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Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms.

ABSTRACT: Background: Wide-necked cerebral aneurysms at a bifurcation can be difficult to treat with endovascular techniques despite recent advancements. Objective: We describe a new technique of micro-scaffold remodeling of the aneurysm neck of wide-necked bifurcation aneurysms by placing one or more microcatheters and/or wires in the efferent vessels. We hypothesize that this technique would be a better choice to change the branch angulation, allowing for an improved configuration to stably deploy coils. We present a retrospective case series to illustrate this technique. Methods: 17 wide-necked bifurcation aneurysms in 17 patients were coil embolized using this technique during a 3 year study period. Branch-vessel microcatheters and/or microwires were used to remodel the aneurysm neck and support the coil mass. Statistical analysis of the branch angulation and neck-width changes were performed during treatment. Long-term clinical outcome and follow-up angiography was obtained in 8 patients. Results: Eleven patients had complete occlusion of their aneurysm (Raymond-Roy Class I), and 6 patients had Raymond-Roy Class 2 immediately after treatment. Efferent vessels demonstrated a statistically significant change in angulation with insertion of microcatheters or microwires, while neck width did not change significantly. There were four intraoperative complications and no neurological morbidity in the immediate post-operative period. Complete occlusion was documented for all 10 subjects with long-term follow-up. Conclusions: The micro-scaffold endosurgical remodeling technique is a useful adjunct in treating wide-necked bifurcation aneurysms. By elevating branch vessels away from the aneurysm neck, this technique allows for dense coil packing while decreasing the need for balloon or stent assistance.

SUBMITTER: Dayawansa S

PROVIDER: S-EPMC6435532 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Y-stent-assisted coiling for wide-neck intracranial aneurysms required further investigation. PURPOSE:Our aim was to analyze outcomes after Y-stent placement in wide-neck aneurysms. DATA SOURCES:We performed a systematic search of 3 data bases for studies published from 2000 to 2018. STUDY SELECTION:According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting Y-stent-assisted coiling of wide-neck aneurysms. DATA ANALYSIS:Random-effects meta-analysis was used to pool the following: aneurysm occlusion rate, complications, and factors influencing the studied outcomes. DATA SYNTHESIS:We included 27 studies and 750 aneurysms treated with Y-stent placement. The immediate complete/near-complete occlusion rate was 82.2% (352/468; 95% CI, 71.4%-93%; I2 = 92%), whereas the long-term complete/near-complete occlusion rate was 95.4% (564/598; 95% CI, 93.7%-97%; I2 = 0%) (mean radiologic follow-up of 14 months). The aneurysm recanalization rate was 3% (20/496; 95% CI, 1.5%-4.5%; I2 = 0%), and half of the recanalized aneurysms required retreatment. The treatment-related complication rate was 8.9% (63/614; 95% CI, 5.8%-12.1%; I2 = 44%). Morbidity and mortality after treatment were 2.4% (18/540; 95% CI, 1.2%-3.7%; I2 = 0%) and 1.1% (5/668; 95% CI, 0.3%-1.9%; I2 = 0%), respectively. Crossing Y-stent placement was associated with a slightly lower complication rate compared with the kissing configuration (56/572 = 8.4%; 95% CI, 5%-11%; I2 = 46% versus 4/30 = 12.7%; 95% CI, 3%-24%; I2 = 0%). Occlusion rates were quite comparable among Enterprise, Neuroform, and LVIS stents, whereas the Enterprise stent was associated with lower rates of complications (8/89 = 6.5%; 95% CI, 1.6%-11%; I2 = 0%) compared with the others (20/131 = 14%; 95% CI, 5%-26%; I2 = 69% and 9/64 = 11%; 95% CI, 3%-20%; I2 = 18%). LIMITATIONS:This was a small, retrospective series. CONCLUSIONS:Y-stent-assisted coiling yields high rates of long-term angiographic occlusion, with a relatively low rate of treatment-related complications. Y-stent placement with a crossing configuration appears to be associated with better outcomes. Although Y-configuration can be obtained using many types of stents with comparable occlusion rates, the Enterprise stent is associated with lower complication rates.

Project description:Background and purposeWe present the results of a systematic review and meta-analysis examining outcomes of endovascular coiling of wide-neck and wide-neck bifurcation aneurysms with and without stent assistance. The aim of our study was to assess angiographic and clinical outcomes.Materials and methodsWe performed a comprehensive literature search for all articles on the endovascular coiling of wide-neck and wide-neck bifurcation aneurysms. Studies meeting our inclusion criteria and abstracted data were selected by 2 independent reviewers. Primary outcomes were >6-month complete or near-complete angiographic occlusion, aneurysm recanalization, and aneurysm retreatment. Secondary outcomes included initial complete or near-complete occlusion, long-term good neurologic outcome, procedure-related morbidity, and procedure-related mortality. Data were analyzed by using random-effects meta-analysis.ResultsIn total, 38 studies including 2446 patients with 2556 aneurysms were included. For all wide-neck aneurysms, immediate complete or near-complete occlusion rate was 57.4% (95% CI, 48.1%-66.8%). Follow-up near-complete occlusion rate was 74.5% (95% CI, 68.0%-81.0%). Recanalization and retreatment rates were 9.4% (95% CI, 7.1%-11.7%) and 5.8% (95% CI, 4.1%-7.5%), respectively. Long-term good neurologic outcome was 91.4% (95% CI, 88.5%-94.2%). For wide-neck bifurcation aneurysms, initial complete or near-complete occlusion rate was 60.0% (95% CI, 42.7%-77.3%), long-term complete or near-complete occlusion rate was 71.9% (95% CI, 52.6%-91.1%), and the recanalization and retreatment rates were 9.8% (95% CI, 7.1%-12.5%) and 5.2% (95% CI, 1.9%-8.4%), respectively.ConclusionsOur study of angiographic and clinical outcomes for patients with wide-neck aneurysms demonstrates that endovascular coiling with or without stent-assisted coiling is safe, with low rates of perioperative morbidity and mortality. Initial and long-term angiographic outcomes were generally satisfactory, but not ideal. These data provide some baseline comparisons against which emergent technologies can be assessed.

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Endosurgical Remodeling of Wide-Necked Bifurcation Aneurysms.

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