M Perras

ARTS (Aspiration-Retriever Technique for Stroke): Initial clinical experience.

Background A new generation of highly navigable large-bore aspiration catheters and retriever devices for intracranial mechanical thrombectomy has markedly improved recanalization rates, time and clinical outcomes. We report collected clinical data utilizing a new technique based on combined large lumen aspiration catheter and partially resheathed stent retriever (ARTS: Aspiration (catheter)–(stent) Retriever Technique for Stroke). This technique is applied, especially in presence of bulky/rubbery emboli, when resistance is felt while retracting the stent retriever; at that point the entire assembly is locked and removed in-toto under continuous aspiration with additional flow arrest. Methods A retrospective data analysis was performed to identify patients with large cerebral artery acute ischemic stroke treated with ARTS. The study was conducted between August 2013 and February 2015 at a single high volume stroke center. Procedural and clinical data were captured for analysis. Results Forty-two patients (median age 66 years) met inclusion criteria for this study. The ARTS was successful in achieving Thrombolysis in Cerebral Infarction (TICI) ≥2b revascularization in 97.6% of cases (TICI 2b = 18 patients, TICI 3 = 23 patients). Patients’ median National Institutes of Health Stroke Scale score at admission was 18 (6–40). A 3-month follow-up modified Rankin Scale value of 0–2 was achieved in 65.7% of the successfully treated patients (average 2.4). Two patients (4.8%) developed symptomatic intraparenchymal hemorrhages. Six procedure unrelated deaths were observed. Conclusions We found that ARTS is a fast, safe and effective method for endovascular recanalization of large vessel occlusions presenting within the context of acute ischemic stroke.

Flow diverter stents for unruptured saccular anterior circulation perforating artery aneurysms: safety, efficacy, and short-term follow-up

Background Anterior circulation perforating artery aneurysms including anterior choroidal artery and lenticulostriate artery aneurysms are rare. Injury to these vessels can lead to severe debilitating symptoms. Objective To present a new approach to treatment using flow diversion technology. Methods Patients treated with a Pipeline embolization device (PED) for perforator artery aneurysms at our institution between June 2012 and May 2013 were identified and included in our retrospective analysis. We evaluated patient vascular risk factors; family history of aneurysms; aneurysm characteristics; National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) on admission; and angiography follow-up and patient clinical outcome at discharge, 6 months, and 1 year. Results We included four patients with a mean age of 59.8 years. Two patients had a positive family history of aneurysms. Patient vascular risk factors included smoking, dyslipidemia, and hypertension. All patients presented with a NIHSS and mRS of 0 on admission. Aneurysms were located at the anterior choroidal (n=2) or lenticulostriate artery (n=2) and were treated with a single PED. No periprocedural or postprocedural complications occurred. The patients were discharged with no change in NHISS or mRS score. Six-month and 1-year follow-up angiography showed complete aneurysm occlusion. Mild intimal hyperplasia was seen in 2 cases at 6 months, but was resolved at the 1-year follow-up. No re-treatment was necessary. NIHSS and mRS remained 0 at follow-up time points. Conclusions Our preliminary results show that flow diversion technology is an effective and safe therapy for complex, hard-to-treat aneurysms in perforating arteries. Larger studies with long-term follow-up are needed to validate our promising results.

Predictors of bleeding complications after rescue coronary interventions.

The purpose of this study was to determine predictors of bleeding complications after current rescue coronary interventions including stenting and adjunctive platelet inhibitors. Previous studies of rescue angioplasty for thrombolytic failure have identified variable rates of bleeding complications with balloon angioplasty alone. Although coronary stents and glycoprotein 2b/3a inhibitors have been shown to improve outcome in a wide variety of coronary interventions, the impact of these therapies on bleeding complications after rescue coronary intervention has not been determined. From 1996 through 1998, we treated 108 consecutive patients with rescue coronary intervention (defined as attempted coronary intervention within 12 hours of thrombolysis for ongoing symptoms or electrocardiogram [ECG] changes) including conventional percutaneous transluminal coronary artery (PTCA), stenting (n=45), and glycoprotein 2b/3a inhibitor use (n=31). In-hospital clinical outcomes were obtained in all patients, and univariate and multivariate predictors of bleeding complications were identified. In hospital, moderate to severe bleeding complications occurred in 17.6% of the cohort, but the rate of severe bleeding complications (2.7%) and vascular repair (1.9%) were low. Independent predictors of bleeding complications were age >60y, female gender, cardiogenic shock, and streptokinase use. Neither the delayed use of abciximab (on average 4 hours after thrombolytic therapy initiation) nor the use of rescue stenting were predictors of increased moderate to severe bleeding complications. Current rescue coronary intervention, including stents and platelet inhibitors, is associated with a low rate of severe bleeding complications. Moderate to severe bleeding complications were more common in selected subgroups of patients but not increased significantly by stenting or delayed abciximab use.

Two-year single-center experience with the ‘Baby Trevo’ stent retriever for mechanical thrombectomy in acute ischemic stroke

Objective To evaluate the safety and efficacy of the ‘Baby Trevo’ (Trevo XP ProVue 3×20 mm Retriever) stent retriever for large vessel occlusions (LVOs) in acute ischemic stroke (AIS). Materials and methods We retrospectively analyzed our stroke database and included all patients treated with the Baby Trevo for distal LVOs in AIS. Patient gender, mean age, vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score at presentation, and modified Rankin Scale (mRS) score at baseline and 90-day follow-up were documented. Reperfusion rates for the vessels treated were recorded using the Thrombolysis in Cerebral Infarction (TICI) classification. Occurrence of vasospasm and new or evolving infarcts in the treated vascular territory was documented. Results Thirty-five subjects with a mean NIHSS score of 18 were included. The Baby Trevo device was used in 38 branches of the anterior and posterior circulations. TICI 2b/3 blood flow was restored after one single pass in 20/38 (52.6%) and after two or three passes in 11 vessels. The remaining vessels required either more than three passes, showed less than a TICI 2b/3 reperfusion (n=3), or demonstrated failure to retrieve the clot (n=4). TICI 2b/3 reperfusion was achieved in 30 patients (85.7%). No vessel injuries, rupture, or significant vasospasm were seen. Overall, a mRS score of ≤2 was seen in 56.5% of the subjects successfully treated with the Baby Trevo at 90 days and in 81.3% of surviving patients; seven patients died (20%). Conclusions Our preliminary data suggest that the ‘Baby Trevo’ achieves a high recanalization rate without any significant risk. Larger cohort studies are needed to validate the clinical benefit.

Use of self-expanding stents for better intracranial flow diverter wall apposition

Background Flow diverter (FD) malapposition is associated with stroke-related complications. We document the use of self-expanding nitinol stents to remove/reduce the ledge of a FD deployed for aneurysm treatment. Methods We identified five patients who were treated with the Pipeline embolization device (PED) in conjunction with a Neuroform EZ stent for inadequate wall apposition of the ends of the FD at our institution between May 2014 and July 2015. Among other parameters, angiographic results, cone-beam computed tomography assessment of wall apposition and patient clinical outcome were evaluated. Results Incomplete device end apposition was seen in three cases, and precarious positioning of the distal end of the PED over the aneurysm neck was seen in two cases. In all five cases, successful treatment with good wall apposition and proper pinning of the PED distal edge was achieved using an additional Neuroform EZ stent. Appropriate aneurysm neck coverage and flow stagnation was seen in all cases. The combination of high radial outward force and open-cell design permits the Neuroform EZ stent to jail the malappositioned edges of the FD while maintaining good vessel-wall apposition itself and prevent migration of the PED. Short-term follow-up angiography showed device patency and complete aneurysm obliteration in all cases. Conclusions Preliminary results of this small case series suggest that the Neuroform EZ stent allows for effective treatment of FD malapposition in selected patients amenable for this endovascular approach. Long-term and larger cohort studies are needed to validate these results.

Onyx embolization in distal dissecting posterior inferior cerebellar artery aneurysms

Background Dissecting aneurysms located along the distal segments of the posterior inferior cerebellar artery (PICA) are extremely rare, accounting for only 0.5–0.7% of all intracranial aneurysms. Treatment of these aneurysms is challenging, both surgically and endovascularly. We present our preliminary experience and clinical data utilizing Onyx as an embolization agent in the treatment of these lesions with proximal parent artery preservation. Methods 7 consecutive ruptured peripheral PICA aneurysms, in 7 patients, were treated with superselective Onyx embolization at our institutions. According to the anatomical classification of Lister et al, these aneurysms were located in the lateral medullary segment (n=1), tonsillomedullary segment (n=1), and the telovelotonsillary segment (n=5) of the PICA. Technical feasibility, procedure related complications, angiographic results, follow-up diagnostic imaging, and clinical outcome were evaluated. Results In all cases, endovascular treatment was successful, with complete occlusion of the aneurysm with proximal parent artery preservation at the final postprocedural angiogram. Procedure related complications were not observed. One patient with a poor clinical condition at admission died during the initial hospital stay due to extensive subarachnoid and intraventricular hemorrhage. No rebleeding or recanalization was noted during follow-up. Two patients had a residual moderate to severe disability at follow-up. Favorable outcomes, with no or mild disability, were observed in four of the surviving patients. Conclusions Angiographic, diagnostic imaging, and clinical results of our small series indicate that Onyx embolization of dissecting distal PICA aneurysms with parent artery preservation is an effective option with acceptable morbidity and mortality rate, in those cases in which surgical clipping or endovascular coiling of the aneurysmal sac is not suitable.

Utilization of a New Intracranial Support Catheter as an Intermediate Aspiration Catheter in the Treatment of Acute Ischemic Stroke: Technical Report on Initial Experience

The endovascular management of acute ischemic stroke (AIS) due to emergency large vessel occlusion (ELVO) has become the standard of care after the recent publication of landmark randomized, controlled trials. Mechanical thrombectomy, in addition to intravenous thrombolysis (within 4.5 hours when eligible), is now part of the algorithm of the standard of care when treating AIS in patients with ELVO in the anterior circulation up to six hours after symptom onset. A newly introduced device, the Arc™ intracranial support catheter (Medtronic, Irvine, USA), is specifically designed for the introduction of neurointerventional devices into the cerebral vasculature and facilitates the delivery of microcatheters into smaller, more distal intracranial vessels. This technical report describes the use of the Arc™ intracranial support catheter in the setting of AIS.

Pipeline Embolization Device for Pericallosal Artery Aneurysms: A Retrospective Single Center Safety and Efficacy Study

BACKGROUND Pericallosal artery aneurysm treatment may be challenging using traditional endovascular techniques. OBJECTIVE To demonstrate the feasibility, efficacy, and safety of endovascular treatment of pericallosal artery aneurysm using flow diverters. METHODS We performed a retrospective review of our institutional database from July 2013 through July 2016 and identified 7 subjects with a pericallosal artery aneurysm treated with the Pipeline embolization device (ev3 Neurovascular, Medtronic, Dublin, Ireland) and at least 1 follow-up angiogram. Technical feasibility, procedural complication, angiographic results, and clinical outcome were evaluated. RESULTS Placement of the Pipeline embolization device was successful in all cases without evidence of procedural complication. Five out of 7 subjects showed a complete aneurysm occlusion at 6- to 12-mo follow-up angiogram. The 2 subjects with persistent aneurysm filling showed decreased aneurysm sac volume on follow-up angiograms (96% and 60%). There was no evidence of in-implant stenosis or intimal hyperplasia. No thromboembolic or hemorrhagic complications were seen during the follow-up period. Only 1 patient had a transient change in Modified Rankin scale score from baseline as a result of different unrelated procedure. CONCLUSION Our preliminary results demonstrate feasibility of the use of flow diverter stent for treatment of aneurysms of the pericallosal artery with rate of aneurysm occlusion comparable to literature and without evidence of increased procedural or short-term morbidity. A long-term and larger cohort study is needed to validate our findings.

E-041 Use of Flow Diverters in the Endovascular Reconstruction of Fusiform Dissecting Vertebral Artery Aneurysms

Introduction/purpose Fusiform aneurysms (FUANs) of vertebral artery are difficult to treat by using current surgical techniques. Endovascular techniques like parent vessel occlusion, trapping, coiling, stent assisted coiling or stent mono-therapy is currently used to treat these aneurysms. The purpose of this study is to assess the efficacy and safety of flow diverters (Pipeline Embolization Device) in the treatment of vertebral artery FUANs compared to currently used therapeutic modalities. Materials and methods From July 2012 to October 2013, a total of 5 vertebral artery fusiform dissecting aneurysms in 5 patients (2 men and 3 women; age range, 39–59 years; mean age, 50.8 years) were treated with pipeline embolization device (PED) at our institution. In 2 patients the aneurysms were an incidental finding whereas in the other 3 cases were associated to neurologic symptoms, such as visual changes, ataxia, facial numbness or vertigo. Location of the aneurysms was as follows: 4 aneurysms on the right and 1 on the left side. 4 aneurysms were centerd at the V4 segment of the vertebral artery (intradural); only one was located at the vertebral V3-V4 segments junction (intra/extradural). Only one patient had family history indicative for intracranial aneurysm. Aneurysms ranged from 5 to 13 mm in maximal diameter. The technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. Results In every case, endovascular treatment was achieved. Immediate angiography demonstrated intra-aneurysmal contrast stagnation, with parent artery preservation in all cases. Major procedure-related complications were not observed. A brief temporary episode of dysarthria was noted in one of the patient. None of the treated aneurysms experienced bleeding or thrombo-embolic complication during the follow-up time. At 6 month follow-up (4 patients) was noted a complete/near complete aneurysm obliteration in 3 patients and partial obliteration in 1 patient. At 1 year follow-up (2 patients) was noted a progression to complete aneurysm obliteration in 1 patient and stable partial embolization in 1 patient. No intimal hyperplasia was noted at 6–12 months follow-up in the cohort of patients analyzed. Conclusion In our preliminary experience vertebral artery fusiform dissecting aneurysms treatment with PED is a safe and efficacious option in treating dissecting or fusiform intracranial aneurysms. Long term studies and larger cohort is recommended for further evaluation of this treatment strategy. Disclosures A. Puri: None. F. Massari: None. S. Hou: None. M. Perras: None. C. Brooks: None. C. Stout: None. M. Gounis: None. A. Wakhloo: None.

E-040 Five-year Single Center Experience of Intracranial Aneurysm Treatment with the PED in Patients of different Age Groups

Purpose To evaluate safety and efficacy of the pipeline embolization device (PED) in patients of different age groups and with incidentally found or recanalised (previously coiled or clipped) aneurysms. Materials and methods All patients with an incidentally found or recanalised aneurysm and treated with the PED at our institution between 2011 and 2016 were included. We then divided the patient cohort into three age groups representing young (Y, ≤45 years), middle age (M, 46- <65 years) and older (O, ≥65 years) individuals. Information on patient’s vascular risk factors, presenting symptoms and mRS on admission was collected. Follow-up imaging was evaluated for aneurysmal occlusion and the presence of intimal hyperplasia. Patient clinical outcome at discharge, 6 and 12 months was documented. Results We included 140 patients harboring 164 aneurysms with 20 patients in the young age group, 88 in the middle age and 32 in the older age group. Male to female ratio was approximately 1:4 overall and interestingly in all age groups as well. The majority of aneurysms were located in the anterior circulation (94.5%) and found incidentally (75%). Twenty-four aneurysms had been previously treated (12 ruptured and 12 unruptured). Smoking, hypertension and dyslipidemia were the most frequently encountered vascular risk factors in all age groups, with smoking being most common in the young, hypertension the most common in the middle age and hypertension/dyslipidemia the most common in the older age group. Median mRS on admission and discharge was 0 for all age groups. The median mRS remained 0 at 6 and 12 month follow-up. Overall mortality and morbidity rate was 2.1% (3/140, M = 2 and O = 1), Complete aneurysm occlusion at 6 and 12 months was seen in 77% (78/101) and 80% (52/65), respectively. Mild intimal hyperplasia was seen in 18 cases total (18%) with 2 cases in the young, 11 in the middle age and 5 in the older age group. Moderate and severe intimal hyperplasia was found in one case each (young and older age group). No retreatment was required. Nine aneurysms (Y = 3, M = 5 and O = 1) which demonstrated near complete occlusion at 6 months showed complete occlusion in 2 cases (M = 2) and stable near complete occlusion in the remaining 7 at the 12 month mark. For aneurysms demonstrating partial occlusion at 6 months (Y = 2, M = 5, O = 3), 12 months follow-up showed progression to complete or near complete occlusion in 1 case each (Y = 1 and M = 1) and stable partial occlusion in 3 cases (M = 3). Available 12 months follow-up for mild intimal hyperplasia detected at 6 months showed resolution in 4 cases (M = 1 and O = 3) and stable mild hyperplasia in 5 cases (Y = 1 and M = 4). One case of moderate intimal hyperplasia at 6 months (young age group) improved to mild hyperplasia at 12 months follow-up. Subanalysis of treatment outcome of incidentally found aneurysms compared to unruptured pretreated or ruptured pretreated aneurysms showed no difference of flow diverter performance between the different aneurysm groups or among the different patient age groups. Conclusion PED placement is feasible and safe in patients of different age groups and with incidental or recanalised aneurysms. Disclosures A. Kuhn: None. J. Lozano: None. K. de Macedo Rodrigues: None. F. Massari: None. A. Wakhloo: 1; C; NIH, Philips Healthcare, Wyss Institute. 2; C; Codman Neurovascular and Stryker Neurovascular. 3; C; Harvard Postgraduate Course, Miami Cardiovascular Institute. 4; C; InNeuroCo Inc, EpiEB and Pulsar Medical. D. Rex: None. M. Gounis: 1; C; NIH, Medtronic Neurovascular, Microvention/Terumo, Cerevasc LLC, Gentuity, Codman Neurovascular, Philips Healthcare, Stryker Neurovascular, Tay Sachs Foundation, and InNeuroCo Inc. 2; C; Codman Neurovascular and Stryker Neurovascular. 4; C; InNeuroCo Inc. M. Marosfoi: None. M. Perras: None. C. Brooks:None. M. Howk: None. A. Puri: 1; C; Stryker Neurovascular and Covidien. 2; C; Codman Neurovascular, Stryker Neurovascular and Covidien. 3; C; Miami Cardiovascular Institute. 4; C; InNeuroCo Inc.