Advances in endovascular aneurysm management: flow modulation techniques with braided mesh devices

Flow diverters and flow disruption technology,alongside nuanced endovascular techniques,have ushered in a new era of treating cerebral aneurysms.Here,we provide an overview of the latest flow modulation devices and highlight their clinical applications and outcomes.

Flow diversion covering the M1 origin as a last resort

Introduction Internal carotid artery termination(ICAT)and proximal A1 aneurysms can be challenging for open surgical clipping or endovascular coiling.Treatment with flow diversion covering the middle cerebral artery(MCA),an end vessel supplying a terminal circulation,has not been reported.Methods A prospective,Institutional Review Board-approved database was analysed for patients with pipeline embolisation device(PED)placement from the anterior cerebral artery(ACA)to the ICA during cerebral aneurysm treatment.Results Nine cases were identified,including five proximal A1,three posterior communicating artery and one ICAT aneurysm locations.Average aneurysm size was 8.3 mm(range 3-17),with 67%saccular and 78%right-sided.Primary indication for treatment was significant dome irregularity(44%),recurrence or enlargement(33%),underlying collagen vascular disorder(11%)and traumatic pseudoaneurysm(11%).Preservation of the ipsilateral ACA(with PED placed in A1)was performed when the anterior communicating artery(67%)or contralateral A1(33%)were absent on angiography.Adjunctive coiling was done in four cases(44%).There was one major stroke leading to mortality(11%)and one minor stroke(11%).Clinical follow-up was 27 months on average.Follow-up digital subtraction angiography(average interval 15 months)showed complete aneurysm obliteration(88%)or dome occlusion with entry remnant(12%).The jailed MCA showed minimal or mild delay(primarily anterograde flow)in 75%of cases and significant delay(reliance primarily on ACA and external carotid artery collaterals)in 25%.Conclusions Covering the MCA with a flow diverting stent should be reserved for select rare cases.Strict attention to blood pressure augmentation during the periprocedural period is necessary to minimise potential ischaemic compromise.

Tandem cervical carotid stenting for stenosis with flow diversion embolisation for the treatment of intracranial aneurysms

Background An estimated 2%-3%of the population harbour an intracranial aneurysm.Concomitant atherosclerotic cervical carotid disease is not uncommon.The management of these two entities remains a challenge within the field.Case presentation We report a single case of concomitant carotid stenosis and two ipsilateral unruptured intracranial aneurysms treated with a single-staged cervical carotid stenting and cerebral aneurysm embolisation with the Pipeline embolisation device.Discussion No consensus currently exists to guide endovascular treatment of intracranial aneurysms associated with asymptomatic ipsilateral stenosis.Here,we present a case of asymptomatic moderate carotid stenosis with two ipsilateral intracranial aneurysms and suggest carotid artery stenting takes procedural priority over aneurysm embolisation in single-stage treatment.The rationale for the sequence of neurointerventions is based on the tracking a robust distal access system beyond a stenotic proximal carotid lesion and stabilisation of the ulcerated plaque to avoid thromboembolic complications associated with plaque irritation during aneurysm embolisation.Additional cases and longer follow-up will be needed to further assess the efficacy of this technique.