Kivilcim Yavuz

Treatment of Intracranial Aneurysms Using the Pipeline Flow-Diverter Embolization Device: A Single-Center Experience with Long-Term Follow-Up Results

BACKGROUND AND PURPOSE: Flow-diverting devices now offer a new treatment alternative for cerebral aneurysms. We present the results of a large single-center series of patients treated with the PED, including long-term follow-up. MATERIALS AND METHODS: Between November 2008 and September 2011, sidewall aneurysms with a wide neck (≥4 mm) or unfavorable dome-neck ratio (≤1.5); large/giant, fusiform, dissecting, blisterlike, and recurrent sidewall aneurysms; aneurysms at difficult angles; and aneurysms in which a branch was originating directly from the sac were treated with the PED. Patients were premedicated with dual antiplatelet medications. Data, including demographics, aneurysm features, clinical presentation, complications, results, and follow-up information, for up to 2 years are presented. RESULTS: Two hundred fifty-one aneurysms in 191 patients were treated. Of these, 96 (38.3%) were large or giant (≥10 mm). In 34/251 (13.5%), PEDs were used for retreatment. Adjunctive coiling was performed in 11 aneurysms (2.1%). The mean number of devices per aneurysm was 1.3. One aneurysm ruptured in the fourth month posttreatment (0.5%), and symptomatic in-construct stenosis was detected in 1 patient (0.5%) treated with percutaneous transarterial angioplasty. Any event rate was 27/191 (14.1%), with a permanent morbidity of 1% and mortality of 0.5%. Control angiography was available in 182 (95.3%) patients with 239 (95.2%) aneurysms. In 121 aneurysms (48.2%), 1- to 2-year control angiography was available. The aneurysm occlusion rate was 91.2% in 6 months, increasing to 94.6%. CONCLUSIONS: Use of the PED is safe, efficacious, and durable in cerebral aneurysm treatment, with low morbidity-mortality and high occlusion rates as confirmed with mid- to long-term control angiography.

Endovascular Treatment of Middle Cerebral Artery Aneurysms with Flow Modification with the Use of the Pipeline Embolization Device

BACKGROUND AND PURPOSE: The Pipeline Embolization Device was reported to be safe and effective in the treatment of sidewall aneurysms, preserving the patency of the vessels covered by the construct. However, to date, the safety and efficacy of this device in treating bifurcation aneurysms remains unknown. We report our preliminary experience with the use of the Pipeline Embolization Device in the management of MCA aneurysms located at the bifurcations, including mid- and long-term follow-up data. MATERIALS AND METHODS: Wide-neck MCA aneurysms, which give rise to a bifurcating or distal branch in which other endovascular techniques are thought to be unfeasible or more risky, were included. Data including demographics, aneurysm features, antiplatelet therapy, complications, and angiographic follow-up results for up to 30 months were recorded. RESULTS: Twenty-five aneurysms located at the MCA bifurcation (n = 21) or distal (n = 4) were treated. Of these, 22 were small and 3 were large. A single device was used in all but 2. No deaths occurred in the series. All patients had at least 1 control angiographic study, 21 of which were DSA (3–30 months), which showed that 12 of the rising branches were patent whereas 6 were filling in reduced caliber and 3 were occluded asymptomatically. According to the last angiographic follow-up, complete occlusion was revealed in 21 of 25 aneurysms (84%). CONCLUSIONS: The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky.

Stent-Assisted Coiling in Endovascular Treatment of 500 Consecutive Cerebral Aneurysms with Long-Term Follow-Up

Five hundred aneurysms treated with a variety of self-expanding stents were clinically assessed and followed angiographically at 6–7 months postprocedure. Thromboembolic phenomena occurred in 21 patients and intraoperative rupture in 4. Initial complete occlusion was achieved in 42.2% progressing to 90.8% at follow-up. Early and late recanalizations were noted in 8% and 2%, respectively. BACKGROUND AND PURPOSE: Stent-assisted coil embolization has become one of the most preferred techniques in the treatment of wide-neck intracranial aneurysms; however, long-term patency and safety of the self-expanding neurostents and their role in durability of the endovascular treatment has remained ambiguous. We sought to retrospectively examine the long-term results of self-expanding stent usage in conjunction with coil embolization in treatment of wide-neck cerebral aneurysms. MATERIALS AND METHODS: We coiled 500 wide-neck cerebral aneurysms with different types of self-expanding neurostent assistance in 468 patients. Patient and aneurysm characteristics, pharmacologic therapy protocol, complications, and initial occlusion grades were analyzed. Patients underwent angiographic follow-up at 6 months to 7 years after treatment. DSA or MRA images of all patients were analyzed to assess the occlusion rate of aneurysms and patency of the parent artery. RESULTS: Enterprise (n = 340), Solitaire (n = 98), Wingspan (n = 41), LEO (n = 16), and Neuroform (n = 5) stent systems were used in this series. Stent-related thromboembolic events occurred in 21 patients and intraoperative rupture occurred in 4 patients. Initially, complete occlusion was achieved in 42.2% of the aneurysms, and, according to the last follow-up data, the rate had progressed to 90.8%. Recanalization rate at 6 months was 8%, whereas the late recanalization rate was 2%. CONCLUSIONS: The use of stents in endovascular treatment provides high rates of complete occlusion and low rates of recurrence at a long-term follow-up study.

A Novel “Y” Stent Flow Diversion Technique for the Endovascular Treatment of Bifurcation Aneurysms without Endosaccular Coiling

BACKGROUND AND PURPOSE: Stent-assisted endovascular treatment and flow diversion techniques are increasingly used for the management of wide-neck intracranial aneurysms. We report our initial clinical experience using a new flow diversion technique for the endovascular management of bifurcation aneurysms. MATERIALS AND METHODS: Eight bifurcation aneurysms were treated by placing 2 stents in Y-configuration with no accompanying endosaccular packing. This treatment technique aimed at flow diversion was selected in these cases because 1) the aneurysm was giant and causing mass effect, 2) the emanating branches were incorporated within the sac, or 3) the aneurysm was too small. Aneurysms were located at middle cerebral (5 aneurysms) and basilar artery bifurcations (3 aneurysms). Five aneurysms were small, 1 was large, and 2 were partially thrombosed giant. Closed-cell stents were used in all Y-stent placement procedures. RESULTS: In all aneurysms, both stents could be placed at the intended locations without any procedural complication. Follow-up angiograms obtained at 3 months to 2 years demonstrated that all stents were patent except for one with asymptomatic P1 occlusion. Complete occlusion with remodelled bifurcation was observed in all middle cerebral artery bifurcation aneurysms and the large basilar tip aneurysm. Residual filling despite reduction in size was observed in both of the partially thrombosed giant aneurysms at 2-year and 3-month follow-up angiograms, respectively. CONCLUSIONS: Flow diversion with double stent placement in Y-configuration provided successful and stable aneurysm occlusion. The technical and clinical results achieved are highly encouraging that this technique may contribute to the endovascular treatment of these complex bifurcation aneurysms.

X-configured stent-assisted coiling in the endovascular treatment of complex anterior communicating artery aneurysms: a novel reconstructive technique.

SUMMARY: Incomplete initial occlusion rates and relatively less long-term durability remain as major problems of endovascular treatment of cerebral aneurysms. Stent-assisted coiling is a well-established current solution to overcome these problems. Double-stent treatment with a Y-configuration has been previously reported to improve the application of coiling to wide-neck bifurcation aneurysms. Herein, a novel technique of X-configured stent-assisted coiling for treatment of wide-neck and complex AcomA aneurysms is described.

Hyperform balloon-assisted endovascular neck bypass technique to perform balloon or stent-assisted treatment of cerebral aneurysms

SUMMARY: We describe a technique to bypass aneurysm neck using the HyperForm balloon to perform balloon- or stent-assisted endovascular treatment of complex large or giant aneurysms with very wide neck in which other methods would fail to obtain an access distal to the aneurysm.

Double stent-assisted coil embolization treatment for bifurcation aneurysms: immediate treatment results and long-term angiographic outcome.

BACKGROUND AND PURPOSE: The goal of endovascular treatment of cerebral bifurcation aneurysms is to achieve safe coiling of the sac along with preserving patency of the diverging branches. Our purpose was evaluate procedural safety and efficacy as well as the long-term durability of endovascular treatment of bifurcation aneurysms with double stent–assisted coiling. MATERIALS AND METHODS: One hundred ninety-one consecutive patients with bifurcation aneurysms were included in this series. Technical failure occurred in 3 aneurysms (1.5%); 188 patients with 193 aneurysms treated with double stent–assisted coiling were retrospectively evaluated; 113 aneurysms were located at middle cerebral artery bifurcation, 42 at the anterior communicating artery, 22 at the basilar artery bifurcation, and the remaining 16 at the internal carotid artery bifurcation; 132 were small (<10 mm), 56 were large (10–25 mm), and 5 were giant (>25 mm). RESULTS: The technical success rate of double-stent application was 98.5% (193 aneurysms). In total, there were 5 procedural complications with an associated rate of 2.7%, one of which led to death (0.5%). Delayed ischemic stroke occurred in 2 patients (1.1%). Overall, permanent morbidity occurred in 2 patients, with associated rate of 1.1%. Follow-up was obtained in 186 aneurysms (96.4%), and recanalization occurred in 4 aneurysms (2.2%). In subgroup analysis, the recanalization rate was 3.8% for large aneurysms and 40% for giant aneurysms. No recanalization occurred in small aneurysms. CONCLUSIONS: Dual stent–assisted coiling of cerebral aneurysms is a feasible and safe procedure. It may offer a curative solution with long-term durability for treatment of wide-neck small and large aneurysms.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

IntroductionWe evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.MethodsA total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.ResultsThe procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.ConclusionOur experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

An unusual central nervous system involvement in rheumatoid arthritis: combination of pachymeningitis and cerebral vasculitis

Severe primary central nervous system (CNS) involvement such as vasculitis and pachymeningitis can rarely occur in rheumatoid arthritis (RA) even in the absence of systemic disease activation. The authors illustrate a female patient with well-controlled RA who presented with headaches, encephalopathy, seizures and relapsing focal neurological deficits. Primary rheumatoid cerebral vasculitis and pachymeningitis were diagnosed based on suggestive brain magnetic resonance (MR) imaging, MR angiography, cerebrospinal fluid analysis and cerebral angiography. MR showed abnormal leptomeningeal enhancement and hyperintense FLAIR signal in the cortical subarachnoid spaces consistent with pachymeningitis. Cerebral angiography findings were consistent with vasculitis. Aggressive treatment resulted in significant clinicoradiological resolution. Cerebral vasculitis is a rare but certain manifestation of RA. This complication can be diagnosed in the presence of suggestive angiographic and CSF findings. The condition may be steroid resistant, and needs to be treated more aggressively.

Neuroapplication of Amplatzer vascular plug: a novel device for parent artery occlusion

Extracranial internal carotid aneurysms are rare, but the complications associated with the traditional surgical reconstruction methods are relatively high. Endovascular treatment has replaced surgery for treatment of a variety of vascular problems. We describe here the treatment of a recurrent extracranial internal carotid artery aneurysm using a detachable balloon combined with the Amplatzer vascular plug.