Flow diverter neuroendovascular stents – Reconstructive endovascular treatment of intracranial aneurysms – Single centre experience

Abstract

Objectives

Flow diverter stents (FDS) are new neuroendovascular tools able to achieve the complete and curative treatment of aneurysm by reconstruction of the parent arteries from which the aneurysm arises. We present our initial experience with flow diverter embolization devices and follow-up results.

Materials and Methods

Patients with large, giant and wide necked aneurysms, saccular, fusiform and recurrent aneurysms were selected for the treatment. All patients were pretreated with dual antiplatelet agents at least for 7 days before procedure and continued taking both agents for 3 months after treatment. A MRI was done after 3 months of treatment and digital subtraction angiogram was performed at 4 months of treatment. After 1 year both MRI and digital subtraction angiogram was performed.

Results

11 patients (age range 37 year to 79 year, mean 51.1) with 11 intracranial aneurysms were treated with 15 flow diverter stents. 9 aneurysm were located on the anterior circulation and 2 on posterior circulation. 8 aneurysms were large (10-25 mm), 2 were small (<10 mm) and 1 was giant (>25 mm) with mean largest diameter of 13.22 mm. 9 were saccular aneurysm and 2 were fusiform, out of these 3 were remnant of the previously treated aneurysm. Treatment was achieved with 10 Silk stents in 7 patients and 5 Pipeline embolization devices in 4 patients. The mean time between treatment and follow up was 9.6 months (range 4-12 months). One mortality was noted due to rebleed after 3 weeks of treatment. Complete angiographic occlusion was achieved in 9 (90%) patients after 4 months and 1 (10%) patient had near complete occlusion at 12 months. All the patients were stable clinically during follow up period.

Conclusion

Endovascular treatment with FDS is safe, easy, and permanent treatment for the selected group of aneurysms. The complete occlusion rate in follow-up study approaches 100% with no angiographic recurrence in this study.

Key words

Aneurysm - flow diverter stents - neuro-endovascular - pipeline embolization device - silk stent

• References

• 1 Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J. et al International Subarachnoid Aneurysm Trail (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomized trial. J Stroke Cerebrovasc Dis 2002; 11: 304-314
• 2 Murayama Y, Nien YL, Duckwiler G, Gobin YP, Jahan R, Frazee J. et al Guglielmi detachable embolization of cerebral aneurysms: 11 years experience. J Neurosurg 2003; 98: 959-966
• 3 Friedman JA, Nichols DA, Meyer FB, Pichelmann MA, McIver JI, Toussaint 3rd LG. et al Guglielmi detachable coil treatment of ruptured saccular cerebral aneursm: Retrospective review of a 10 year single centre experience. AJNR Am J Neuroradiol 2003; 24: 526-533
• 4 Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR. et al Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: The Buenos Aires Experience. Neurosurgery 2009; 64: 632-643
• 5 Fiorella D, Woo HH, Albuquerque FC, Nelson PK. Definitive reconstruction of circumferential, fusiform intracranial aneurysm with the pipeline embolization device. Neurosurgery 2008; 62: 1115-1121
• 6 Kulcsar Z, Ernemann U, Wetzel SG, Bock A, Goericke S, Panagiotopoulos V. et al High profile flow diverter implantation in the basilar artery: Efficacy in the treatment of aneurysms and the role of the perforators. Stroke 2010; 41: 1690-1696
• 7 Lubicz B, Collignon L, Raphaeli G, Pruvo JP, Bruneau M, Witte OD. et al Flow diverter stent for endovascular treatment of intracranial aneuryms. A prospective study in 29 patients with 34 aneurysms. Stroke 2010; 41: 2247-2253
• 8 Weibers DO, Whisnant JP, Hutson 3rd J, Meissner I, Brown Jr RD, Piepgras DG. et al Unruptured intracranial aneurysms: Natural History, clinical outcome and risks of surgical and endovascular treatment. Lancet 2003; 362: 103-110
• 9 Canton G, Levy DI, Lasheras JC, Nelson PK. Flow changes caused by the sequential deployment of stents across the neck of sidewall cerebral aneurysms. J Neurosurg 2005; 103: 891-902
• 10 Szikora I, Guterman LR, Wells KM, Hopkins LN. Combined use of stents and coils to treat experimental wide necked carotid aneurysms: Preliminary results. AJNR Am J Neuroradiol 1994; 15: 1091-1102
• 11 Kulcsar Z, Ernemann U, Wetzel SG, Bock A, Goericke S, Panagiotopoulos V. et al High profile flow diverter (Silk) implantation in the basilar artery: Efficacy in the treatment of aneurysms and the role of the perforators. Stroke 2010; 41: 1690-1696
• 12 Kallmes DF, Ding YH, Dai D, Kadirvel R, Lewis DA, Cloft HJ. A new endoluminal, flow-disrupting device for treatment of saccular aneurysms. Stroke 2007; 38: 2346-2352
• 13 Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W. et al Treatment of intracranial anueyrsms by functional reconstruction of the parent artery: Budapest experience with Pipeline embolization device. AJNR Am J Neuroradiol 2010; 31: 1139-1147
• 14 Fiorella D, Kelly ME, Albuquerque FC, Nelson PK. Curative reconstruction of a giant midbasilar trunk aneurysm with the pipeline embolization device. Neurosurgery 2009; 64: 212-217
• 15 Weisel JW, Litvinov RI. The biochemical and physical process of fibrinolysis and effects of clot structure and stability on the lysis rate. Cardiovasc Hematol Agents Med Chem 2008; 6: 161-180
• 16 Turowski B, Macht S, Kulcsar Z, Hanggi D, Stummer W. Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts?. Neuroradiology 2011; 53: 37-41
• 17 Bendszus M, Hagel C, Maurer M, Schütz A, Vince GH, Monoranu MC. et al Fatal recurrent subarachnoid hemorrhage after complete endovascular aneurysm occlusion. AJNR Am J Neuroradiol 2006; 27: 2058-2060
• 18 Mustafa W, Kadziolka K, Anxionnat R, Pierot L. Direct carotid-cavernous fistula following intracavernous carotid aneurysm treatment with flow-diverter stent: A case report. Intervent Neuroradiol 2010; 16: 447-450
• 19 Turowski B, Macht S, Kulcsar Z, Hanngi D, Stummer W. Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (Silk Stent). Neuroradiology 2011; 53: 37-41
• 20 Kulcsar Z, Houdart E, Bonafe A, Parker G, Millar J, Goddart AJ. et al Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow diversion treatment. AJNR Am J Neuroradiol 2011; 32: 20-25
• 21 Fiorella D, Hsu D, Woo HH, Tarr RW, Nelson PK. Very late thrombosis of a pipeline embolization device construct: Case report. Neurosurgery 2010; 67: 313-314
• 22 Kulcsar Z, Wetzel SG, Augsburger L, Gruber A, Wanke I, Rufenacht DA. Effect of flow diversion treatment on very small ruptured aneurysms. Neurosurgery 2010; 67: 789-793
• 23 Piano M, Valvassori L, Quilici L, Pero G, Boccardi E. Midterm and long term follow-up of cerebral aneurysms treated with flow diverter devices: A single -center experience. J Neurosurg 2013; 118: 408-416
• 24 Cruz JP, O’Kelly C, Kelly M, Wong JH, Alshaya W, Martin A. et al Pipeline Embolization device in aneurismal subarachnoid hemorrhage. AJNR Am J Neuradiol 2013; 34: 271-276
• 25 Cebral JR, Mut F, Raschi M, Scrivano E, Ceratto R, Lylyk P. et al Aneurysm rupture following treatment with flow diverter stents: Computational hemodynamics analysis of treatment. AJNR Am J Neuradiol 2011; 32: 27-33
• 26 Appelboom G, Kadri K, Hassan F, Leclerc X. Infectious aneurysm of the cavernous carotid artery in a child treated with a new-generation of flow-diverting stent graft: Case report. Neurosurgery 2010; 66: 623-624
• 27 Shankar JJ, Vandorpe R, Pickett G, Maloney W. SILK flow diverter for treatment of intracranial aneurysms: Initial experience and cost analysis. J Neurointerv Surg 2013; 5 (Suppl. 03) iii11-iii15
• 28 Ringelstein A, Schlamann M, Goericke SL, Monninghoff C, Sandalcioglu IE, El Hindy N. et al 3 year follow up after endovascular aneurysm treatment with Silk flow diverter. Rofo 2013; 185: 328-332