Pipeline flow-diverter stent for endovascular treatment of intracranial aneurysms: preliminary experience in 20 patients with 27 aneurysms.

OBJECTIVE: To report our preliminary experience with the Pipeline flow-diverter stent for the endovascular treatment (EVT) of intracranial aneurysms. METHODS: Between September 2009 and October 2010, 20 patients with 27 fusiform or wide-necked unruptured aneurysms were included and treated by Pipeline stent placement alone. Technical issues, immediate findings, delayed complications, and clinical and imaging follow-up at three and six months were assessed. RESULTS: EVT was successfully performed in all patients. Clinical outcome was excellent in all but one patient who died. This latter patient developed a massive infarct due to a delayed stent thrombosis. Other complications without permanent deficit included one perimesencephalic subarachnoid hemorrhage and one retroperitoneal hematoma. Minor technical issues without clinical consequence were encountered in nine patients and included stent migration, stent misplacement, unanticipated stent shortening, and the impossibility to recapture the distal coil tip of the supporting device. Angiographic follow-up in 19 patients with 25 aneurysms showed 21 complete occlusions, one neck remnant, and three incomplete occlusions. No significant parent artery stenosis was seen. CONCLUSION: This study shows that the Pipeline stent is useful for EVT of fusiform and wide-necked intracranial aneurysms. Moreover, the stent is well tolerated with a low rate of intra-stent stenosis at short-term follow-up. However, technical improvements are needed to ensure safe and precise use of the device.

Flow-diverter stent for the endovascular treatment of intracranial aneurysms: a prospective study in 29 patients with 34 aneurysms.

BACKGROUND AND PURPOSE: The purpose of this study is to report our preliminary experience with the flow-diverter Silk stent for the endovascular treatment of intracranial aneurysms. METHODS: This prospective study was approved by the authors' ethical committees. Twenty-nine patients with 34 fusiform or wide-necked unruptured aneurysms were included and treated by Silk stent placement alone by 2 physicians in 3 different centers. Technical issues, immediate findings, delayed complications, clinical follow-up, and imaging follow-up at 3 and 6 months were assessed. RESULTS: Endovascular treatment was successfully performed in 26 patients (90%). In 3 patients, the stent could not be delivered. Mortality and morbidity rates were of 4% (1 of 26) and 15% (4 of 26), respectively; 1 patient died from a delayed aneurysm rupture related to stent migration, 3 experienced a thromboembolic event, and 1 patient developed progressive visual disturbances related to an increased mass effect. Clinical outcome in 25 patients was unchanged (n=19), improved (n=2), or worsened (=4). Angiographic follow-up in 24 patients (29 aneurysms) showed 20 complete occlusions (69%), 1 neck remnant (3.5%), and 8 incomplete occlusions (27.5%). Significant parent artery stenosis at 6 months occurred in 8 cases (33%). CONCLUSIONS: Despite the potential interest of the Silk flow-diverter stent to treat complex intracranial aneurysms without coils, the delayed complication rate is quite high and leads to use this technique only in selective cases.

Comparison of intravenous alteplase with a combined intravenous-endovascular approach in patients with stroke and confirmed arterial occlusion (RECANALISE study): a prospective cohort study.

BACKGROUND: The efficacy of intravenous (IV) alteplase is restricted by the speed of recanalisation and the site of the occlusion. The aim of this study was to ascertain the effect of a combined IV-endovascular approach (intra-arterial alteplase and, if required, additional thrombectomy) in patients with stroke due to arterial occlusion. METHODS: We compared recanalisation rates, neurological improvement at 24 h, and functional outcome at 3 months between two periods (February, 2002, to March, 2007, vs April, 2007, to October, 2008) in patients in a prospective registry who were treated with different regimens of alteplase within 3 h of symptom onset. Patients with confirmed occlusion who were treated before April, 2007, were treated with IV alteplase; after April, 2007, patients were treated with a systematic IV-endovascular approach. Analysis was by intention to treat. FINDINGS: 46 (87%) of 53 patients treated with the IV-endovascular approach achieved recanalisation versus 56 (52%) of 107 patients in the IV group (adjusted relative risk [RR] 1.49, 95% CI 1.21-1.84; p=0.0002). Early neurological improvement (NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h) occurred in 32 (60%) patients in the IV-endovascular group and 42 (39%) patients in the IV group (adjusted RR 1.36, 0.97-1.91; p=0.07). Favourable outcome (mRS of 0-2 at 90 days) occurred in 30 (57%) patients in the IV-endovascular group and 47 (44%) patients in the IV group (adjusted RR 1.16, 0.85-1.58; p=0.35). The mortality rate at 90 days was 17% in both groups, and symptomatic intracranial haemorrhage was reported in five (9%) patients in the IV-endovascular group and in 12 (11%) patients in the IV group. Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV-endovascular group. INTERPRETATION: An IV-endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion. In patients treated with an IV-endovascular approach, a shorter time from symptom onset to recanalisation is associated with better clinical outcomes.