysms of the anterior and posterior cerebral circulation: comparison of the morphometric features

Background

Intracranial aneurysms (IAs) located in the posterior circulation are considered to have higher annual bleed rates than those in the anterior circulation. The aim of the study was to compare the morphometric factors differentiating between IAs located in the anterior and posterior cerebral circulation.

Methods

A total number of 254 IAs diagnosed between 2009 and 2012 were retrospectively analyzed. All patients qualified for diagnostic, three-dimensional rotational angiography. IAs were assigned to either the anterior or posterior cerebral circulation subsets for the analysis. Means were compared with a t-test. The univariate and stepwise logistic regression analyses were used to determine the predictors of morphometric differences between the groups. For the defined predictors, ROC (receiver-operating characteristic) curves and interactive dot diagrams were calculated with the cutoff values of the morphometric factors.

Results

The number of anterior cerebral circulation IAs was 179 (70.5 %); 141 (55.5 %) aneurysms were ruptured. Significant differences between anterior and posterior circulation IAs were found for: the parent artery size (5.08?±?1.8 mm vs. 3.95?±?1.5 mm; p?Conclusions Aspect ratio and parent artery size were found to be predictive morphometric factors in differentiating between anterior and posterior cerebral IAs.     

Endovascular treatment of carotid blowout syndrome

Background

Carotid blowout syndrome (CBS) is a life-threatening complication of head and neck cancer and radiation therapy. Endovascular techniques have emerged as preferable alternatives to surgical ligation for treatment of CBS. We performed a systematic review and meta-analysis to study periprocedural complications and outcomes of CBS patients treated with coil embolization and covered stents.

Late events and mid-term results after endovascular aneurysm repair

Purpose

To evaluate the late events and mid-term results after endovascular aneurysm repair (EVAR).

Methods

Between December 2006 and May 2012, 175 abdominal aortic aneurysms were treated by EVAR. Aneurysm-related events were analyzed.

Results

The complications that occurred during the EVAR procedure were renal artery occlusion in two patients, access artery injury in two, delivery failure in one, retrograde aortic dissection in one, and death from hepatic failure in one patient. Five adverse endoleaks (four type I, one type III) remained at discharge, and the technical success rate was 97 %. On follow-up, limb occlusion had occurred in five patients. Unilateral renal atrophy was found in three patients, but none of the patients required new hemodialysis. Sac enlargement (≥5 mm) developed in ten patients. Their culprit endoleaks were type Ia in one, II in eight, and V in one patient. Transarterial embolization was performed for three out of the eight type II endoleaks. The rate of freedom from secondary re-intervention was 93 % at 3 and 5 years, respectively. The survival and freedom from aneurysm-related events rates were 74 % at 3 years and 47 % at 5 years.

Conclusions

The mid-term results of EVAR were excellent with a low rate of aneurysm-related deaths, although there were relatively high aneurysm-related event rates. Sac re-enlargement from type II endoleaks was the most common major issue at the mid-term follow-up.     

Five-year experience in using coil embolization for ruptured intracranial aneurysms: outcomes and incidence of late rebleeding

OBJECT: During a 5-year period 317 patients presenting with aneurysmal subarachnoid hemorrhage were successfully treated by coil embolization within 30 days of hemorrhage. The authors followed patients to assess the stability of aneurysm occlusion and its longer-term efficacy in protecting patients against rebleeding. METHODS: Patients were followed for 6 to 65 months (median 22.3 months) by clinical review, angiography performed at 6 months posttreatment, and annual questionnaires. Stable angiographic occlusion was evident in 86.4% of small and 85.2% of large aneurysms with recurrent filling in 38 (14.7%) of 259 aneurysms. Rebleeding was caused by aneurysm recurrence in four patients (between 11 and 35 months posttreatment) and by rupture of a coincidental untreated aneurysm in one patient. Annual rebleeding rates were 0.8% in the 1st year, 0.6% in the 2nd year, and 2.4% in the 3rd year after aneurysm embolization, with no rebleeding in subsequent years. Rebleeding occurred in three (7.9%) of 38 recurrent aneurysms and in one (0.4%) of 221 aneurysms that appeared stable on angiography. CONCLUSIONS: Periodic follow-up angiography after coil embolization is recommended to identify aneurysm recurrence and those patients at a high risk of late rebleeding.     

Relevance of Surgery after Embolization of Gastrointestinal and Abdominal Hemorrhage

Background

Gastrointestinal and abdominal bleeding can lead to life-threatening situations. Embolization is considered a feasible and safe treatment option. The relevance of surgery has thus diminished in the past. The aim of the present study was to evaluate the role of surgery in the management of patients after embolization.

Methods

We performed a retrospective single-center analysis of outcomes after transarterial embolization of acute abdominal and gastrointestinal hemorrhage between January 2009 and December 2012 at the Sisters of Charity Hospital, Linz. Patients were divided into three groups, as follows: upper gastrointestinal bleeding (UGIB), lower gastrointestinal bleeding (LGIB), and abdominal hemorrhage.

Results

Fifty-four patients with 55 bleeding events were included. The bleeding source could be localized angiographically in 80 %, and the primary clinical success rate of embolization was 81.8 % (45/55 cases). Early recurrent bleeding (<30 days) occurred in 18.2 % (10/55) of the patients, and delayed recurrent hemorrhage (>30 days) developed in 3.6 % (2/55). The mean follow-up was 8.4 months, and data were available for 85.2 % (46/54) of the patients. Surgery after embolization was required in 20.4 % of these patients (11/54). Failure to localize the bleeding site was identified as predictive of recurrent bleeding (p = 0.009). More than one embolization effort increased the risk of complications (p = 0.02) and rebleeding (p = 0.07).

Conclusions

Surgery still has an important role after embolization in patients with gastrointestinal and abdominal hemorrhage. One of five patients required surgery in cases of early and delayed rebleeding or because of ischemic complications (2/55 both had ischemic damage of the gallbladder) and bleeding consequences.