Advances in endovascular aneurysm management: coiling and adjunctive devices

Endovascular coil embolisation continues to evolve and remains a valid modality in managing ruptured and unruptured cerebral aneurysms.Technological advances in coil properties,adjunctive devices and interventional techniques continue to improve long-term aneurysm occlusion rates.This review elaborates on the latest advances in next-generation endovascular coils and adjunctive coiling techniques for treating cerebral aneurysms.

Procedural complexity independent of P2Y12 reaction unit(PRU)values is associated with acute in situ thrombosis in Pipeline flow diversion of cerebral aneurysms

background Acute in situ thrombosis is an ischaemic phenomenon during Pipeline embolisation device(PED)procedures with potentially high morbidity and mortality.There is controversy regarding the role of platelet function testing with P2Y12 assay as a predictor of intraprocedural thromboembolic events.There is limited knowledge on whether procedural complexity influences these events.Methods Data were collected retrospectively on 742 consecutive PED cases at a single institution.Patients with intraprocedural acute thrombosis were compared with patients without these events.results A cohort of 37 PED cases with acute in situ thrombosis(mean age 53.8 years,mean aneurysm size 8.4 mm)was matched with a cohort of 705 PED cases without intraprocedural thromboembolic events(mean age 56.4 years,mean aneurysm size 6.9 mm).All patients with in situ thrombosis received intra-arterial and/or intravenous abciximab.The two groups were evenly matched in patient demographics,previous treatment/subarachnoid hemorrhage(SAH)and aneurysm location.There was no statistical difference in postprocedural P2Y12 reaction unit(PRU)values between the two groups,with a mean of 156 in the in situ thrombosis group vs 148 in the control group(p=0.5894).Presence of cervical carotid tortuosity,high cavernous internal carotid artery grade,need for multiple PED and vasospasm were not significantly different between the two groups.The in situ thrombosis group had statistically significant longer fluoroscopy time(60.4 vs 38.4 min,p<0.0001),higher radiation exposure(3476 vs 2160 mGy,p<0.0001),higher rates of adjunctive coiling(24.3% vs 8.37%,p=0.0010)and higher utilisation of balloon angioplasty(37.8% vs 12.2%,p<0.0001).Clinically,the in situ thrombosis cohort had higher incidence of major and minor stroke,intracerebral haemorrhage and length of stay.Conclusions Predictors of procedural complexity(higher radiation exposure,longer fluoroscopy time,adjunctive coiling and need for balloon angioplasty)are associated with acute thrombotic events during PED placement,independent of PRU values.

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.

Multimodal management of giant cerebral aneurysms: review of literature and case presentation

The pathophysiology of giant cerebral aneurysms renders them difficult to treat.Advances in technology have attempted to address any shortcomings associated with open surgery or endovascular therapies.Since the introduction of the flow diversion technique,the endovascular approach with flow diversion has become the first-line modality chosen to treat giant aneurysms.A subset of these giant aneurysms may persistent despite any treatment modality.Perhaps the best option for these recurrent and/or persistent giant aneurysms is to employ a multimodal approach-both surgical and endovascular-rather than any single technique to provide a curative result with favourable patient outcomes.This paper provides a review of the histopathology and treatment options for giant cerebral aneurysms.Additionally,an illustrative case is presented to highlight the unique challenges of a curative solution for giant cerebral aneurysms that persist despite initial treatment.

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.