Bowen Jiang

Immediate procedural outcomes in 44 consecutive Pipeline Flex cases: the first North American single-center series

Background Flow diversion is an established technique for treatment of cerebral aneurysms. The Pipeline embolization device (PED) is the only FDA-approved flow diverting stent in the USA. A second-generation device, PED Flex, has recently been released with modifications to the delivery system. Published reports of experience with this new device are limited. Objective To describe the initial outcomes from the first North American series using the PED Flex—a single-center experience of 44 cases. Methods All patients consecutively treated with the PED Flex embolization device from February 2015 through April 2015 were included in the study. Data were collected for patient demographics, aneurysm characteristics, technical procedural details, and early outcomes. Results PED Flex treatment was attempted in 42 patients (mean 56.6±2.0u2005years) with 44 aneurysms (mean size 6.5±0.6u2005mm), 41/44 (93%) of which were anterior circulation and 3/44 (7%) were posterior circulation. PED Flex was successfully implanted in 43/44 cases (98%). A single device was used in 41/43 cases (95%), with a mean of 1.07±0.05 devices implanted per case. Resheathing was performed in 4/44 cases (9%). Mean postprocedure hospital length of stay was 1.3±0.2u2005days. One significant neurological complication (2.3%) occurred, which was a stroke in a patient non-compliant with the prescribed antiplatelet regimen. Conclusions Pipeline Flex is a second-generation flow diverter with enhanced features compared with the first-generation PED. These modifications allow for more reliable deployment with continued improvements in procedural safety.

Declining complication rates with flow diversion of anterior circulation aneurysms after introduction of the Pipeline Flex: analysis of a single-institution series of 568 cases

OBJECTIVEThe second-generation Pipeline embolization device (PED), Flex, has several design upgrades, including improved opening and the ability to be resheathed, in comparison with the original device (PED classic). The authors hypothesized that Flex is associated with a lower rate of major complications.METHODSA prospective, IRB-approved, single-institution database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion. The PED classic was used from August 2011 to January 2015, and the Pipeline Flex has been used since February 2015.RESULTSA total of 568 PED procedures (252 classic and 316 Flex) were performed for anterior circulation aneurysms. The average aneurysm size was 6.8 mm. Patients undergoing treatment with the Flex device had smaller aneurysms (p = 0.006) and were more likely to have undergone previous treatments (p = 0.001). Most aneurysms originated along the internal carotid artery (89% classic and 75% Flex) but there were more anterior cerebral artery (18%) and middle cerebral artery (7%) deployments with Flex (p = 0.001). Procedural success was achieved in 96% of classic and 98% of Flex cases (p = 0.078). Major morbidity or death occurred in 3.5% of cases overall: 5.6% of classic cases, and 1.9% of Flex cases (p = 0.019). On multivariate logistic regression, predictors of major complications were in situ thrombosis (OR 4.3, p = 0.006), classic as opposed to Flex device (OR 3.7, p = 0.008), and device deployment in the anterior cerebral artery or middle cerebral artery as opposed to the internal carotid artery (OR 3.5, p = 0.034).CONCLUSIONSFlow diversion of anterior circulation cerebral aneurysms is associated with an overall low rate of major complications. The complication rate is significantly lower since the introduction of the second-generation PED (Flex).

P-016 Successful Flow Diversion of Cerebral Aneurysms in Plavix Hyporesponders (PRU ≥ 200): An Argument for Antiplatelet Monotherapy?

Introduction Endovascular aneurysm treatment by flow diversion has classically relied on dual anti-platelet therapy with Aspirin and Plavix to reduce thrombotic complications. The heterogenous Plavix response of patients has made P2Y12 testing increasingly popular. Plavix hyporesponders (defined as PRU ≥ 200) are often re-dosed with Plavix or switched to alternate anti-platelet regimens. However, little clinical validation exists for these practices, and they might actually increase risks of hemorrhagic complications. We sought to evaluate periprocedural outcomes following flow diversion in patients maintained on standard Aspirin and Plavix regimens with PRU ≥ 200. Methods A single-center prospectively collected aneurysm database was reviewed for adult patients on standard dual antiplatelet regimens (Aspirin 325 mg + Plavix 75 mg daily) who underwent endovascular embolization of ICA and proximal ACA/Acom aneurysms with the Pipeline Embolization Device (PED). Patients with pre-embolization P2Y12 testing and PRU level ≥200 were included. Results 49 patients (mean age 56, 74% women) met inclusion criteria. Forty-seven (96%) patients had a single aneurysm treated, and 2 (4%) had 2 aneurysms treated; 84% of aneurysms were on the ICA and 16% on the ACA (Acom and A1-2). Aneurysm size ranged from 2–28 mm. PED length ranged from 10–35 mm. Pre-procedure PRU levels ranged from 200 to 361. RePro was administered in 5/49 (10%) cases, with platelet plug visualized in 4/49 cases (8%). Four patients (8%) had transient neurological deficits (resolved completely during hospital stay), with only 1 of these requiring ReoPro during the procedure. No patients had major or minor permanent strokes, and no patients had hemorrhagic complications. Conclusions Hyporesponse to Plavix (PRU ≥ 200) is not a contraindication to aneurysm treatment with the PED in patients on a standard dual antiplatelet regimen of Aspirin 325 mg and Plavix 75 mg daily. These data suggest a diminutive role of Plavix in preventing thrombotic complications during these procedures. Disclosures G. Colby: 1; C; Stryker, Medtronic. 2; C; Microvention. L. Lin: 1; C; Stryker. D. Lubelski: None. M. Bender: None. R. Xu: None. B. Jiang: None. J. Huang: None. R. Tamargo: None. A. Coon: 1; C; Sequent. 2; C; Stryker, Medtronic, Microvention, Sequent.

Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice

Background: The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown. Methods: We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon’s practice. Results: A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location (P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion. Conclusion: Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically.

Bullough’s bump: unusual protuberant fibro-osseous tumor of the temporal bone. Case report

Scalp and calvarial masses are common in children and the differential diagnosis is broad. The authors recently cared for a child with an unusual fibro-osseous lesion of the temporal bone that has previously not been described in the pediatric neurosurgery literature. A 10-year-old girl presented with a firm, slowly enlarging protuberant mass arising from the squamous suture of the temporal bone without intracranial extension. The mass was removed en bloc through a temporal craniectomy and cranioplasty was performed. The patient had a smooth postoperative course. Histological examination showed multiple oval osseous islands dispersed throughout a bland fibrous stroma. The pathological diagnosis was Bulloughs bump, a rare, benign fibro-osseous neoplasm first described in 1999, and only 8 reported cases appear in the literature. Here the authors report the first case of Bulloughs bump in a child.

Pipeline Embolization for Salvage Treatment of Previously Stented Residual and Recurrent Cerebral Aneurysms

Introduction: This study assessed the safety and effectiveness of the Pipeline embolization device (PED) for persistent and recurrent aneurysms previously treated with either a vascular reconstruction device (VRD) or a flow diverter (FD). Methods: A prospective, IRB-approved database was analyzed for patients treated with PED for aneurysms previously treated with a stent. Results: Twenty procedures were performed on 18 patients, 11 with prior FD, 7 with VRD, and 2 previously treated with both. Overall, 15 aneurysms were saccular (75%), and size was 13.5 ± 7.6 mm. Location was internal carotid artery (ICA) in 14 cases (70%) and posterior circulation in 6 cases (30%). Average prior treatments were 1.7. Previously FD cases were re-treated at an average of 18.1 months from most recent treatment. Each case used 1 device, 82% with distal coverage and 82% with proximal coverage of prior stent. Balloon remodeling was performed in 3 cases (27%) and no in-stent thrombosis was observed. Previously VRD stent-coiled cases were re-treated at an average of 87.5 months. These cases used on average 1.9 devices, 89% with distal and 100% proximal coverage. Adjunctive coiling was performed in 1 case (11%), balloon remodeling in 5 cases (56%), and 2 cases (28%) developed thrombosis that resolved with abciximab. Re-VRD cases were longer (59.1 vs. 33.7 min, p = 0.02) than re-FD. Angiographic follow-up was available for 16 cases (80%). In re-FD, occlusion was complete in 56% and partial progressive in 33% at 17.1 months digital subtraction angiography. In re-VRD, occlusion was complete in 57% and partial progressive in 27% at 8.1 months. Two complications occurred (10%), including one asymptomatic cervical ICA occlusion and one stent occlusion with associated mortality (5%). Clinical follow-up was 17.8 months on average (range 0.5–51.9). Conclusions: Salvage flow diversion for previously stented aneurysms is technically challenging but offers good prospects of aneurysm obliteration with acceptable complication rates.

E-100 Use of the 0.027 VIA Microcatheter for Pipeline Embolization of Cerebral Aneurysms: A Technical Note

Introduction Pipeline embolization devices (PEDs) are designed for delivery through a 0.027” microcatheter such as the Marksman (Medtronic). Challenges with second generation FlexPEDs include limited support from the Marksman for consistent resheathing and providing enough push for delivery. The VIA27 (Sequential) is an alternative 0.027” microcatheter originally designed for intrasaccular flow diverter delivery. Here we describe our experience with the VIA27 in the delivery of PEDs. Methods We retrospectively identified patients who underwent PED treatment with the VIA27 microcatheter at our institution. Patient demographics, equipment utilized, intraprocedural catheter positions and periprocedural complications were documented. Results 36 patients underwent 40 embolizations of 44 aneurysms with 48 PEDs (Table 1) using the VIA27. The average age was 59.9 ± 11.0 years; 7 (17.5%) were male. Most aneurysms 41 (93.2%) were located anteriorly. The average aneurysm size was 7.2 mm with 38 (86.4%) small, 3 (6.82%) large, and 3 (6.82%) giant. The VIA27 was successfully used to deploy all 48 PEDs (Figure 1). 6 attempts were made to resheath the PED during placement; all were successful. The distal tip of the catheter was located in the ACA 4 (10%), MCA 32 (80%), supraclinoidal ICA 1 (2.5%), basilar 2 (5%), and distal vertebral 1 (2.5). In 3 (7.5%) cases where the VIA27 catheter was unable to track, alternate catheters were used to advance and then exchanged back to the VIA27. In 3 (7.5%) instances, the Marksman was unable to provide adequate push for PED deployment; the VIA27 was exchanged for placement of the PED. No patients experienced iatrogenic vessel injury or other microcatheter associated complications.Abstract E-100 Table 1 Number (%) Total cases 40 Total patients 36 Age (years) 59.9 ± 11.0 Male 7 (17.5%) Total aneurysms treated 44 Aneurysm size 7.2 mm Anterior circulation 41 (93.2%) Cavernous 6 (14.6) Clinoidal 3 (7.3) Ophthalmic 14 (34.1) Communicating 12 (29.3) Anterior communicating 5 (12.2) Distal ACA 1 (2.3) Posterior circulation 3 (6.8) PICA 1 (2.3) Vertebral 2 (4.5) Triaxial system 40 Guide sheath NeuronMax 32 (80) Select catheter JB-1 34 (85) Guide catheter Catalyst 0.058 36 (90) Navien 0.058 8 (20) Microcatheter Via 0.027 inch 40 (100) Marksman 3 (7.5) Pipeline embolization devices 48 Cervical tortuosity 10 (25%) Guide catheter position ACA 4 (10) MCA 32 (80) Supraclinoidal ICA 1 (2.5) Basilar 2 (5) Vertebral 1 (2.5) Clinical success VIA tracked to target 40 (100) Successful resheathing 6/6 (100%) Successful treatment 40 (100)Abstract E-100 Figure 1 (A) Angiogram demonstrates a R Pcomm aneurysm. (B) Introduction of the PED. The distal PED was opened in the MCA and withdrawn back into the supraclinoid ICA

E-097 Use of the Catalyst 5 Distal Access Catheter for Treatment of Intracranial Aneurysms: The First North American Experience

Introduction Distal intracranial support systems provide a safe and stable foundation during endovascular approaches to intracranial aneurysms. Increased catheter support allows for precise manipulation of microcatheters/devices, critical when dealing with distal targets, larger device-delivery systems, and increased vessel tortuosity. The Navien and Neuron catheters were developed to meet this demand. Here, we report the first published experience using the AXS Catalyst 5 catheter (Stryker), the newest next-generation distal access catheter. Methods A single-center aneurysm database was reviewed to identify patients who underwent endovascular embolization with the Catalyst 5 (Figure 1). Patient demographics, equipment utilized, cervical ICA tortuosity, intraprocedural catheter positions, and periprocedural complications were documented.Abstract E-097 Figure 1 (A) The Catalyst5 distal access catheter. (B) Pipeline embolization of an 2.7mm L A2-A3 aneurysm. The FlexPED is in the A2/A3 junction with the VIA and Catalyst catheters