Flow diversion for the treatment of intracranial bifurcation aneurysms: a systematic review and meta-analysis

Abstract

BackgroundFlow diversion (FD: flow diversion, flow diverter) is an endovascular treatment for many intracranial aneurysm types; however, limited reports have explored the use of FDs in bifurcation aneurysm management. We analyzed the safety and efficacy of FD for the management of intracranial bifurcation aneurysms.MethodsA systematic review identified original research articles that used FD for treating intracranial bifurcation aneurysms. Articles with >4 patients that reported outcomes on the use of FDs for the management of bifurcation aneurysms along the anterior communicating artery (AComA), internal carotid artery terminus (ICAt), basilar apex (BA), or middle cerebral artery bifurcation (MCAb) were included. Meta-analysis was performed using a random effects model.Results19 studies were included with 522 patients harboring 534 bifurcation aneurysms (mean size 9 mm, 78% unruptured). Complete aneurysmal occlusion rate was 68% (95% CI 58.7% to 76.1%, I2=67%) at mean angiographic follow-up of 16 months. Subgroup analysis of FD as a standalone treatment estimated a complete occlusion rate of 69% (95% CI 50% to 83%, I2=38%). The total complication rate was 22% (95% CI 16.7% to 28.6%, I2=51%), largely due to an ischemic complication rate of 16% (95% CI 10.8% to 21.9%, I2=55%). The etiologies of ischemic complications were largely due to jailed artery hypoperfusion (47%) and in-stent thrombosis (38%). 7% of patients suffered permanent symptomatic complications (95% CI 4.5% to 9.8%, I2=6%).ConclusionFD treatment of bifurcation aneurysms has a modest efficacy and relatively unfavorable safety profile. Proceduralists may consider reserving FD as a treatment option if no other surgical or endovascular therapy is deemed feasible.

Vanguard Study: Initial experience with the new fourth generation Pipeline Vantage Flow Diverter (PVFD): 6-month results, technical and clinical considerations

“…This relatively high rate of ischemic complications has also been described in previous studies involving FDS treatment of MCA bifurcation aneurysms. 20 A recent study demonstrated a significant delay in the MR brain perfusion values was detected in the vascularized territory of a jailed arterial branch following flow diversion when compared with the contralateral MCA territory. 21 Although these changes in arterial flow were rarely accompanied by clinical findings in the aforementioned study, 21 further interpretation was limited by its modest sample size of 18 patients.…”

Safety and effectiveness of LEO stents for dual stent-assisted embolization combined with IA and IV intra-procedural infusion of tirofiban in the treatment of wide-necked intracranial bifurcation aneurysms

“…This discrepancy in bleeding rates was attributed to the administration of tirofiban, facilitating a prompt restoration of platelet function upon discontinuation. A recent meta-analysis investigating the utilization of flow diversion-assisted embolization for intracranial bifurcation aneurysms reported TEs and HEs incidences of approximately 16 and 4%, respectively ( 29 ). In the present study, the incidence of TEs was notably lower compared to the meta-analytic findings, while the incidence of HEs was marginally higher; however, it is critical to note that no severe bleeding events were observed.…”

Endovascular treatment of intracranial internal carotid artery bifurcation region aneurysms

“…The WEB device is designed for wide-necked bifurcation aneurysms and is typically used at four typical locations: the MCA bifurcation, AcomA, basilar apex and ICA apex ( 12 , 50 ). After deployment in the aneurysm sac, the device provides immediate flow disruption, leading to aneurysm thrombosis and endothelialization across the aneurysm neck over time.…”

“…Ruptured or daughter-sac/multilobed, large or giant, growing ICA bifurcation region aneurysms may need treatment, including open surgery and endovascular treatment (EVT) (7)(8)(9)(10). Currently, EVT, including traditional coiling, flow diverter (FD) and Woven EndoBridge device (WEB) (MicroVention, Tustin, California, United States) deployment, has been used for the treatment of ICA bifurcation region aneurysms (11,12). However, EVT is challenging due to the unfavorable morphologic features of ICA bifurcation aneurysms.…”