Onyx™ Cast Fragmentation After Embolization of Endoleaks.

PURPOSE: Endoleaks are common following endovascular aneurysm repair (EVAR), and the liquid embolic material Onyx has been widely used in their treatment. We report our experience of long-term morphological changes of Onyx casts on surveillance imaging. MATERIALS AND METHODS: We identified 10 patients over 10 years who underwent Onyx embolization in our institution. Morphological changes of Onyx casts were assessed on surveillance radiographs and computed tomography (CT) scans. Relevant outcome data and sequelae were obtained via electronic patient records. RESULTS: Twelve procedures were performed on 10 cases, 9 for type 2, and 1 for a type 1a endoleak. Five cases showed evidence of Onyx fragmentation on follow-up imaging ranging from a single fracture to gross fragmentation with migration of fragments. Of these 5, 3 had achieved primary success but 2 went on to develop recurrence of endoleak. Onyx volume ranged from 4 to 46.5 ml (median 10.5 ml) per patient with larger volumes demonstrating the most marked fragmentation on follow-up. Follow-up ranged from 9 months to 8 years (median 2.25 years). CONCLUSION: To our knowledge, this is the first report of Onyx fragmentation after endoleak embolization. If long-term morphological stability of the Onyx cast is necessary to maintain aneurysm seal, then Onyx may not offer a permanent solution to some patients with post-EVAR endoleaks. Our study cannot ascertain whether the observed changes were the cause or the effect of ongoing aneurysm growth, persistent endoleak, and/or other forces acting on the solidified polymer, but it raises important questions on the use of Onyx in this setting.

Percutaneous Hydrogel Coil Embolization of Aneurysms and Coronary Artery Fistulae in Congenital Heart Disease.

Patients with congenital heart disease frequently have aneurysms or coronary artery fistulae that necessitate treatment. Metal vascular coils have been a mainstay of treatment for these lesions. In 2002, coils coated or filled with expandable hydrogel were introduced to treat cerebral aneurysms; however, the literature on their use in patients with congenital heart disease is limited. We present 5 cases in which large vascular lesions in children or adolescents with congenital heart disease were successfully occluded with hydrogel coils.

Electrothermal Coil Detachment Failure in Flow Diverter-Assisted Coiling of a Small Blister Aneurysm: Technical Considerations and Possible Solutions.

Flow diversion stenting combined with coiling offers both immediate protection from rebleeding for ruptured aneurysms and long-term stability for wide-necked or blister aneurysms. It is particularly useful for tiny ruptured aneurysms, alleviating the concern that small coils may prolapse between the struts of conventional stents. We employed this technique in a very small, broad-based ruptured aneurysm of the internal carotid, jailing the coiling microcatheter with a Pipeline Embolization Device. However, coil detachment repeatedly failed, until we withdrew the detachment zone into the microcatheter. We suggest that if the tip of the coiling catheter is adjacent to the stent, contact between the junction zone of the coil and the high metal density of the flow diverter may prevent proper electrothermal coil detachment. Detachment can be undertaken successfully within the microcatheter, though care must be taken thereafter to fully push the detached coil tail into the aneurysm.

Rapid temporary coiling of the parent artery for the management of intraprocedural aneurysm rupture.

Intraprocedural rupture (IPR) of an intracranial aneurysm is the most feared complication of primary and stent-assisted coiling because it carries a high risk of morbidity and mortality. The endovascular strategy applied to control IPR depends on the cause of the rupture and stage of the procedure. Rupture during primary or stent-assisted coiling is traditionally managed with the use of continued packing, balloon microcatheter placement, or in rare cases, with parent artery sacrifice. In this technical note, we describe the use of temporary coiling of the parent artery to control IPR in three cases. Temporary parent artery coiling creates a subocclusive state, resulting in aneurysmal blood flow reduction without interruption of blood flow to the distal territory. Flow reduction combined with the thrombogenicity of the previously deployed coils results in hemostasis. In the cases presented here, IPR occurred during the late stage of coiling. In each case, parent artery coiling was performed along with heparin reversal. After confirmation of hemostasis, the coils were retrieved to restore normal blood flow. We demonstrate that the technique of temporary parent artery coiling may be a safe and effective option for the management of IPR during primary or stent-assisted coiling.

Transcatheter Closure of Ruptured Sinus of Valsalva Aneurysm with Double-Disc Perimembranous VSD Occluder in Man with Mechanical Aortic Valve.

Sinus of Valsalva aneurysm, a rare cardiac anomaly, can be life-threatening if it ruptures. Transcatheter closure has emerged as an effective alternative to surgical management; however, it has rarely been reported in patients with previous mechanical aortic valve replacements. We describe the case of a 45-year-old man who presented with a ruptured aneurysm of the noncoronary sinus of Valsalva 14 years after the implantation of a mechanical aortic valve. The ruptured aneurysm was closed by transcatheter means with use of a double-disc perimembranous ventricular septal defect occluder. The patient remained asymptomatic one year after the procedure. Our case suggests that transcatheter closure with use of this type of occluder is a viable method for successfully repairing ruptured sinus of Valsalva aneurysms in patients who have mechanical aortic valves.

The therapeutic challenge of giant splenic artery aneurysm: a case repport / O desafio terapêutico do aneurisma gigante da artéria esplênica: um relato de caso

ABSTRACT Giant splenic artery aneurysm is a rare condition that represents an eminent life threatening for the patient, requiring, therefore, urgent surgical correction. A 61-year-old woman, former smoker, hypertensive, hypercholesterolemic and multipara sought our service because of a large tumor in the mesogastrium, which was an abdominal ultrasound finding. Despite the size of the tumor, the patient was asymptomatic. The angiotomography and the magnetic resonance image of the abdomen were suggestive of giant splenic artery aneurysm with more than 10cm in diameter that was confirmed by an angiography. She underwent surgery, open splenectomy, and partial aneurysmectomy. The approach of the celiac artery, which was ligated, was only possible with medialvisceral rotation because there was no possibility to view it through the anterior access. The histopathological test of aneurysmatic wall revealed atheroma plaques in the intima. The patient progressed without complications and she was discharged cured. In general, giant splenic artery aneurysms are symptomatic, however, as in the case we report, it may be asymptomatic and found in abdominal imaging exam. Although less invasive Interventional methods exist, such as laparoscopy and endovascular techniques, they were considered inappropriate in this case. Conventional open surgery should be the therapy of choice for a giant splenic artery aneurysm.

RESUMO O aneurisma gigante da artéria esplênica constitui condição rara, que representa risco de vida iminente para o paciente, necessitando, consequentemente, de correção cirúrgica urgente. Mulher de 61 anos, ex-fumante, hipertensa, com hipercolesterolêmica e multípara nos procurou por apresentar grande tumor no mesogástrio, achado de ultrassonografia abdominal. Apesar das dimensões do tumor, era assintomática. Angiotomografia e ressonância magnética de abdômen sugeriam tratar-se de aneurisma gigante de artéria esplênica com mais de 10cm de diâmetro, confirmado por angiografia. Foi submetida a tratamento cirúrgico aberto, tendo sido realizadas esplenectomia e aneurismectomia parcial. A abordagem do tronco celíaco, que foi ligado, só foi possível com rotação visceral medial, pois não havia possibilidade de visualizá-lo pela via anterior. O exame anatomopatológico da parede do saco aneurismático revelou placas de ateroma na íntima. A paciente evoluiu sem intercorrências e teve alta hospitalar curada. Aneurismas da artéria esplênica de dimensões avantajadas, em geral, são sintomáticos, porém, como no caso em questão, podem ser assintomáticos e descobertos em exame de imagem do abdômen. Apesar de existirem métodos intervencionistas menos invasivos, como laparoscopia e técnicas endovasculares, eles não foram considerados adequados neste caso. Diante de um aneurisma gigante de artéria esplênica, a conduta terapêutica de eleição é a cirurgia convencional aberta.

Update on flow diverters for the endovascular management of cerebral aneurysms.

Flow diversion has become a well-accepted option for the treatment of cerebral aneurysms. Given the significant treatment effect of flow diverters, numerous options have emerged since the initial Pipeline embolization device studies. In this review, the authors describe the available flow diverters, both endoluminal and intrasaccular, addressing nuances of device design and function and presenting data on complications and outcomes, where available. They also discuss possible future directions of flow diversion.

Safety and efficacy of aneurysm treatment with WEB: results of the WEBCAST study.

OBJECT WEB is an innovative intrasaccular treatment for intracranial aneurysms. Preliminary series have shown good safety and efficacy. The WEB Clinical Assessment of Intrasaccular Aneurysm Therapy (WEBCAST) trial is a prospective European trial evaluating the safety and efficacy of WEB in wide-neck bifurcation aneurysms. METHODS Patients with wide-neck bifurcation aneurysms for which WEB treatment was indicated were included in this multicentergood clinical practices study. Clinical data including adverse events and clinical status at 1 and 6 months were collected and independently analyzed by a medical monitor. Six-month follow-up digital subtraction angiography was also performed and independently analyzed by a core laboratory. Success was defined at 6 months as complete occlusion or stable neck remnant, no worsening in angiographic appearance from postprocedure, and no retreatment performed or planned. RESULTS Ten European neurointerventional centers enrolled 51 patients with 51 aneurysms. Treatment with WEB was achieved in 48 of 51 aneurysms (94.1%). Adjunctive implants (coils/stents) were used in 4 of 48 aneurysms (8.3%). Thromboembolic events were observed in 9 of 51 patients (17.6%), resulting in a permanent deficit (modified Rankin Scale [mRS] Score 1) in 1 patient (2.0%). Intraoperative rupture was not observed. Morbidity (mRS score > 2) and mortality were 2.0% (1 of 51 patients, related to rupture status on entry to study) and 0.0% at 1 month, respectively. Success was achieved at 6 months in 85.4% of patients treated with WEB: 23 of 41 patients (56.1%) had complete occlusion, 12 of 41 (29.3%) had a neck remnant, and 6 of 41 (14.6%) had an aneurysm remnant. CONCLUSIONS The WEBCAST study showed good procedural and short-term safety of aneurysm treatment with WEB and good 6-month anatomical results.

PC400 volumetric coils minimize radiation, reduce procedure time and optimize packing density during endovascular treatment in medium sized cerebral aneurysms.

BACKGROUND AND OBJECTIVES: The Penumbra Coil 400 (PC400) is designed to improve endovascular filling for intracranial aneurysms. The aim of this retrospective, single-operator study was to compare the use of the PC400 with conventional 0.010inch coils in procedure time, X-ray exposure and packing density. METHODS: We collected data from 31patients with 6 to 10mm diameter aneurysms embolized using the PC400, from May 2012 to November 2013. This group was compared with a control group of 27patients treated with conventional 0.010inch coils by the same operator. In both groups, clinical events, number of coils used, duration and cost of procedure, time of fluoroscopy and packing density were studied. RESULTS: No serious adverse events were found in either group. Asymptomatic prolapse of coil loop into the parent artery were noted in two patients. Number of coils used was 4.45/6.35 in PC400 and control groups, respectively. Duration of procedure was 29.8/49.2minutes respectively (P-value=0.0002), and time of fluoroscopy was 28/41minutes (P-value=0.0109). Total radiation was 6098/6876cGy.cm(2) respectively. Comparison of packing densities after the first coil showed respectively 22.7%/10.6%, and after the final imaging, 53%/28.5% (P-values<0.0001). Complete or near complete occlusion on follow-up at 3months was 100% for PC400 versus 92% in the control group. Using 0.010inch coils may result in a 56% increase in treatment cost. CONCLUSION: PC400 coils save procedural time and time of fluoroscopy, are cost saving and allow dramatic improvement of packing density on final imaging.

A comparison of open and endovascular treatment strategies for the management of splenic artery aneurysms.

Splenic artery aneurysms are rare with an incidence of less than 0.8%. Evidence to support an endovascular management strategy over open surgical repair for SAA is limited. We used the Nationwide Inpatient Sample to compare open to endovascular SAA repair by assessing postoperative outcomes, length of hospital stay, and mortality. Multivariate logistic regression analysis was done to determine predictors of postoperative complications. There were 2316 admissions with a diagnosis code for SAA [347 (14.9%) endovascular repair and 112 (4.8%) open surgery]. There was a statistically significant lower rate of cardiac (2.3% vs 6.9%, P = 0.05) and pulmonary (8.9% vs 16.1%, P = 0.05) complications for the endovascular repair group. The risk of surgical site infection was also lower (0.6% vs 5.1%, P = 0.01) in the endovascular group. Median in-hospital LOS was greater for open repairs (6 vs. 4 days, P = 0.01). There were no statistically significant differences across procedures for renal complications (8.9%, P = 0.88) or in-hospital mortality (3%, P = 0.99). Regression analysis established procedure type to be independent predictor of postoperative complications. Endovascular repair of SAA is therefore associated with a lower complication rate and less resource utilization but no difference in mortality peri-operatively. This may justify an endovascular first treatment strategy in the management of SAA.

Analysis of 36 patients with type B aortic intramural hematoma: clinical presentations, treatments and outcomes in a single center / 中国医师杂志

Objective To review the clinical manifestation,diagnosis method,misdiagnosis,risk factors,treatments and prognosis of Stanford B aortic intramural hematoma (IMHB).Methods All of the Stanford B aortic IMHB patients admitted in Wuhan Union hospital from January 2008 to December 2013 were analyzed.The clinical manifestation,diagnosis method,misdiagnosis,managements and prognosis were studied.Furthermore,the effect and long-term survival of different therapies were compared,including medical treatment and endovascular repair.The statistics was performed with SPSS 16.0.Results There were 36 B aortic IMHB patients,and the percent of male patients was 72.22％.The mean age of IMHB was 60.19 ± 11.12.Most patients complained of acute chest and back pain,accompanied with hypertension.Twenty-eight patients (77.78％) received medication therapy,among them,there were 5 patients died of aortic rupture; eight patients (22.22％) received endovascular surgery,one died of cerebral hemorrhage (12.5％).No difference was found between medication therapy and endovascular surgery (17.86％ vs 12.5％,P ＞0.05).Conclusions For simple type B aortic IMHB patients,medication therapy and a dynamic monitoring of full aortic CT angiography was recommended,and for pejorative patients the endovascular treatment should be taken actively.

Endovascular Stent-Graft Placement and Secondary Intervention for Abdominal Aortic Aneurysm in a Patient who had a Previously Inserted Iliac Stent

Endovascular repair of abdominal aortic aneurysm is associated with low morbidity and mortality rates when compared to open surgery, and this can be used in patients who are at a high risk for open surgical repair. Also, secondary intervention is an important for achieving intermediate and long term success of endovascular repair of abdominal aortic aneurysm as this can resolve complications. We report here on endovascular stent-graft placement and a secondary interventional procedure in the abdominal aortic aneurysm of a patient who had a previously inserted iliac stent.

Unruptured Aneurysms with Cranial Nerve Symptoms: Efficacy of Endosaccular Guglielmi Detachable Coil Treatment

OBJECTIVE: To evaluate the efficacy of endosaccular Guglielmi detachable coil (GDC) treatment of unruptured aneurysms causing cranial nerve (CN) symptoms. MATERIALS AND METHODS: Among a database of 218 patients whose aneurysms were treated using GDC, seven patients met the criteria for unruptured aneurysms presenting with symptoms and signs of CN palsy. Changes in CN symptoms before and after GDC treatment were reviewed. RESULTS: Aneurysms were located in the internal carotid-posterior communicating artery (n=3), the basilar bifurcation (n=1) and the cavernous internal carotid artery (n=3). CN symptoms included ptosis (n=6), mydriasis (n=2), and extraocular muscle (EOM) disorder (CN III: n=4; CN VI: n=3). Overall, improvement or resolution of CN symptoms after treatment was noted in five patients. CN symptoms in cases involving small (< or =10 mm) and intradural aneurysms tended to respond better to GDC treatment. Ptosis was the initial symptom to show improvement, while EOM dysfunction responded least favourably. CONCLUSION: GDC coil packing appears to be an appropriate treatment method for the relief of CN symptoms associated with intracranial aneurysms.

Stent Assisted Coil Embolization of a Dissecting Aneurysm of the Vertebral Artery: A Case Involving a Patient with Hypoplasia of the Contralateral Vertebral Artery

A dissecting aneurysm of the vertebral artery may be treated conservatively, surgically, or using an endovascular approach. Proximal clipping, wrapping or trapping are surgical treatment methods, and endovascular treatment with coils and balloons is performed where a dissecting aneurysm is located near the midline or the appropriate surgical manipulation is difficult. As the contralateral vertebral artery of this patient was hypoplastic, the stent-assisted coil embolization technique was employed to preserve the ipsilateral vertebral artery. We describe a clinical case of dissecting aneurysm of the vertebral artery occurring in a patient in whom a hypoplastic contralateral vertebral artery was successfully treated.

Usefulness of "Double-catheter" Technique in GDC Treatment of Intracranial Wide-necked Aneurysm

Purpose: To describe two different methods of "double-catheter" techniques for the treatment of wide-necked intracranial aneurysms. MATERIALS AND METHODS: Using two microcatheters simultaneously, we treated two wide-necked ophthalmic aneurysms and one wide-necked basilar bifurcation aneurysm. In the two cases of ophthalmic aneurysms, the two microcatheters were placed in the aneurysm sac, thus allowing two coils to be braced across the aneurysmal neck before either was detached. In the case of the basilar bifurcation aneurysm, a microcatheter was placed in the posterior cerebral artery (PCA), and another within the aneurysm lumen. When making the first frame with a GDC, we tried to ensure that the frame of the coil and the microcatheter in the PCA did not over-lap. Then, through the microcatheter positioned at the PCA, angiography was performed and flow pattern and dye-disappearance time were evaluated. Subsequent coils were introduced, but in order to preserve PCA flow, not beyond the frame of the first coil. RESULTS: All three aneurysms were successfully embolized without parent artery compromise and the patients were discharged in good neurological condition. CONCLUSION: The "double-catheter" technique can provide a valuable option for treating wide-necked aneurysms, especially when 'balloon remodeling' is not feasible and/or the relationship between the aneurysmal neck and adjacent parent artery cannot be ascertained.

Changes of Incompletely Embolized Aneurysm with Tungsten Coils: An Experimental Study in Dogs

PURPOSE: To evaluate changes of residual aneurysms according to the size of aneurysmal neck andthrombogenicity of a tungsten coil after incomplete embolization of experimental lateral aneurysms. MATERIALS AND METHODS: Eleven experimental lateral aneurysms with different aneurysmal neck size were created in the commoncarotid arteries of mongrel dogs. They were then divided into narrow-neck(n=3), wide-neck(n=6) and spontaneouslythrombosed control(n=2) groups. After confirmation of aneurysmal patency, incomplete embolizations of varyingdegrees (about 30% to near total occlusion) were performed using 5mm-diameter tungsten coils. Angiography wasperformed immediately before and after, and one and six weeks after embolizations. The size of residual aneurysmwas measured on each angiogram. After the last angiography, embolized aneurysms were excised and examined underlight and electron microscopes. RESULTS: On angiograms obtained 6 weeks after embolization, all residual narrowneck aneurysms were completely occluded, whereas in those with a wide-neck, therre was either no change (n=4) or aslight increase in size(n=2). On light microscopy, all narrow-neck aneurysms showed total organized fibrosis whileall control aneurysms and half those with a wide neck showed unorganized thrombi. The embolized group showed ahigher degree of organization in the aneurysmal cavity than did the control group. Neointima formation was seen inall embolized aneurysms, but no aneurysm showed foreign body reaction. On electron microscopy, uniform thicknessof plasma coatings was noted on the surface of the tungsten coils. CONCLUSION: A wide-neck residual aneurysm maypersist or increase in size, while one with a narrow-neck can be thrombosed after incomplete embolization withtungsten coils in a lateral aneurym. Careful consideration might be necessary in the embolization of wide-neckaneurysms. With plasma coatings on its surface and organized fibrosis, tungsten coil can be an useful forembolization of an aneurysm.

Endovascular Treatment of Abdominal Aortic Aneurysm by Bifurcated Stent Graft

PURPOSE: To evaluate the effectiveness and safety of endoluminal bifurcated stent graft for the treatment of AAA. MATERIALS AND METHODS: Between August 1997 and August 1998, 20 patients with AAA underwent treatment involving the use of a bifurcated stent graft. Fourteen in whom the aneurysm involved only bifurcation and six patients in whom the common iliac arteries were involved. For one patient, a stent with a short proximal neck measuring 12 mm was used. The stent graft was inserted by means of a unilateral surgical femoral arteriotomy. After the procedure, follow up involving CT and aortography was performed between month 3 and month 12. RESULTS: The primary success rate with the first trial was 79 percent (15 of 19 patients), and the overall success rate was 84 percent; one perigraft leak was successfully corrected. In one case, technical failure occurred due to a tortuous iliac vessel and spasm. Procedure-related complications occurred in 16% of patients (3 of 19), one of whom died due to acute renal failure following a contrast overdose. CONCLUSION: Endovascular treatment of infrarenal AAA by means of a bifurcated stent graft was effective and safe. In particular, if the proximal neck measured more than 1cm, any AAA could be treated using bifurcated stent graft. Further investigation of the outcome and complications arising during long-term follow-up are needed, however.

Clinical Application of Stent-Graft Using Gianturco Stent and Poly-tetra-fluoro ethylene (PTFE) in AorticAneurysm

PURPOSE: To evaluate the effectiveness of treatment of aortic aneurysm with endoluminal stent-grafts usingGianturco stent and poly-tetra-fluoro ethylene (PTFE). MATERIALS AND METHODS: In ten patients with aorticaneurysm, eleven procedures were performed using tubular (n=7) or bifurcated (n=4) Gianturco Z-stents covered withPTFE to treat aortic disease (six atherosclerotic aortic aneurysms, four pseudoaneurysms of abdominal aorta inthree patients with Behcet's disease, and one penetrating atherosclerotic ulcer). Spiral CT angiography was usedfor follow-up from 14 days to 31 months (mean, 12 months). The effectiveness of stent-grafts was evaluated duringfollow-up. RESULTS: In all cases, implantation of stent-grafts was technically successful ; in five, perigraftleakage was detected on completion of aortography. On initial post-procedural CT images obtained 4 - 24 days afterinsertion of the stent-graft, complete thrombosis of the aneurysm was seen in seven cases and perigraft leakage infour. Two of the four cases in which leakage was seen on initial CT improved spontaneously during follow-up.Procedure-related thromboembolism occurred in one case, which was managed by thrombolytic therapy without residualsequelae. During follow-up CT, the size of aortic aneurysms of atherosclerotic disease did not change. Thepseudoaneurysms of Behcet's disease decreased and eventually completely disappeared, with only residual periaorticsoft tissue. CONCLUSION: For the treatment of aortie diseases, stent grafting using a Gianturco stent and PTFE isclinically feasible, safe, and effective.

Endovascular Treatment of 20 Acutely Ruptured Cerebral Aneurysms with Detachable Coils

PURPOSE: To evaluate the preliminary results of endovascular coil treatment of acutely ruptured aneurysms. MATERIALS AND METHODS: Between August 1995 and December 1997, 18 patients with 20 ruptured aneurysms weretreated. They were classified as Hunt and Hess grade I (n=3), grade II (n=1), grade III (n=3), grade IV (n=10) orgrade V (n=1). Endovascular treatment was performed at mean 5.2 (range, 1-18) days. The first aneurysm was treatedwith mechanical detachable spirals (MDS) and the others with Guglielmi detachable coils (GDC). Aneurysm size wascategorized as small (n=17) or large (n=3). Ten aneurysms were located in the anterior circulation, and ten in theposterior circulation. Using the Glasgow outcome scale (GOS), clinical outcome was evaluated 5 to 27 months aftertreatment in 11 patients. Three patients had already died. RESULTS: In 14 of the 18 patients (16 of 20 aneurysms: 80%), treatment was successful. Four aneurysms failed due to unsuccessful catheter placement (n=2), smallaneurysm (n=1) or occlusion of the parent vessel (n=1). Total occlusion was observed in 13 aneurysms; 95-99%, orsubtotal occlusion, in two, and less than 95%, or incomplete occlusion, in one. Technical complications includedpassing of wire (n=1) and unintentional parent artery occlusion (n=1). There was a 7.1%(1/14) morbidity rate, butno mortality related to the technique. Six patients with Hunt and Hess grade I-III had good clinical outcome (3with GOS 1, and 2 with GOS 2). Four of the nine patients who were grade IV-V showed clinical improvement (GOS 3);two patients were clinically unchanged (GOS 4), and three died from the severity of primary hemorrhage. CONCLUSION: Endovascular coil treatment is a reasonable alternative for patients who are not candidates forconventional surgical treatment or in whom such treatment has failed.