Geoffrey P. Colby

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.

Predictors of functional outcome following treatment of posterior fossa arteriovenous malformations

Posterior fossa arteriovenous malformations (AVM) present particular therapeutic challenges. Studies aimed at clarifying risk of hemorrhage focus on obliteration rates, but few have addressed functional outcomes in these patients. In this study, we aim to explore the predictors of good functional outcome for posterior fossa AVM after treatment. A retrospective review of patients diagnosed with posterior fossa AVM at our institution from 1990 to 2013 was performed, and 61 patients met the inclusion criteria. Functional outcomes were assessed using the modified Rankin Scale (mRS), and mRS ⩽ 1 was defined as good outcome. Within our cohort, 39 patients presented with hemorrhage (64.0%). Spetzler-Martin grades were I (n = 9, 14.8%), II (n = 20, 32.8%), III (n = 22, 36.1%), IV (n = 8, 13.1%), and V (n = 2, 3.3%). Patients were treated with surgery (n = 8), radiosurgery (n = 34), embolization (n = 2) or multimodal therapies (n = 8). Nine patients did not undergo treatment. Average follow-up was 41.9 months. Obliteration of AVM was confirmed in 44.3% of patients (n = 27). Forty-three patients (70.5%) achieved good functional outcomes (mRS ⩽ 1). The absence of pre-treatment symptoms (p < 0.01) and AVM obliteration (p = 0.04) were predictive of good functional outcomes. In contrast, non-hemorrhagic presentation was not a significant predictor (p = 0.60). Asymptomatic presentation and AVM obliteration are associated with good functional outcomes in patients with posterior fossa AVM. Non-hemorrhagic presentation does not necessarily predict good functional outcome. Therefore treatment should not be considered only for those who present with hemorrhage. Posterior fossa AVM should be considered for definitive treatment in order to prevent future hemorrhages and subsequent poor functional outcomes.

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.

Hemorrhage risk and clinical features of multiple intracranial arteriovenous malformations

The aim of this report is to examine clinical characteristics, treatment strategies, and annual hemorrhage incidence rate for patients with multiple arteriovenous malformations (MAVM). The PubMed and EMBASE databases and the arteriovenous malformations (AVM) database at The Johns Hopkins Hospital were searched to identify patients with MAVM. Data related to demographics, clinical features, management, and treatment outcomes were analyzed with descriptive statistics. Thirty-eight patients met the inclusion criteria. The annual hemorrhage incidence rate was 6.7%. Surgical intervention remained the most common single-modality treatment from 1949-2011. Between 1990 and 2011, multiple-modality treatment strategies (36% of cases) were employed more frequently. The most common presenting features were neurological deficit (74%) and hemorrhage (63%). In patients undergoing staged treatment of MAVM, hemorrhage of an untreated nidus (n=5), visualization of a new nidus (n=9), and disappearance of an untreated nidus (n=2) were observed. Limitations of this study include small sample size and reporting bias. The annual hemorrhage incidence rate for MAVM patients was approximately two- to three-fold greater than the reported annual hemorrhage rates for solitary AVM. Combining different treatment modalities has become the most common management strategy. The potential instability of remaining nidi with staged or incomplete treatment necessitates close follow-up in these cases.

Femoral access in 100 consecutive subarachnoid hemorrhage patients: the "craniotomy" of endovascular neurosurgery

BackgroundFemoral access is a fundamental element of catheter-based cerebral angiography. Knowledge of location of the common femoral artery (CFA) bifurcation is important as the risk of retroperitoneal bleeding is increased if the puncture is superior to the inguinal ligament and there is an increased risk of thrombosis and arteriovenous fistula formation if the puncture is distal into branch vessels. We sought to characterize the location of the CFA bifurcation along with the presence of significant atherosclerosis or iliac tortuosity in a contemporary series of subarachnoid hemorrhage (SAH) patients.FindingsThe records of a prospective single-center aneurysm database were reviewed to identify 100 consecutive SAH patients. Using an oblique femoral arteriogram, the presence of significant atherosclerosis, iliac tortuosity, and the CFA bifurcation were assessed. The CFA bifurcation was graded according to its position with respect to the femoral head: below (grade 1), lower half (grade 2), and above the upper half (grade 3).We found a CFA bifurcation grade 1 in 50 patients (50%, mean age 51.2 years), grade 2 in 40 patients (40%, mean age 55.5 years), and grade 3 in 10 patients (10%, mean age 58.2 years). Whereas 30 of 90 patients with CFA grades I or II were male (33%), only 10% with grade 3 were male (1 of 10, p = 0.12). Mean age for significant atherosclerosis was 65.5 +/- 2.6 years versus 50.9 +/- 1.6 years (p < 0.001) without, and iliac tortuosity was 64.9 +/- 2.4 years versus 50.3 +/- 1.6 years (p < 0.001) without.ConclusionsAlthough a requisite element of endovascular treatment in SAH patients, femoral access can be complicated by a high common femoral artery bifurcation and the presence of atherosclerotic disease and/or iliac artery tortuosity. In this study, we found a grade 3 (above the femoral head) CFA bifurcation in 10% patients, with 90% of these patients being female. We also found the presence of atherosclerotic disease and iliac tortuosity to be significantly more likely in patients older than 65 years of age.

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

Retained transcranial knife blade with transection of the internal carotid artery treated by staged endovascular and surgical therapy: technical case report.

BACKGROUND AND IMPORTANCE: We describe the use of proximal and distal endovascular coil embolization of the internal carotid artery followed by operative removal of a retained foreign object transecting the petrocavernous portion of the internal carotid artery. CLINICAL PRESENTATION: A 20-year-old man sustained a stab wound to the left temporal skull and presented with a retained knife blade. He reported a headache at presentation, but remained neurologically intact with a Glasgow Coma Scale of 15. Computed tomography imaging and subsequent angiography confirmed complete transection of the petrocavernous segment of the left internal carotid artery with effective tamponade by the knife blade in situ and satisfactory collateral flow across the Circle of Willis. Coil embolization of the left internal carotid artery was performed. Retrograde embolization of the petrocavernous internal carotid segment distal to the injury was performed via vertebral and posterior communicating artery access. Antegrade embolization of the internal carotid artery proximal to the injury was completed and the patient was transferred to the operating room for craniectomy and foreign body extraction. Postoperative computed tomography angiography revealed no parenchymal hemorrhage, mass effect, or midline shift, and successful embolization of the internal carotid artery. At 6-week follow-up, the patient remained neurologically intact with no infectious or vascular complications. CONCLUSION: Staged endovascular and surgical therapy provides complete assessment and effective control of damaged vessels when retained intracranial foreign bodies are present. Given the high risk of vascular injury with retained transcranial foreign bodies, this strategy should be considered a safe approach for these challenging cases. ABBREVIATIONS: GCS, Glasgow Coma Scale ICA, internal carotid artery