Clinical application of Neuroform Atlas stent-assisted coiling in the treatment of unruptured wide-neck intracranial aneurysms / 北京大学学报(医学版)

OBJECTIVE@#To assess the safety and efficacy of Neuroform Atlas stent used in treatment of unruptured wide-neck intracranial aneurysms.@*METHODS@#Clinical data of 62 patients with unruptured wide-neck intracranial aneurysms undergoing Neuroform Atlas stent-assisted coiling from August 2020 to September 2021 were retrospectively analyzed. There were 64 aneurysms in those 62 patients. Among them, 25 aneurysms were located at the bifurcation of M1 segment on middle cerebral artery, 16 at the anterior communicating artery, 10 at the C7 segment of internal carotid artery, 5 at the C6 segment of internal carotid artery, 4 at the apex of basilar artery, 3 at the A3 segment of anterior cerebral artery, and 1 at the M2 segment of middle cerebral artery. All the patients underwent Neuroform Atlas stent-assisted coiling, including 49 patients with single stent assisted coiling and 15 patients with dual stents assisted coiling (14"Y"style and 1"X"style). After the procedure, the immediate DSA was performed to evaluate the status of aneurysm occlusion and the parent artery patency. The clinical follow-up was performed 3 months after the operation and evaluated based on the modified Rankin Scale(mRS).DSA image was reviewed at 6 months after operation and Raymond grading scale was used to assess the status of aneurysm occlusion and the parent artery patency.@*RESULTS@#A total of 62 patients with 64 aneurysms were all achieved technical success(100%).The immediate post-procedural Raymond scale was assessed, including Raymond Ⅰ in 57 aneurysms(89.1%, 57/64), Raymond Ⅱ in 6 aneurysms(9.3%, 6/64) and Raymond Ⅲ in 1 aneurysm(1.6%, 1/64). The peri-procedural complications rate was 4.8%(3/62), 2 patients developed intraoperative thrombosis and 1 patient suffered from local subarachnoid hemorrhage. Among them, 55 patients obtained 3 months clinical follow-up after operation and all the patients had good outcomes (mRS≤2), 50 patients with 52 aneurysms were followed up with DSA 6 months after operation, including Raymond Ⅰ in 45 aneurysms(86.5%, 45/52), Raymond Ⅱ in 4 aneurysms(7.7%, 4/52) and Raymond Ⅲ in 3 aneurysms(5.8%, 3/52).@*CONCLUSION@#Neuroform Atlas stent for the treatment of unruptured wide-neck intracranial aneurysms has high safety and good efficacy, and has its advantages over other traditional stents.

The therapeutic effect of balloon-assisted coiling and stent-assisted coiling of ruptured intracranial aneurysms in the acute phase / 中华急诊医学杂志

Objective To investigate the perioperative complications and therapeutic effects of balloon-assisted coiling (BAC) and stent-assisted coiling (SAC) in patients with ruptured intracranial aneurysms in the acute phase. Methods Totally 91 patients with 91 intracranial ruptured aneurysms were treated with BAC or SAC in our hospital between January 2014 and December 2016. Among them, 37 patients were treated with BAC and 54 patients with SAC respectively. Of the two groups, the position distribution and shape of aneurysms, and the complications after procedures and the therapeutic effects were summarized and evaluated retrospectively using chi-square test. Results The width of the aneurysm neck was narrower in the BAC-treated group compared to the SAC-treated group (3.31±1.63 mm vs. 4.35±2.10 mm, P=0.01). The aneurysm body/neck ratio (B/N) was lower in the BAC-treated group than in the SAC-treated group (1.64 ± 0.46 vs. 1.35±0.66, P=0.025). The recurrence rate was higher in the BAC-treated group than that in the SAC-treated group (18.9％ vs. 0.9％, P=0.005). There was no statistical difference in perioperative complication in both the BAC-treated group and SAC-treated group. However, 2 patients died due to the relative postoperative intracranial bleeding in the SAC-treated group. Better outcomes (Modified Rankin Score, mRS, 0-2) were achieved in the BAC-treated group compared to the SAC-treated group (94.6％ vs. 88.9％, P=0.028) at the follow-up visit. Conclusions These findings suggested that there is no difference between the BAC-treated group and the SAC-treated group in the risk of complication. BAC can achieve a better prognosis,but it is more prone to relapse. The SAC method was more appropriate for wider neck aneurysms. It was also an option to coiling the aneurysm in BAC in acute phase firstly, followed by additional treatment in SAC during the follow-up period.

Frontiers and prospects in stent-assisted coiling in acutely ruptured intracranial aneurysms / 医学研究生学报

Stent-assisted coiling has been widely used in endovascular treatment of wide-necked,giant and fusiform intracra-nial aneurysm,and has become an important technique for endovascular treatment of intracranial aneurysms. However,for acutely rup-tured intracranial aneurysms,stent implantation will cause platelet aggregation and increase the incidence of ischemic events. There-fore,dual antiplatelet therapy should be used during perioperative period of endovascular treatment. However,the use of antiplatelet drugs may increase the risk of rebleeding and increase the difficulty and risk of subsequent external ventricular drainage and evacuation of intracranial hematoma. Therefore,the feasibility and safety of stent-assisted coiling in acutely ruptured intracranial aneurysms are still in dispute. In this article,we briefly introduce the progress in stent-assisted coiling in acutely ruptured intracranial aneurysms.

The effect of ultra-early stent-assisted coil embolization in the treatment of ruptured wide-necked intracranial aneurysms / 天津医药

Objective To explore the efficacy of ultra-early stent-assisted coil (SAC) in the treatment of intracranial rupture of wide- necked aneurysms. Methods The angiographic and clinical data of 24 patients (including 8 male, 16 female, age ranged from 29 to 86 years, with a median age 59) with acutely ruptured wide-necked intracranial aneurysms treated with SAC were retrospectively analyzed. The postoperative complications and clinical results were observed. The postoperative embolization was assessed according to the Raymond grading standard. The assessment of the follow-up results from 6 to 12 months after procedure was observed according to the modified Rankin Scale (mRS) score. Results Procedure-related complications occurred in 3 patients (12.5%). All of them were hemorrhagic events, of which 2 cases died. Perioperative death was found in 3 cases. Of the 19 surviving patients, 17 showed good recovery (mRS 0-2). After 6 to 12 months of DSA, no recurrence of aneurysm was found in 10 follow-up patients. Conclusion Ultra-early stent-assisted coil treatment for intracranial wide-neck rupture aneurysm can improve the success rate of embolization and reduce the recurrence.

Kissing Aneurysms at Fenestrated Proximal Basilar Artery: Double-barrel Stent-assisted Coiling Using Dual Closed-cell Stents

Kissing aneurysms associated with a proximal basilar artery fenestration are an exceedingly rare and unique therapeutic challenge due to anatomical complexity. This report describes double-barrel stent-assisted technique with dual closed-cell stents for the successful endovascular coiling of kissing aneurysms from a proximal basilar artery fenestration.

Efficacy comparison of Solitaire AB and Enterprise stent-assisted embolization of intracranial wide-necked aneurysms / 中国脑血管病杂志

Objective To compare the effect of Solitaire AB and Enterprise stent-assisted endovascular embolization of intracranial wide-necked aneurysms. Methods The clinical data 218 patients with intracranial aneurysm treated with Solitaire AB stent or Enterprise stent in Guangdong General Hospital from January 2012 to December 2014 were analyzed retrospectively. Seventy patients were treated with Solitaire AB stents and 148 were treated with Enterprise stents. They were followed up after procedure (2 months to 2 years). The Raymond grade and the modified Rankin scale (mRS)scores were used to compare the efficacy of the 2 kinds of stents. Results There were no significant differences in patients before procedure in the Hunt-Hess grade (Z = 1. 550,P = 0. 121),Fisher grade (Z =1. 537,P =0. 124),aneurysm size (Z =0. 192,P =0. 848),and position (χ2 = 0. 337,P = 0. 736)between the 2 stent groups,while there were no significant differences in patients after procedure in the instant Raymond grade (Z = 0. 682,P = 0. 495), follow-up Raymond grade (Z = 0. 206,P =0. 837),and mRS score (P =0. 662)between the 2 stent groups. Further multivariate Logistic regression analysis showed that the stent type (Solitaire AB stent or Enterprise stent),Raymond grade follow-up grade (OR,0. 029 ,95% CI 0. 126 - 0. 199,P = 0. 661 ),and postoperative mRS score (OR,2. 000,95% CI 0. 204 - 19. 603,P = 0. 552)had no influence on the prognosis. Conclusions In the assisted embolization of intracranial wide-necked aneurysms using the Solitaire AB and Enterprise stents,the effects of both stents are good in the assisted embolization of intracranial wide-necked aneurysms.

Easy Advancement of a Large-Profile Microcatheter (Excelsior XT27(TM)) by Parallel Use of Two Microguidewires For Stent Delivery / 신경중재치료의학

PURPOSE: In the endovascular treatment of cerebral aneurysms, navigating a large-bore microcatheter for delivery of an open-cell stent can be challenging, especially in wide-necked bifurcation aneurysms. We were able to overcome this difficulty by parallel use of two microguidewires through the stent-delivery microcatheter. MATERIALS AND METHODS: From December 2014 to April 2015, we treated 15 patients with wide-necked bifurcation aneurysms. For stent delivery, we used a 300-cm 0.014-in microguidewire (Transend), which was placed into the target branch using an exchange technique. A 0.027-in microcatheter (Excelsior XT-27), which was designed for the stent, was advanced over the exchange microguidewire. If we had trouble in advancing the microcatheter over the exchange microguidewire, we inserted a regular microguidewire (Traxcess), into the microcatheter lumen in a parallel fashion. We also analyzed the mechanism underlying microcatheter positioning failure and the success rate of the 'parallel-wire technique'. RESULTS: Among the 15 cases, we faced with navigation difficulty in five patients. In those five cases, we could advance the microcatheter successfully by applying the parallel-wire technique. There were no procedure-related complications. CONCLUSION: Simply by using another microguidewire together with pre-existing microguidewire in a parallel fashion, the stent-delivery microcatheter can be easily navigated into the target location in case of any advancement difficulty.

Severe perioperative neurological complications underwent stent assisted coil embolization of intracranial aneurysm / 中国脑血管病杂志

Objective To analyze the perioperative clinical character of the severe neurological complications in intracranial aneurism treated with stent-assisted coiling(SAC). Methods 203 cases of intracranial aneurysms patients treated by SAC were enrolled retrospectively(ruptured aneurysm group 45 cases and un-ruptured,aneurysm group 158 cases)and the perioperative clinical character of the serious neurological complications(11 cases)was further analyzed. Results The total rate of serious neurological complication was 5. 4%,11 cases of patients with 13 aneurysms got 13 stents. In the ruptured aneurysm group, 5 cases(11. 1%)suffered severe neurological complications,including intraoperative bleeding in one case, postoperative stent-related ischemia in one case,both 2. 2% . Postoperative bleeding 2 cases(4. 4%),and one case of bleeding during anesthesia induced stage(2. 2%). In the unruptured aneurysm group,intraoperative bleeding in three cases,and postoperative stent-related ischemia in three cases,both 1. 9% . No bleeding case during anesthesia induced stage or postoperative period. Although active rescue treatments were performed, 8 patients eventually died,and the total mortality rate was 3. 9% . Conclusion Intracranial aneurysms patients following SAC treatment may suffer from bleeding,ischemia,severe neurological complications, severe disability,and even die. So,we have to strengthen perioperative management.

Stent-assisted coiling for unruptured vertebral dissecting aneurysm / 实用医学杂志

Objective To evaluate the efficacy of stent-assisted coiling in the treatment of unruptured vertebral dissecting aneurysm. Methods We retrospectively reviewed 59 consecutive patients with unruptured vertebral dissecting aneurysms that underwent endovascular treatment. 31 patients received single stent-assisted coiling, 28 patients received multiple stent-assisted coiling. Results Clinical outcome was favorable in 56 of the 59 patients, the modified Rankin Scale score had no difference in both groups (P = 0.24). The immediate obliteration grade in multiple-stent group was higher than that in single-stent group (75.0% vs. 41.9%, P=0.010). What′s more, the recurrence rate was lower in multiple-stent group (0% vs. 19.4%, P = 0.043). Conclusions Stent-assisted coiling in the treatment of unruptured vertebral dissecting aneurysm is safe and effective , multilayer disposition of stents with coils will decrease the complications and facilitate the aneurysmal occlusion. Larger , prospective studies are necessary to explore the long-term outcomes of reconstruction therapy.

Iatrogenic Carotid-Cavernous Fistula after Stent Assisted Coil Embolization of Posterior Communicating Artery Aneurysm

Stent assisted coiling (SAC) is a useful technique for the treatment of wide necked complex aneurysm. As the frequency of SAC increases, stent-related complications such as thromboembolism, aneurysm rupture, and vessel rupture have been reported. However, to the best of our knowledge, carotid-cavernous fistula (CCF) after SAC has never been reported. The authors experienced a case of direct CCF after a SAC procedure for treatment of a complex posterior communicating artery (PCoA) aneurysm regrowth, which was treated by clip ligation 12 years before. The patient was managed conservatively and angiograms performed three months after the procedure showed the complete obliteration of the left PcoA aneurysm and the spontaneous disappearance of CCF. Navigation of Solitaire stent lumen with microcatheter can cause unexpected arterial injury, especially when the proximal tip is placed in the curved portion. It seems to be desirable to place the proximal tip of Solitaire stent in the straight portion whenever possible to reduce the risk of inadvertent arterial injury which might be caused by future navigation of stent lumen.

Very Late Stent Thrombosis after Sole Stent-Assisted Coiling at the Paraclinoid Giant Aneurysm : Could Prophylactic Antiplatelet Therapy Be Ceased at the Only 1 Year after Procedure?

Stent thrombosis is a major limitation of stent-assisted coiling, which is an effective method for treating wide-necked aneurysms. Although early in-stent thrombosis has been reported, very late stent thrombosis (VLST) (>1 year) has not been reported following implantation of a single self-expandable stent designed for coiling. Herein, the authors present a case of VLST that occurred 14 months after single stent implantation in a large paraclinoid aneurysm with an ultra-wide neck involving the parent artery circumferentially. This case indicates the need for establishing guidelines regarding the optimal duration of prophylactic antiplatelet therapy following stent-assisted coiling, which remains undefined in the neuroendovascular field.

The Stent-Assisted Coil-Jailing Technique Facilitates Efficient Embolization of Tiny Cerebral Aneurysms

OBJECTIVE: Tiny cerebral aneurysms are difficult to embolize because the aneurysm's sac is too small for a single small coil, and coils within the aneurysm may escape from the confinement of a stent. This study was performed to introduce the stent-assisted coil-jailing technique and to investigate its effect on the coil embolization of tiny intracranial aneurysms. MATERIALS AND METHODS: Sixteen patients with tiny intracranial aneurysms treated with the stent-assisted coil-jailing technique between January 2011 and December 2013 were retrospectively reviewed and followed-up. RESULTS: All aneurysms were successfully treated with the coil-jailing technique, and at the end of embolization, complete occlusion of the aneurysm was achieved in 9 cases (56.3%), incomplete occlusion in 6 (37.5%), and partial occlusion in 1 (6.3%). Intraprocedural complications included acute thrombosis in one case (6.3%) and re-rupture in another (6.3%). Both complications were managed appropriately with no sequela. Follow-up was performed in all patients for 3-24 months (mean, 7.7 months) after embolization. Complete occlusion was sustained in the 9 aneurysms with initial complete occlusion, progressive thrombosis to complete occlusion occurred in the 6 aneurysms with initial near-complete occlusion, and one aneurysm resulted in progressive thrombosis to complete occlusion after initial partial occlusion. No migration of stents or coils occurred at follow-up as compared with their positions immediately after embolization. At follow-up, all patients had recovered with no sequela. CONCLUSION: The stent-assisted coil-jailing technique can be an efficient approach for tiny intracranial aneurysms, even though no definite conclusion regarding its safety can be drawn from the current data.

Bilateral Vertebral Artery Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage Treated by Staged Coil Trapping and Covered Stents Graft

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

Initial Experience with Neuroform EZ in the Treatment of Wide-neck Cerebral Aneurysms / 신경중재치료의학

PURPOSE: Stent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported. MATERIALS AND METHODS: Seventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed. RESULTS: In all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm. CONCLUSION: The Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.

Total Occlusion of the Internal Carotid Artery by Subacute In-Stent Thrombosis and Subsequent Spontaneous Recanalization After Stent-Assisted Coil Embolization / 신경중재치료의학

We present a 61-year-old female with an unruptured intracranial aneurysm on the left superior hypophyseal artery. The patient was treated with endovascular management, stent-assisted coil embolization. Multiple embolic infarction and total occlusion of the left internal carotid artery (ICA) was occurred one day later. At 14 days of heparinization, complete recanalization of the ICA and full recovery of neurologic symptoms were achieved. Stent-assisted coil embolization is not without risk of instent thrombosis and the subsequent embolism. The cause of subacute in-stent thrombosis and natural course were uncertain; however, the clinical course may potentially be fatal. Therefore, rapid diagnosis and proper treatment are recommended.

Temporary Semi-Jailing Technique Avoiding Inevitable Antiplatelet Medication for Coil Embolization of Wide-necked Cerebral Aneurysms / 신경중재치료의학

PURPOSE: Stent-assisted neck remodeling for wide-necked aneurysms requires long-term medication with antiplatelet agents. We describe here a temporary semi-jailing technique (SJT) for wide-necked aneurysms that avoids the need for antiplatelet medications. MATERIALS AND METHODS: Among 101 patients who underwent stent- and/or balloon-assisted embolizations, 3 wide-necked aneurysms, including 1 ruptured aneurysm, underwent the temporary SJT using Enterprise stents. Temporary SJTs were used due to resistance to antiplatelet agents prior to cardiac surgery or to a ruptured aneurysm with a wide neck. The aneurysms were located in the middle cerebral artery, the paraclinoid internal carotid artery segment, and the posterior communicating artery. RESULTS: Enterprise stents were retrieved after coiling without any change in coil mass stability. The final angiogram showed good patency of each parent artery, good stability of the coil mass and total occlusion of the aneurysm. None of the patients experienced any periprocedural or delayed neurological complications. While retrieving the stent from tortuous vessels, we experienced the jumping phenomenon associated with this device. CONCLUSION: Temporary SJTs have the advantage of stent retrieval, thus avoiding inevitable antiplatelet medication. However, care should be taken in tortuous vessels to avoid the jumping phenomenon associated with the device.