Treatment of visceral artery aneurysms and pseudoaneurysms with the use of cerebral flow diverting stents: initial experience

Abstract

Background: Flow-diverter stents (FDS) are designed to maintain laminar flow in the parent artery and sidebranches and to promote thrombosis of the aneurysm. Although these devices were developed for use in intracranial circulation, FDS could be employed to treat aneurysms regardless of their location, when anatomic factors may limit the efficacy of classic endovascular techniques. The objective of this study is to describe the initial experience of a single center in the treatment of visceral artery aneurysms and pseudoaneurysms (VAA-VAP) with cerebral FDS, analyzing safety, efficacy and 1-year outcome. Between 2016 and 2018 six patients (4 women, mean age 57.6) underwent treatment with FDS of 4 VAA and 2 VAP located in renal (4), hepatic (1) and splenic arteries (1). Mean aneurysm diameter was 14.3 mm (range 8-22). All the aneurysms had sidebranches arising from the neck or had an unfavorable dome-to-neck ratio. Technical success, safety, efficacy and 1-year outcome were analyzed. Follow-ups (FU) with Color-Doppler US and CTA ranged from 12 to 36 (mean 20) months. Results: Technical success was achieved in all cases. There were no aneurysm rupture nor reperfusion after exclusion. Five out of six (83.3%) FDS were patent at each FU; all the aneurysms showed shrinkage with a mean dimensional reduction rate of 55.8%. Sac thrombosis was observed in 4 aneurysms at 1 (n = 3) and at 12-month FUs. There was one sidebranch occlusion with evidence of a small area of kidney hypoperfusion at the 12-month FU, which was asymptomatic. In one patient, a reintervention was needed because CTA showed a severe in-stent stenosis, which was symptomatic. Mean hospitalization was 4.1 days. Conclusions: Treatment of morphologically complex VAA and VAP with cerebral FDS proved to be safe and efficient. Stronger evidence from larger populations are required.

Endovascular treatment of pancreaticoduodenal aneurysm with braided stent-assisted coil embolization using intraoperative cone-beam computed tomography guidance

“…Reported case series have shown encouraging results using flow-diverting stents to treat visceral aneurysms. 10 , 11 These devices provide a scaffold to alter flow toward the parent vessels of the aneurysm. This scaffold was initially designed to assist with coil embolization but, later, evolved into multilayer, braided stents composed of cobalt/chromium and/or nitinol with differing porosity and pore densities.…”

“… 8 , 9 Clinical experience with treating visceral aneurysms using these novel stents has also been evolving. 10 , 11 , 12 The low-profile visualized intraluminal support (LVIS) system (MicroVention Terumo, Aliso Viejo, CA) is a braided stent designed to assist coil embolization.…”

Use of Interventional Neuroradiology Devices (Solitaire AB and Cascade Net) in the Treatment of Complex Renal Aneurysms through Stent-Assisted Coil Embolisation

“…The use of stents/grafts is another valid option within conventional techniques, although it has not proven to be the most appropriate for these sites, unlike the main renal artery, because the branches to the side of the branch to be treated are excluded and covered by the stent, which may lead to areas of renal ischaemia. Furthermore, the high profile of covered stents and difficulty inserting them into narrow and curved branches such as in this case make their devices to be avoided in this area in routine practice [2].…”

“…The endovascular treatment of wide neck aneurysms or aneurysms located in the bifurcations of the renal artery is a challenge for conventional endovascular techniques (simple coil embolisation) due to the risk of coil migration. The use of stents/grafts is another valid but less popular option due to the increased risk of areas of ischaemia in this renal location (bifurcations) [2].…”

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives

“…Flow-diverting stents were initially developed for the treatment of cerebral aneurysms [ 91 ] and have been recently introduced in VAAs. Given a theoretical capacity of flow-diverters to obtain aneurysm thrombosis, preserving patency of its efferent branches [ 92 , 93 ], their use is preferable in districts at higher risk of ischemia, to maintain patency of both the target artery and side branches arising from the aneurysm. This strategy was initially developed in 2012 using a cobalt, multilayer, self-expandable stent (Cardiatis, Isnes, Belgium), specifically approved for peripheral and visceral aneurysms [ 94 ], but unsatisfactory findings were reported during the follow-up: only 60% of stent patency was observed at two years [ 95 ] and a case of disconnection of two overlapped stents [ 96 ] was reported.…”