Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome

Iosif, Christina; Mounayer, Charbel; Yavuz, Kivilcim; Saleme, Suzana; Geyik, Serdar; Cekirge, H Saruhan; Saatçi, Işıl

doi:10.3174/ajnr.a5022

Cited by 62 publications

(42 citation statements)

References 25 publications

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“…2 Only 1 study reports long-term followup based on clinical and digital subtraction angiography (DSA) imaging controls. 14 MRI control data are also lacking. Gawlitza et al previously published a series of 17 patients with a relatively short follow-up time (range 3-36 months), with MRI results, reporting on silent perforator stroke.…”

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confidence: 99%

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

Michelozzi

Darcourt

Guenego

et al. 2019

Journal of Neurosurgery

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OBJECTIVEThe purpose of this study is to present the authors’ medium-term results, with special emphasis on complications, occlusion rate of the aneurysm sac (digital subtraction angiography [DSA] and MRI), and the fate of cortical branches and perforating arteries covered (“jailed”) by the flow diverter (FD) stent.METHODSBetween January 2010 and September 2017, 29 patients (14 female) with 30 aneurysms were treated with an FD stent. Twenty-one aneurysms were at the middle cerebral artery bifurcation, 8 were in the anterior communicating artery region, and 1 was a pericallosal artery bifurcation. Thirty-five cortical branches were covered. A single FD stent was used in all patients. Symptomatic and asymptomatic periprocedural and delayed complications were reported. DSA and MRI controls were analyzed to evaluate modification of the aneurysm sac and jailed branches.RESULTSPermanent morbidity was 3.4% (1/29), due to a jailed branch occlusion, with a modified Rankin Scale (mRS) score of 2 at the last follow-up. Mortality and permanent complication with poor prognosis (mRS score > 2) rates were 0%. The mean follow-up time for DSA and MRI (mean ± SD) was 21 ± 14.5 months (range 3–66 months) and 19 ± 16 months (range 3–41 months), respectively. The mean time to aneurysm sac occlusion (available for 24 patients), including stable remodeling, was 11.8 ± 6 months (median 13, range 3–27 months). The overall occlusion rate was 82.1% (23/28), and it was 91.7% (22/24) in the group of patients with at least 2 DSA control sequences. One recanalization occurred at 41 months posttreatment. At the time of publication, at the latest follow-up, 7 (20%) of 35 covered branches were occluded, 18 (51.4%) showed a decreased caliber, and the remaining 10 (28.5%) were unchanged. MRI T2-weighted sequences showed complete sac reabsorption in 7/29 aneurysms (24.1%), and the remaining lesions were either smaller (55.2%) or unchanged (17.2%). MRI revealed asymptomatic and symptomatic ischemic events in perforator territories in 7/28 (25%) and 4/28 (14.3%) patients, respectively, which were reversible within 24 hours.CONCLUSIONSFlow diversion of bifurcation aneurysms is feasible, with low rates of permanent morbidity and mortality and high occlusion rates; however, recurrence may occur. Caliber reduction and asymptomatic occlusion of covered cortical branches as well as silent perforator stroke are common. Ischemic complications may occur with no identified predictable factors. MRI controls should be required in all patients to evaluate silent ischemic lesions and aneurysm sac reabsorption over time.

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confidence: 99%

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

Michelozzi

Darcourt

Guenego

et al. 2019

Journal of Neurosurgery

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“…The early use of flow diversion was centered on the treatment of aneurysms arising from the internal carotid artery (ICA) with 79/108 (73.1%) aneurysms treated in the PUFS study arising from either the cavernous or ophthalmic segments of the ICA and the majority of the aneurysms being between 10 and 25 mm in size (78.7%). Since the publication of this K p48MW pivotal trial, numerous reports on the use of flow diversion distal to the circle of Willis have been published [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. Ravindran et al [26] recently reported their multicohort study of FDS use distal to the circle of Willis defined as at or beyond the A1, M1 and P1 segments of the ACA, MCA and PCA, respectively.…”

Section: Discussionmentioning

confidence: 99%

The p48MW Flow Diverter—Initial Human Experience

et al. 2019

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Background and Purpose The use of flow diverters to treat aneurysms arising from small caliber parent vessels has been reported. This article reports the results of the first in experiences with the p48MW (p48 Movable Wire) in humans, a device specifically designed to target vessels 1.75-3 mm in diameter. Methods This monocentric study retrospectively reviewed the prospectively maintained database to identify all patients treated with the p48MW device between January 2017 and January 2019 at this institution. Patient demographics, aneurysm characteristics, angiographic and clinical follow-up were recorded as well as complications. Results A total of 25 patients (20 female) with an average age of 55 ± 12.9 years (range 34-84) with 25 aneurysms were identified. The majority of the aneurysms was located in the anterior circulation (19/25, 76%). The average aneurysm dome width was 3.98 ± 3.6 mm (range 1.2-13 mm). Complete occlusion was seen in 18/24 (75%) aneurysms with neck remnants in 1/24 (4.2%) and continued aneurysm filling seen in the remaining cases (5/24, 20.8%). Adequate occlusion was seen in 79.2% of aneurysms (Raymond Roy Classification [RRC] grade I or II) during the follow-up period. There was a single technical complication with inappropriate deployment of the first p48MW. There was a single clinical complication (4%); however, the patient made a complete recovery (modified Rankin Scale [mRS] 0) and one patient died secondary to uncontrollable status epilepticus following acute subarachnoid hemorrhage unrelated to the treatment. Conclusion The p48MW is safe and effective for the treatment of aneurysms including those arising from distal vessels.

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“…The above model is consistent with most published bifurcation aneurysm FD treatment experience. 29 In the largest to date MCA experience by Iosif et al, 7 the low incidence of ischemic complications was attributed by the authors to careful antiplatelet management and preferential use of a single, slightly oversized flow The ratio of r:R represents a primary-to-collateral circuit relative resistance, with higher r:R values corresponding to increasingly efficient support. In the extreme example of R ϭ 0, flow into the parenchymal territory remains unchanged regardless of metal coverage.…”

Section: Discussionmentioning

confidence: 99%

“…Beyond our rigid model, long-term biologic adaptations tend to promote growth of collaterals when available, leading to eventual occlusion of covered branches, which likely proceeds after the reduction in demand for flow through the branch is followed by gradual endothelial overgrowth; this progressive occlusion has been consistently found by multiple groups in various settings to be overwhelmingly asymptomatic. 5,7,9,11,12,29,30 Furthermore, predictable enlargement of collaterals can be part of a staged treatment strategy. When collaterals are not readily available, as may be expected in a number of MCA bifurcation situations for example, covered branches tend to remain patent.…”

Section: Discussionmentioning

confidence: 99%

“…However, both in the United States and, more commonly, abroad, the PED and other flow diverters (FDs) are being used to treat more distal aneurysms, including those affecting the MCA bifurcation, 7 anterior communicating artery, 8 posterior communicating artery (PcomA) segments (including in the setting of "fetal PcomA" 9 ), distal anterior cerebral artery, 10 and others. 6,11,12 While reasons for these trends are complex and multifactorial, published results have been generally encouraging, 7,8,11,12 with a few groups reporting a high burden of ischemic complications. 13,14 The mechanisms responsible for efficiency of flow diversion in aneurysm treatment have been well-described.…”

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confidence: 99%

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Toward Better Understanding of Flow Diversion in Bifurcation Aneurysms

Shapiro¹,

Shapiro

Raz³

et al. 2018

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE:Flow diversion is being increasingly used to treat bifurcation aneurysms. Empiric approaches have generally led to encouraging results, and a growing body of animal and ex vivo literature addresses the fate of target aneurysms and covered branches. Our prior investigations highlighted the dynamic nature of metal coverage provided by the Pipeline Embolization Device and suggested strategies for creating optimal single and multidevice constructs. We now address the geometric and hemodynamic aspects of jailing branch vessels and neighboring target aneurysms. MATERIALS AND METHODS:Fundamental electric and fluid dynamics principles were applied to generate equations describing the relationships between changes in flow and the degree of vessel coverage in settings of variable collateral support to the jailed territory. Given the high complexity of baseline and posttreatment fluid dynamics, in vivo, we studied a simplified hypothetic system with minimum assumptions to generate the most conservative outcomes. RESULTS:In the acute setting, Pipeline Embolization Devices modify flow in covered branches, principally dependent on the amount of coverage, the efficiency of collateral support, and intrinsic resistance of the covered parenchymal territory. Up to 30% metal coverage of any branch territory is very likely to be well-tolerated regardless of device or artery size or the availability of immediate collateral support, provided, however, that no acute thrombus forms to further reduce jailed territory perfusion. CONCLUSIONS:Basic hemodynamic principles support the safety of branch coverage during aneurysm treatment with the Pipeline Embolization Device. Rational strategies to build bifurcation constructs are feasible. ABBREVIATIONS: FD ϭ flow diverter; PcomA ϭ posterior communicating artery; PED ϭ Pipeline Embolization Device

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Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome

Cited by 62 publications

References 25 publications

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

Flow diversion treatment of complex bifurcation aneurysms beyond the circle of Willis: complications, aneurysm sac occlusion, reabsorption, recurrence, and jailed branch modification at follow-up

The p48MW Flow Diverter—Initial Human Experience

Toward Better Understanding of Flow Diversion in Bifurcation Aneurysms

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