Efficacy of Willis covered stent of intracranial pseudoaneurysms in the internal carotid artery: A systematic review and meta-analysis

Objective:To evaluate the efficacy of a novel coated stent in the treatment of intracranial pseudoaneurysm.Methods:MEDLINE,EMBASE,and PubMed databases were searched for literature published between 1990 and April 2022 according to PRISMA guidelines.All studies with≥10 patients reporting successful implantation of Willis covered stent,therapeutic effect,complications,and postoperative follow-up were included.The combined incidence and corresponding 95%confidence intervals were assessed using a generalized linear mixed method and random effects model.Results:Five studies(116 patients with pseudoaneurysms)were included.The experimental groups in the selected studies showed a combined technical success rate of 81.03%(OR=18.31,95%CI=9.39-35.69,I^(2)=79%,P<0.001).Clinical follow-up showed that the complete cure rate was as high as 94.4%after the follow-up(OR=106.81,95%CI=39.08-291.88,I^(2)=0%,P=0.71).Conclusions:Willis covered stent is feasible,safe,and effective in the treatment of intracranial pseudoaneurysm.

Willis covered stent in the treatment of a recurrent blood blister-like aneurysm after pipeline implementation:A case report

Blood blister-like aneurysms(BBAs)are fragile and difficult to treat.However,the optimal treatment has yet to be determined.Pipeline embolization devices and Willis covered stent implementation are still controversial strategies for treating BBA.Herein,we report a case of recurrent BBA successfully treated with a Willis covered stent.A long-term follow-up angiography after the procedure indicated complete occlusion of the aneurysm.This case demonstrates the safety and efficacy of applying the Wills cover stent in the treatment of recurrent BBA after Pipeline implantation.

Reconstructive treatment of symptomatic vertebral artery dissecting aneurysms with Willis covered stent: Initial experience

Background:Symptomatic vertebral artery dissecting aneurysm(VADA)is a challenging disease with controversy on treatment strategy due to anatomic configuration and their nature.Moreover,the outcomes of reconstructive treatment have not been well established.Objective:To evaluate the safety and efficacy of reconstructive endovascular treatment(EVT)for symptomatic VADAs with Willis covered stent.Methods:We evaluated retrospectively 13 patients with symptomatic VADAs who treated with Willis covered stent,compared with stent-assisted coiling(SAC)on the characteristics,posttreatment course,angiographic and clinical follow-up outcomes at an average of 14.4 months(range,3-48 months).Results:A total of 33 patients with symptomatic VADAs were reviewed,23 of these patients with ruptured VADAs.The technical successful rate is 100%respectively in Willis covered stent(Group A)and SAC(Group B,n=20).The initial complete occlusion rate was significant higher in group A(100%)than group B(30%)(p<0.01).Major procedure-related complications were not significant different in the two groups.Serial follow-up angiograms revealed 5 recurrent VADAs in group B and no recurrence in group A(p>0.05).No obvious in-stent stenosis and no re-hemorrhage and delayed ischemic symptoms during the follow-up period.The final angiograms of all survived patients demonstrated the complete occlusion rate was higher in group A(100%)than group B(80%),but no significant statistical difference(p>0.05).Clinical outcomes were favorable in 31(93.9%),severe disability occurred in one in group B,and only one death in group A.The final clinical outcomes were also not significant difference in the two groups(p>0.05).Conclusions:Our initial result demonstrated reconstructive EVT with Willis covered stent provides a viable approach for selected symptomatic VADAs involving the intracranial and extracranial segments,which is similar to favorable results with SAC.However,an expanded clinical experiences and larger cohort studies are needed.

Endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases using Willis covered stent

Background:To report the clinical results and experiences of endoleak management and postoperative surveillance following endovascular repair of internal carotid artery vascular diseases(ICAVDs)using Willis covered stents.METHODS:Seventy-three patients with ICAVD who received Willis covered stent implantation between November 2013 and September 2018 were retrospectively reviewed.The clinical data of endoleak management and postoperative surveillance were analyzed.RESULTS:Seventy-three cases with ICAVD,including 57 aneurysms,11 carotid-cavernous sinus fistulas(CCF),and 5 surgical injuries,were all successfully installed with covered stents.Total isolation of ICAVDs was achieved in 59 patients(80.8%),and endoleaks were observed in 14 patients(19.2%).Of the 14 patients with endoleaks,12 had type I endoleaks and 2 had type II;13 had aneurysms and one had CCF.10 patients with type I endoleaks received balloon dilatation,and 7 of them underwent a second stent-graft implantation after then.One patient with type II endoleak received embolization of the branch artery,and another one received follow-up observation.Endoleaks resolved in 6 patients and were minimal in 5 patients after balloon dilatation or the second stent implantation.During the follow-up period,minor endoleaks spontaneously resolved in 4 patients and minimal endoleaks were still demonstrated in 4 patients without enlargement of residual lumen and rupture.CONCLUSIONS:Endoleaks are the major complication after endovascular repair of ICAVDs and represent one of the limitations of this procedure.Improving the understanding and management of endoleaks can be beneficial in the clinical setting,including the popularization and application of this technique.

Fatal complication, rescue therapy;covered stent for coronary artery perforation

Introduction: Although coronary perforation is a rare complication observed during intervenetional procedures, it has a considerably high mortality rate. The prevelance of coronary perforation has been reported to be 0.20%-0.6%. Its sudden development, the patient’s agitation and development of rapid collapse render intervention difficult. Materials and Method: The presence of perfusion balloon and covered stent in clinics is life-saving. In the present study, we retrospectively reviewed 17 cases with coronary artery perforation that were treated between 2009 and 2012. Of these patients, 10 (58.8%) were men and 7 (41.2%) were women;the median age was 62.8 ± 8.3 years. The coronary artery perforation resulted from guide wire in 23.5%, balloon dilatation in 58.8% and stent implantation in 17.6%. All the lesions were either type B or C lesions. Results: The extensiveness of perforation was Ellis grade I in 23.5%, grade II in 47.1% and grade III in 29.4% of the cases. In the treatment of the perforation, polytetrafluoroethylene-covered stent graft was implemented in 9 (52.9%) patients, whilst conventional and emergency surgical therapy was performed in 8 (47.1%) patients. Grade I perforations occurred due to the guide wire and were managed with conventional therapy (p < 0.05). Grade II and III perforations resulted from balloon and stent. The majority of these patients were inserted Graft Stent (stent graft in 52.9% and conventional therapy in 23.5% of the cases (p < 0.05). Although all the stent grafts were successfully implanted, the complete control of bleeding was achieved only in 77.7% of the patients. Mortality was not observed in grade I perforation, whilst all cases resulted in mortality had grade III perforation. Conclusion: These data indicate that there is a need for further advanced technology in the coronary artery perforation despite of currently available therapeutic options.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents(FCSEMS)represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology.A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth.Additionally,FCSEMS can be easily removed.All these features address issues faced by plastic and uncovered metal stents.The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures,biliary leak,and post-sphincterotomy bleeding.

Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

BACKGROUND Studies have shown that covered self-expandable metallic stents(CSEMS)with a low axial forces after placement can cause early recurrent biliary obstruction(RBO)due to precipitating sludge formation.AIM To ascertain whether the angle of CSEMS after placement is a risk factor for RBO in unresectable distal malignant biliary obstruction(MBO).METHODS Between January 2010 and March 2019,261 consecutive patients underwent selfexpandable metallic stent insertion by endoscopic retrograde cholangiopancreatography at our facility,and 87 patients were included in this study.We evaluated the risk factors for RBO,including the angle of CSEMS after placement as the primary outcome.We measured the obtuse angle of CSEMS after placement on an abdominal radiograph using the SYNAPSE PACS system.We also evaluated technical and functional success,adverse events,time to RBO(TRBO),non-RBO rate,survival time,cause of RBO,and reintervention procedure as secondary outcomes.RESULTS We divided the patients into two cohorts based on the presence or absence of RBO.The angle of CSEMS after placement(per 1°and per 10°)was evaluated using the multivariate Cox proportional hazard analysis,which was an independent risk factor for RBO in unresectable distal MBO[hazard ratio,0.97 and 0.71;95%confidence interval(CI):0.94-0.99 and 0.54-0.92;P=0.01 and 0.01,respectively].For early diagnosis of RBO,the cut-off value of the angle of CSEMS after placement using the receiver operating characteristic curve was 130°[sensitivity,50.0%;specificity 85.5%;area under the curve 0.70(95%CI:0.57-0.84)].TRBO in the<130°angle group was significantly shorter than that in the≥130°angle group(P<0.01).CONCLUSION This study suggests that the angle of the CSEMS after placement for unresectable distal MBO is a risk factor for RBO.These novel results provide pertinent information for future stent management.

NuMED CHEATHAM-PLATINUM STENT AND BALLOON IN BALLOON DELIVERY CATHETER FOR TREATMENT OF NATIVE COARCTATION OF THE AORTA

COARCTATION of the aorta (CoA) is a congenital heart defect involving a narrowing of the aorta.The narrowed segment called coarctation is most likely to happen in the segment just after the aortic arch.The narrowing can be removed by surgery or sometimes by a nonsurgical balloon dilation.However, aortic coarctation may recur even after successful surgery or balloon dilation.Fortunately, coarctation can now be treated with nonsurgical balloon dilation associated with implanting a stent using cardiac catheterization.Herein we reported our experience in a 19-year-old boy with CoA who underwent successful covered Cheatham-Platinum (CP) stent implantation for the coarctation.

Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report

BACKGROUND Acute iatrogenic colorectal perforation(AICP)is a serious adverse event,and immediate AICP usually requires early endoscopic closure.Immediate surgical repair is required if the perforation is large,the endoscopic closure fails,or the patient's clinical condition deteriorates.In cases of delayed AICP(>4 h),surgical repair or enterostomy is usually performed,but delayed rectal perforation is rare.CASE SUMMARY A 53-year-old male patient underwent endoscopic submucosal dissection(ESD)at a local hospital for the treatment of a laterally spreading tumor of the rectum,and the wound was closed by an endoscopist using a purse-string suture.Unfortunately,the patient then presented with delayed rectal perforation(6 h after ESD).The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery(TEM);however,the perforation worsened and became enlarged,multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred,and the internal anal sphincter was damaged.As a result,the perforation became more complicated.Due to the increased bleeding,surgical treatment with suturing could not be performed using TEM.Therefore,the patient was sent to our medical center for follow-up treatment.After a multidisciplinary discussion,we believed that the patient should undergo an enterostomy.However,the patient strongly refused this treatment plan.Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared,we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent(SECMS)in combination with a transanal ileus drainage tube(TIDT).CONCLUSION For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation,a SECMS combined with a TIDT can be used and may result in very good outcomes.

Biliary metal stents should be placed near the hilar duct in distal malignant biliary stricture patients

BACKGROUND Endoscopic biliary drainage using a self-expandable metallic stent(SEMS)has been widely performed to treat distal malignant biliary obstruction(DMBO).However,the optimal position of the stent remains unclear.AIM To determine the ideal position for SEMS placement.METHODS In total,135 DMBO patients underwent SEMS(uncovered or covered)placement over a ten-year period.A total of 127 patients with biliary obstruction between the junction of the cystic duct and Vater’s papilla were enrolled.An SEMS was placed through the upper common bile duct 2 cm from the biliary hilar duct in 83 patients(Hilar group)or near the top of the biliary obstruction in 44 patients(Lower group).Technical and functional success,adverse events,and risk factors for SEMS dysfunction were evaluated.RESULTS The stent patency period was significantly longer in the Hilar group than in the Lower group(P value<0.01).In multivariate analysis,the only statistically significant risk factor for SEMS dysfunction was being in the Lower group(hazard ratio:9.94,95%confidence interval:2.25–44.0,P<0.01).CONCLUSION A longer patency period was achieved by positioning the SEMS near the biliary hilar duct.

Exfoliative esophageal bleeding caused by blind placement of a nasogastric tube:Two cases and a literature review

Transnasal intubation is a clinical operation usually performed blindly at the bedside.Mild adverse events,such as epistaxis and tube misplacement,are relatively common.Esophageal bleeding or perforation and other serious adverse events are rare.In the present study,two cases of severe diffuse esophageal bleeding caused by the blind placement of a nasogastric tube are described.These cases were successfully treated using a covered metal stent or Sengstaken-Blakemore tube.A review of the literature regarding the possible causes of such adverse events and the potential endoscopic treatments for severe hemorrhage are discussed.

Fatal arterial hemorrhage after pancreaticoduodenectomy:How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND Although arterial hemorrhage after pancreaticoduodenectomy(PD)is not frequent,it is fatal.Arterial hemorrhage is caused by pseudoaneurysm rupture,and the gastroduodenal artery stump and hepatic artery(HA)are frequent culprit vessels.Diagnostic procedures and imaging modalities are associated with certain difficulties.Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD.Although complete hemostasis may be obtained by endovascular treatment(EVT)or surgery,liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur.We herein discuss therapeutic options for fatal arterial hemorrhage after PD.AIM To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.METHODS We retrospectively investigated 16 patients who developed arterial hemorrhage after PD.The patients’clinical characteristics,diagnostic procedures,actual treatments[transcatheter arterial embolization(TAE),stent-graft placement,or surgery],clinical courses,and outcomes were evaluated.RESULTS The frequency of arterial hemorrhage after PD was 5.5%.Pancreatic leakage was observed in 12 patients.The onset of hemorrhage occurred at a median of 18 d after PD.Sentinel bleeding was observed in five patients.The initial EVT procedures were stent-graft placement in seven patients,TAE in six patients,and combined therapy in two patients.The rate of technical success of the initial EVT was 75.0%,and additional EVTs were performed in four patients.Surgical approaches including arterioportal shunting were performed in eight patients.Liver infarction was observed in two patients after TAE.Two patients showed a poor outcome even after successful EVT.These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT.Fourteen patients were successfully treated.CONCLUSION Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

A Case of Thoracic Aortic Aneurysm with Hemoptysis as the First Symptom

This article reports a case of thoracic aortic aneurysm with hemoptysis as the first clinical manifestation, hemoptysis as the first clinical manifestation is very uncommon and to the best of our knowledge, only twenty of such cases have been previously reported. The case report presented here constitutes the longest course of the disease reported in medical literature, and good recovery after thoracic endovascular aortic repair, may help us to increase the understanding and diagnosis of the disease.

Enlarged and Colored Enhanced 3D Printing of Renal Artery Aneurysms for Improved Imaging and Treatment Planning

Three dimensional printing (3D printing) technology is increasingly used to improve results in many areas of medicine. Physical models produced by this technology allow better appreciation of complex anatomical and pathologic conditions. In cardiovascular medicine and surgery, 3D modeling has been reported to be of help in treatment planning of abdominal aortic aneurysm, especially in cases of complex angulations and branching at the aneurysm neck. Here we report the use of 3D printing in cases of renal aneurysms. Enhanced 3D models of CTA images of renal aneurysms were prepared in house using common and freely available software programs, and an accurate desktop 3D printer. Eight reconstructed models were enlarged by a factor of 2 or more and then differentially painted to delineate normal arteries and aneurysmatic ones. These enhanced 3D solid models allowed visual and tactile inspection for a better appreciation of complex aneurysms. Color enhancement of these models added another dimension of comprehension, even for experienced surgeons and invasive radiologists, and allowed more accurate measurements of branch numbers, distances, and angles in space even with severe tortuosity. Endovascular use of covered stents and embolization techniques could be easily envisioned preoperatively. We conclude that enhanced, enlarged, and colored 3D printed models are a powerful tool for preoperative endovascular treatment planning of complex renal artery aneurysms.

Optimization of biliary drainage in inoperable distal malignant strictures

BACKGROUND Given most patients with distal malignant biliary obstruction present in the nonresectable stage,palliative endoscopic biliary drainage with fully covered metal stent(FCMS)or uncovered metal stent(UCMS)is the only available measure to improve patients’quality of life.Half covered metal stent(HCMS)has been recently introduced commercially.The adverse effects and stent function between FCMS and UCMS have been extensively discussed.AIM To study the duration of stent patency of HCMS and compare it with FCMS and UCMS to optimize biliary drainage in inoperable patients with distal malignant obstruction.Secondary aims in our study included evaluation of patients’survival and the rates of adverse events for each type of stent.METHODS We studied 210 patients and randomized them into three equal groups;HCMS,FCMS and UCMS were inserted endoscopically.RESULTS Stent occlusion occurred in(18.6%,17.1%and 15.7%in HCMS,FCMS and UCMS groups,respectively,P=0.9).Stent migration occurred only in patients with FCMS(8.6%of patients).Cholangitis and cholecystitis occurred in 11.4%and 5.7%of patients,respectively,in FCMS.Tumor growth occurred only in 10 cases among patients with UCMS after a median of 140 d,sludge occurred in nine,seven and one patients in HCMS,FCMS and UCMS,respectively(P=0.04).CONCLUSION Given the prolonged stent functioning time,the use of HCMS is preferred over the use of UCMS and FCMS for optimizing biliary drainage in patients with distal malignant biliary obstruction.

Multiple recurrent cystic echinococcosis with abdominal aortic involvement: A case report

BACKGROUND Recurrent cystic echinococcosis(CE)with vital organ involvement is a challenge for clinicians.Herein,we report a case of aortic involvement in recurrent retroperitoneal CE lesions following primary splenic CE resection.CASE SUMMARY A 60-year-old male was admitted due to progressive abdominal pain and poor appetite.He was diagnosed with multiple recurrent CE with abdominal aortic involvement according to preoperative evaluation.During surgical resection,major aortic bleeding accidentally occurred while dissecting the cyst,which was firmly attached to the abdominal aortic wall.Hemostasis attempts were conducted to deal with this emergency situation and maintain circulation.Postinterventional recovery was uneventful,and 2-year follow-up showed no sign of recurrence or any other complications.CONCLUSION Radical resection of recurrent complicated CE with aortic involvement should be carefully planned and performed to prevent possible severe adverse complications,thereby improving the postoperative outcome.

Diagnosis and endovascular treatment of spontaneous direct carotid-cavernous fistula

Background Spontaneous direct carotid-cavernous fistula （CCF） is relatively rare and few reports have been found in the literature. The aim of this paper was to report the clinical characteristics, imaging findings and curative effect of endovascular treatment for patients with spontaneous direct CCF. Methods We retrospectively analyzed the clinical data of nine patients with spontaneous direct CCF admitted between May 2003 and November 2007 and the outcomes.of endovascular treatment. Sudden neuro-ophthalmological symptoms were the most common clinical presentation at diagnosis （n=8）. No patients had a history of head trauma. Cerebral digital subtraction angiography （DSA） was performed on all cases under local anesthesia and seven cases received endovascular treatment. Results In eight patients, internal carotid angiograms recorded during the early arterial phase revealed aneurysms located in the cavernous sinuses, and in one patient, a dilated internal carotid artery （ICA） was seen. Among the nine cases, seven received endovascular treatment via a transarterial approach and complete occlusion of the fistula was obtained with no technique-related complications, one died suddenly before treatment and one gave up treatment. A detachable balloon was used as the embolic material in two cases, a detachable balloon and detachable coil as the embolic material in two cases, balloon-assisted coil embolization in two cases and covered stents were successfully placed in the parent vessel to exclude the aneurysm and fistula from circulation in one case. During a follow-up period of 3-48 months, all treated patients remained asymptomatic except for one patient who suffered from ipsilateral decreased vision. Conclusions Most spontaneous direct CCF may be caused by a ruptured intracavernous aneurysm with direct shunting into the cavernous sinus. Endovascular treatment seems to be a safe and effective method for treating spontaneous direct CCF.

Endovascular treatment of pseudo-aneurysm occurring after embolization of traumatic carotid cavernous fistula with detachable balloons

Traumatic carotid-cavemous fistula （CCF） is an abnormal passageway between the intracavemous carotid artery and the cavernous sinus after a head injury. Most CCFs have direct high flow. Clinical presentations primarily depend on the pressure inside the cavernous sinus and on the direction of the venous drainage. The ideal goal for the treatment of direct CCF is the obliteration of the fistula while preserving the internal carotid artery （ICA）. Transarterial embolization of direct CCF with detachable balloons has been proven to be the best option for an initial treatment, although transarterial embolization by detachable balloons is frequently associated with pseudo-aneurysm formation. Many treatment options such as coiling, stent-assisted coiling, and covered stent have been proposed to treat pseudo-aneurysm. However, the best management for a pseudo-aneurysm occurring after an embolization of a CCF with detachable balloons remains unknown. In this article, we will report our successful attempt in treating the said pseudo-aneurysm. We initially dealt with a pseudo-aneurysm occurring after an embolization of a CCF with stent-assisted coiling; then, the pseudoaneurysm recanalized, and eventually a covered stent was placed for the recanalized pseudoaneurysm.