Denis Herbreteau

A proposed angiographic classification of intracranial arteriovenous fistulae and malformations

We propose an angioarchitectural classification of intracranial vascular lesions as arteriovenous, arteriolovenous and arteriolovenulous fistulae. In order to validate this classification, 99 intracranial arteriovenous lesions were reviewed in 98 patients. Arteriolovenulous fistulae included 39 isolated brain arteriovenous malformations (AVMs) and 1 AVM associated with a giant arteriovenous fistula (AVF). Arteriovenous fistulae included 8 giant AVFs of the brain, 6 vein of Galen aneurysms and 10 direct caroticocavernous fistulae. Arteriolovenous fistulae included 1 isolated brain AVM, 4 vein of Galen aneurysms and 30 dural AVMs. The angioarchitectural classification has three advantages. It is simple and accurate, with no reference to the congenital or acquired nature of the lesion. It allows separate identification of a special group, the arteriolovenous fistulae. It also indicates the endovascular approach: arteriolovenulous fistulae should be treated via the arterial route only, while arteriovenous and arteriolovenous fistulae can be treated via transarterial or transvenous approaches.

Uterine necrosis after arterial embolization for postpartum hemorrhage

BACKGROUND Selective embolization is an effective and reputedly safe method of managing pregnancy-related bleeding. However, we report an ischemic uterine necrosis after arterial embolization. CASE The patient had heavy postpartum bleeding treated by embolization of the uterine arteries using polyvinyl alcohol particles (diameter 150–250 and 300–600 μm) and gelatin sponge pledgets. Her postoperative recovery was complicated by menorrhagia and pelvic pain. Because of the persistent menorrhagia and risk of infection, a hysterectomy was performed. Histopathology of the hysterectomy specimen revealed massive ischemic myometrial necrosis. CONCLUSION This complication is most likely related to the small size of the particles used. In the management of postpartum bleeding by arterial embolization, the material of choice is gelatin sponge pledgets, and the use of small particles should be avoided.

Long-Term Follow-Up of 1036 Cerebral Aneurysms Treated by Bare Coils: A Multicentric Cohort Treated between 1998 and 2003

BACKGROUND AND PURPOSE: The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms. MATERIALS AND METHODS: Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment. RESULTS: Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results. CONCLUSIONS: Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.

Predictive factors for fibroids recurrence after uterine artery embolisation

Objectives  To assess clinical failure and symptom recurrence after uterine artery embolisation (UAE) and to define predictive factors.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms.

BACKGROUND AND PURPOSE: The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population. MATERIALS AND METHODS: Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed. RESULTS: Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3–24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%). CONCLUSIONS: In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Endovascular treatment of brain arteriovenous malformations using onyx: Results of a prospective, multicenter study

BACKGROUND AND PURPOSE To evaluate the safety and efficacy of onyx for embolization of brain arteriovenous malformations (BAVM). METHODS A prospective, multicenter study was conducted in France to evaluate embolization of BAVM with onyx. From May 2003 to March 2005, 50 patients (26 females, 24 males; mean age: 34.8 years, range: 16-64years) were included. Clinical presentation was haemorrhage in 22 patients (44.0%), seizures in 16 patients (32.0%), headaches in six patients (12.0%) and progressive neurological deficit in two cases (4.0%). Four patients were asymptomatic (8.0%). RESULTS One hundred and forty-ninesessions of embolization were performed: one to eight sessions/patient with a mean of 3.0sessions. One hundred and sixteen sessions (77.9%) were performed with onyx, 20 sessions (13.4%) with glue and 13 sessions (8.7%) with onyx and glue. Symptomatic acute postembolization haemorrhage (APEH) was observed in four cases (8.0% per patient). At 1 month, morbidity and mortality related to the treatment were of 8% and 2%, respectively. Complete BAVM occlusion was obtained in 8.3% of cases. In the remaining cases, occlusion rate was between 99 and 80% in 56.3% of patients, 79 and 60% in 16.7%, and less than 60 in 18.7%. In case of incomplete occlusion, complementary treatment was performed by radiosurgery. CONCLUSION Onyx is suitable for BAVM embolization with acceptable morbidity and mortality.

Safety and efficacy of aneurysm treatment with WEB: results of the WEBCAST study.

OBJECT WEB is an innovative intrasaccular treatment for intracranial aneurysms. Preliminary series have shown good safety and efficacy. The WEB Clinical Assessment of Intrasaccular Aneurysm Therapy (WEBCAST) trial is a prospective European trial evaluating the safety and efficacy of WEB in wide-neck bifurcation aneurysms. METHODS Patients with wide-neck bifurcation aneurysms for which WEB treatment was indicated were included in this multicentergood clinical practices study. Clinical data including adverse events and clinical status at 1 and 6 months were collected and independently analyzed by a medical monitor. Six-month follow-up digital subtraction angiography was also performed and independently analyzed by a core laboratory. Success was defined at 6 months as complete occlusion or stable neck remnant, no worsening in angiographic appearance from postprocedure, and no retreatment performed or planned. RESULTS Ten European neurointerventional centers enrolled 51 patients with 51 aneurysms. Treatment with WEB was achieved in 48 of 51 aneurysms (94.1%). Adjunctive implants (coils/stents) were used in 4 of 48 aneurysms (8.3%). Thromboembolic events were observed in 9 of 51 patients (17.6%), resulting in a permanent deficit (modified Rankin Scale [mRS] Score 1) in 1 patient (2.0%). Intraoperative rupture was not observed. Morbidity (mRS score > 2) and mortality were 2.0% (1 of 51 patients, related to rupture status on entry to study) and 0.0% at 1 month, respectively. Success was achieved at 6 months in 85.4% of patients treated with WEB: 23 of 41 patients (56.1%) had complete occlusion, 12 of 41 (29.3%) had a neck remnant, and 6 of 41 (14.6%) had an aneurysm remnant. CONCLUSIONS The WEBCAST study showed good procedural and short-term safety of aneurysm treatment with WEB and good 6-month anatomical results.

Late Leiomyoma Expulsion after Uterine Artery Embolization

A case of late expulsion of a leiomyoma after uterine artery embolization (UAE) is reported in a 49-year-old woman who underwent UAE for a huge (13 cm x 12 cm; 1,061 cm(3)) bleeding- and bulk-related intramural leiomyoma diagnosed with ultrasonography. Free-flow embolization was performed with 150-400-microm polyvinyl alcohol particles and absorbable particle sponge. Symptoms and myoma size were successfully controlled until 44 months, at which time the patient reported vaginal discharge. A 7-cm necrotic, partly submucosal leiomyoma was detected. The patient refused hysterectomy and spontaneously expelled the leiomyoma through the cervix 6 months later. In conclusion, UAE necessitates long-term follow-up and women should be warned of late complications.

WEB Treatment of Intracranial Aneurysms: Clinical and Anatomic Results in the French Observatory

BACKGROUND AND PURPOSE: Flow disruption with the WEB device is a new technique for the endovascular treatment of wide-neck bifurcation aneurysms. To obtain precise data regarding the safety and efficacy of this treatment with high-quality methodology, the prospective French Observatory study was conducted. Analysis of these data is presented, including 1-year follow-up. MATERIALS AND METHODS: Patients with bifurcation aneurysms for which WEB treatment was indicated were included in this prospective, multicenter Good Clinical Practice study. Clinical data, including adverse events and clinical status at 1 month and 1 year, were collected and independently analyzed by a medical monitor. An independent core laboratory evaluated the anatomic results at 1 year following the procedure. RESULTS: Ten French neurointerventional centers included 62 patients (39 women), 33–74 years of age (mean, 56.6 ± 9.80 years) with 63 aneurysms. Aneurysm locations were the middle cerebral artery in 32 aneurysms (50.8%), anterior communicating artery in 16 (25.4%), basilar artery in 9 (14.3%), and internal carotid artery terminus in 6 (9.5%). Morbidity and mortality at 1 month were, respectively, 3.2% (2/62 patients) and 0.0% (0/62). Morbidity and mortality (unrelated to the treatment) at 1 year were, respectively, 0.0% (0/59) and 3.4% (2/59 patients). At 1 year, complete occlusion was observed in 30/58 aneurysms (51.7%); neck remnant, in 16/58 aneurysms (27.6%); and aneurysm remnant, in 12/58 aneurysms (20.7%). CONCLUSIONS: This prospective French Observatory study showed very good safety of aneurysm treatment with the WEB, with a high rate of adequate aneurysm occlusion at 1 year (79.3%).

WEB Treatment of Intracranial Aneurysms: Feasibility, Complications, and 1-Month Safety Results with the WEB DL and WEB SL/SLS in the French Observatory

BACKGROUND AND PURPOSE: Safety analyses in the French Observatory have shown that treatment of intracranial aneurysms by using flow disruption with the Woven EndoBridge Device (WEB) is safe, with low morbidity and no mortality. The objective of this study was to analyze treatment feasibility, complications, and safety results in patients treated with the Woven EndoBridge Device Dual-Layer (WEB DL) and Woven EndoBridge Device Single-Layer/Single-Layer Sphere (WEB SL/SLS) in the French Observatory. MATERIALS AND METHODS: Patients with bifurcation aneurysms were included in this prospective, multicenter good clinical practices study. A medical monitor independently analyzed procedural and clinical data. The study started with the WEB DL, and secondarily, the WEB SL/SLS was authorized in the study. RESULTS: Between November 2012 and January 2014, 10 French centers included 62 patients with 63 aneurysms. Thirty patients with 31 aneurysms were treated with the WEB DL, and 32 patients with 32 aneurysms, with the WEB SL/SLS. The percentage of anterior communicating artery aneurysms treated with WEB SL/SLS was significantly higher (37.5%) compared with WEB DL (12.9%) (P = .04). The WEB SL/SLS was more frequently used in aneurysms of <10 mm than the WEB DL (respectively, 96.9% and 67.7%; P = .002). Morbidity was similar in both groups (WEB DL, 3.3%; WEB SL/SLS, 3.1%), and mortality was 0.0% in both groups. CONCLUSIONS: This comparative study shows increased use of WEB treatment in ruptured, small, and anterior communicating artery aneurysms when using WEB SL/SLS. There was a trend toward fewer thromboembolic complications with the WEB SL/SLS. With both the WEB DL and WEB SL/SLS, the treatment was safe, with low morbidity and no mortality.