Silk device for the treatment of intracranial aneurysms, part 1: periprocedural results, technical aspects and learning curve

Abstract

Failure of these treatments led the physicians and the industry to investigate new techniques for better success rates to treat these large complex aneurysms. With the development of low-profile microcatheter-delivered self-expanding stents, intracranial parent artery reconstruction became feasible. Initially used technique was stent assisted coiling that resulted in better packing of the coils. With stenting, recurrence rates █ INTRODUCTION Endovascular aneurysm embolization with coils have been criticised for inability to achieve durable aneurysm exclusion when compared to surgical clipping. With coil embolization, this is valid especially for large and wide neck aneurysms that cannot be occluded completely during the procedure and at follow-up they usually show high rates of re-canalization (8,27). AIM:We evaluated the procedural outcomes of intracranial aneurysm treatment with the Silk device and its relation with operator experience. We also detailed some technical points we learned throughout our experience. MATERIAL and METHODS:One hundred and six consecutive patients with intracranial aneurysms treated using Silk (BaltExtrusion, Montmorency, France) stent between October 2010 and November 2013 were included. Patients were evaluated in terms of age, sex, aneurysm size, location, technical success, and adverse events. RESULTS:There were 106 patients (71 female) undergoing 116 procedures with a mean age of 49.8 (range: 3-78 years). Mean aneurysm size was 10.7±8.0 (range, 2-40 mm). Technical success of the procedures was 96.5%. Adverse event rate was 11.2%. Among adverse events, there were 4 adverse events without complications, 2 mild complications, 7 severe complications, 4 of which resulted with death. The adverse event rate was significantly higher during the first half of the operator's experience. The rate of adverse events seemed to stabilize after around 50 patients. Adverse events, regardless of the presence or absence of a clinical complication, were more frequent in aneurysms larger than 18.5 mm. CONCLUSION:Safety of flow-diverter (FD) placement for intracranial aneurysms increases with operator experience. Training programs in endovascular management of cerebrovascular diseases and relevant fellowship curricula must be adapted to include sufficient flow diverter experience. The learning curve needs to be kept in mind when studies comparing different FD devices or those comparing other treatments to FDS are planned.

Stent-assisted coiling of cerebral aneurysms with the Neuroform Atlas stent

“…Wall apposition is better with BR devices, 18,19 yet this is technique/operator dependent and optimal apposition does not invariably occur. 11,20 Arterial angular remodeling is also more prominent with CC stents than with others. 1 Finally, angiographic visibility is better with BR devices.…”

The experience of derivoŽ embolisation device in intracranial aneurysms

“…If adjunctive intrasaccular aneurysm treatment was planned or if further proximal support was needed, larger bore sheaths were used. After the navigation of the microcatheter across the aneurysm neck over a cerebral microguide wire, a variety of previously described techniques were used to deploy DED and to appose it to the vessel wall as much as possible (8). After placement, the microcatheter was advanced over the delivery wire to recapture the delivery system in most cases.…”

Tapered flow diverters in the treatment of intracranial aneurysms

“…More specifically, when the device is chosen according to the arterial segment with lower diameter, overexpansion occurs in the larger arterial segment and this is associated with severe shortening as well as suboptimal apposition and even migration if re-crossing of the device with the deployment catheter is necessary. When the choice is made according to the larger diameter of the parent artery on the other hand, difficulties in stent deployment and hourglass formation at bends are encountered (10). Based on our limited experience, technically, TFDs are more easily deployed in arterial segments with size discrepancy.…”