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Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms.

ABSTRACT: Objective: Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device or technique. Therefore, our study aimed to present our experiences with both techniques, providing a considered approach on when to perform endovascular reconstruction or sacrifice. Materials and Methods: We retrospectively reviewed patients with subarachnoid hemorrhage in our database, suffering from dissecting aneurysms of the intradural vertebral arteries and treated endovascularly in the acute setting. A total of 16 cases were included. Clinical history, radiologic findings and outcomes were analyzed. Results: In 7 patients a reconstructive approach was chosen with 4 of them receiving stent-assisted coiling as primary strategy. One of the 7 patients suffered early re-bleeding due to progression of the dissection and therefore treatment was augmented with implantation of 2 flow diverters. The remaining 2 patients were primarily treated with flow diverters in telescoping technique. In 9 patients a deconstructive approach was followed: 6 patients were treated with proximal coil-occlusion of the V4 segment, 3 patients received distal coiling of the V4 segment. Two patients died (GOS 1) in the subacute stage due to sequelae of recurrent episodes of raised intracranial pressure and parenchymal hemorrhage. Two patients kept severe disability (GOS 3), six patients had moderate disability (GOS 4) and seven patients showed full recovery (GOS 5). None of the patients suffered from a procedural or postprocedural ischemic stroke. Conclusions: In patients with good collateral vascularization, proximal, or distal partial segment sacrifice via with endovascular coil occlusion seems to yield the best risk-benefit ratio for treatment of ruptured dissecting V4 aneurysms, especially since no continued anticoagulation is required and possibly essential surgery remains feasible in this scenario. If possible, PICA occlusion should be avoided-although even proximal PICA occlusion can become necessary, when weighing against the risk of an otherwise untreated ruptured V4 dissecting aneurysm. Contrarily, if the dominant V4 segment is affected, the hemodynamic asymmetry prohibits occlusion and necessitates reconstruction of the respective segment. For this, implants with high metal coverage treating the entire affected segment appear to be the most promising approach.

SUBMITTER: Schob S

PROVIDER: S-EPMC6424888 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms.

Schob Stefan S Becher Anett A Bhogal Pervinder P Richter Cindy C Hartmann Anna A Köhlert Katharina K Arlt Felix F Ziganshyna Svitlana S Hoffmann Karl-Titus KT Nestler Ulf U Meixensberger Jürgen J Quäschling Ulf U

Frontiers in neurology 20190313

<b>Objective:</b> Ruptured dissecting aneurysms of the intracranial vertebral arteries exhibit an extraordinarily high risk for morbidity and mortality and are prone to re-rupture. Therefore, early treatment is mandatory to induce stagnation of the critical dynamic mural process. Appropriate endovascular approaches are segment sacrifice and reconstruction, however, both carry specific risks and benefits. To date most studies discuss only one of these approaches and focus on one specific device o ...[more]

PMID: 30918497

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Project description:Background Aneurysmal rupture in the aortoiliac segment is a severe, life-threatening condition. Nowadays, in addition to surgical treatment, the implantation of a covered stent graft constitutes a feasible, minimally invasive treatment option. A novel approach is the add-on of transarterial aneurysm sac embolization with N-butyl-cyanoacrylate (NBCA). Here, we report our experience of performing this add-on embolization procedure after endovascular aneurysm repair for complex ruptured aneurysms of the aortoiliac segment. Material and Methods We describe six patients (mean age of 75.2 years; all male) with ruptured aneurysms in the visceral aortic and aortoiliac segment in whom a high-volume transarterial aneurysm sac embolization was performed as an add-on therapy to the implantation of an aortic prosthesis. The aim of this add-on intervention was to achieve the definite embolization of the aneurysmal rupture site and to ensure the best possible aneurysmal sealing. We report the feasibility, technical success, and considerations of using NBCA as well as clinical and follow-up imaging results, given their availability. Results Technical success was achieved in all cases. Clinical success was achieved in four cases. No periprocedural complications or reinterventions were reported. The mean full procedure time was 107.8 min. The mean radiation dose was 12,966.1 cGy/cm2. A mean amount of 10.7 mL of NBCA mixed with lipiodol in a 1:3 to 1:5 ratio was used for all patients. Available follow-up imaging up to 36 months after the procedure showed no aneurysm progression or endoleaks. In two patients, the NBCA cast had almost fully dissolved over the course of follow-up. Conclusions Our study underscores the notion that aneurysm sac embolization using high volumes of NBCA with ethiodized oil as an embolic agent is a feasible and add-on treatment option for optimizing the exclusion of the aneurysm from patients with ruptured aneurysms in the aortoiliac segment.

Project description:PurposeThe PEVAR Trial demonstrated that compared to open femoral exposure, elective percutaneous endovascular AAA repair (ePEVAR) is associated with decreased perioperative morbidity and access site complications. We hypothesized that PEVAR for ruptured AAA (rPEVAR) may also improve perioperative morbidity compared to open femoral exposure (rEVAR). There are currently no reports that evaluate the utility and outcomes of rPEVAR.Materials and methodsFrom 2015 to 2021, all patients who underwent an endovascular repair of a ruptured AAA at a single institution were included in the study and grouped into rPEVAR and rEVAR. Demographics, procedural details (successful preclose technique, conversion to femoral cutdown), postoperative variables (blood transfusion, ICU and hospital length of stay) and short-term outcomes (30-day major adverse events (30-day MAE) and 30-day femoral access-site complications (30-day FAAC)) were collected and compared with 50 historical ePEVAR patients from the PEVAR Trial. Statistical significance was determined using χ 2 or Fisher's exact test for categorical variables, and Mann-Whitney U-test for continuous variables.Results35 patients were identified (21 rPEVAR; 14 rEVAR), 86% were male with a mean age of 72 ± 9 years. All patients underwent emergent endovascular aortic repair with 100% technical success. Seventeen patients (49%) presented with evidence of hemorrhagic shock and 22 patients (63%) had blood transfusion. 30-day MAE occurred in 12 patients (34%) (7 rPEVAR; 5 rEVAR). There was no difference in demographic, perioperative outcomes and 30-day MAE rate between rPEVAR and rEVAR patients. Compared to ePEVAR patient (from PEVAR trial), rPEVAR patients had higher rate of 30-day MAE (34% vs. 6%; p < 0.006) but no difference in 30-day FAAC (19% vs. 12%; p = 0.54). The success rate of the preclose technique was higher in ePEVAR compared to rPEVAR (96% vs. 76%; p = 0.02), but the rate of conversion to femoral cutdown was similar between the two groups (10% vs. 4%; p = 0.57).ConclusionEmergent rPEVAR appears to have similar outcomes when compared to rEVAR. Although patients undergoing rPEVAR have higher 30-day major adverse events rate compared to ePEVAR, the method of percutaneous femoral cannulation does not appear to increase the overall procedural or 30-day femoral artery access-site complications.

Project description:Background and Purpose: Endovascular treatment (EVT) for acute vertebrobasilar intracranial atherosclerosis-related large vessel occlusion (ICAS-LVO) and its outcomes are not well known. We aimed to evaluate endovascular and clinical outcomes of vertebrobasilar ICAS-LVO patients who underwent EVT. Methods: Consecutive acute stroke patients who underwent EVT for vertebrobasilar LVO were retrospectively reviewed. Patients were assigned to the ICAS (+) or the ICAS (-) group based on angiographical findings. Procedural details and clinical outcomes were compared between the ICAS (+) and ICAS (-) groups. Results: This study included 77 patients with acute vertebrobasilar LVO who underwent EVT. Among the study subjects, 24 (31.2%) had an ICAS-LVO. Recanalization was achieved in 19 patients in the ICAS (+) group (79.2%), which was comparable with the ICAS (-) group (84.9%; p = 0.529). However, recanalization using conventional endovascular modalities (stent retriever thrombectomy, contact aspiration thrombectomy, or intra-arterial urokinase infusion) was less successful in the ICAS (+) group (36.8%) than the ICAS (-) group (100.0%; p < 0.001). All the remaining patients in the ICAS (+) group required specific rescue treatments appropriate for ICAS, including balloon angioplasty, stenting, or intra-arterial glycoprotein IIb/IIIa inhibitor infusion to obtain a successful recanalization. Procedural time was not significantly longer in the ICAS (+) group. The rates of favorable outcomes (37.5% vs. 41.5%; p = 0.740), death, and symptomatic intracerebral hemorrhage were not significantly different between the groups. Conclusion: ICAS-LVO was common in patients who underwent EVT for acute vertebrobasilar LVO. Although conventional modalities were often ineffective for vertebrobasilar ICAS-LVO, a comparable recanalization rate could be obtained with ICAS-specific modalities. Recanalization rate and procedural time were comparable, and clinical outcomes did not differ between patients with or without ICAS-LVO.

Project description:ObjectiveOutcomes of stent-assisted coil embolization (SACE) have not been well established in the setting of vertebrobasilar dissecting aneurysms (VBDAs) due to the low percentage of cases that need treatment and the array of available therapeutic options. Herein, we presented clinical and radiographic results of SACE in patients with VBDAs.Materials and methodsA total of 47 patients (M:F, 30:17; mean age ± SD, 53.7 ± 12.6 years), with a VBDA who underwent SACE between 2008 and 2014 at two institutions were evaluated retrospectively. Medical records and radiologic data were analyzed to assess the outcome of SACE procedures. Cox proportional hazards regression analysis was conducted to determine the factors that were associated with aneurysmal recanalization after SACE.ResultsStent-assisted coil embolization technically succeeded in all patients. Three cerebellar infarctions occurred on postembolization day 1, week 2, and month 2, but no other procedure-related complications developed. Immediately following SACE, 25 aneurysms (53.2%) showed no contrast filling into the aneurysmal sac. During a mean follow-up of 20.2 months, 37 lesions (78.7%) appeared completely occluded, whereas 10 lesions showed recanalization, 5 of which required additional embolization. Overall recanalization rate was 12.64% per lesion-year, and mean postoperative time to recanalization was 18 months (range, 3-36 months). In multivariable analysis, major branch involvement (hazard ratio [HR]: 7.28; p = 0.013) and the presence of residual sac filling (HR: 8.49, p = 0.044) were identified as statistically significant independent predictors of recanalization. No bleeding was encountered in follow-up monitoring.ConclusionStent-assisted coil embolization appears feasible and safe for treatment of VBDAs. Long-term results were acceptable in a majority of patients studied, despite a relatively high rate of incomplete occlusion immediately after SACE. Major branch involvement and coiled aneurysms with residual sac filling may predispose to recanalization.

Dataset Information

Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms.

Publications

Segment Occlusion vs. Reconstruction-A Single Center Experience With Endovascular Strategies for Ruptured Vertebrobasilar Dissecting Aneurysms.

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