Treatment of broad-based intracranial aneurysms with the LVIS EVO … – Nature.com

Patients

112 patients (median age 58years; range 3875years, 82 female) harboring 118 aneurysms were included in the analysis. 97 aneurysms (82.2%) in 94 patients were discovered incidentally, 13 patients with 15 aneurysms (12.7%) had acute SAH, 2 aneurysms (1.7%) led to acute cranial nerve palsy due to the target aneurysm, 2 patients with 2 aneurysms (1.7%) had acute stroke due to emboli from the target aneurysm, and one patient had an aneurysm (0.8%) symptomatic with seizure. 10 aneurysms (8.5%) were residual aneurysms after endovascular (n=7; 5.9%) or surgical treatment (n=3; 2.5%). 107 aneurysms (90.7%) were located in the anterior circulation, 11 (9.3%) in the posterior circulation. The median width of the aneurysm dome was 5mm (range 128mm), and the median width of the aneurysm neck was 3.9mm (range 119mm), resulting in a median dome-to-neck ratio of 1.3. All but 3 aneurysms (97.5%) had a dome-to-neck-ratio of2. Table 1 summarizes the patient and aneurysm characteristics.

A single LVIS EVO stent was used in 107 aneurysms (90.7%). Another device was used in 11 aneurysms (9.3%). The additional device was a Neuroform Atlas Stent (Stryker, Kalamazoo, MI, USA) in 10 cases, implanted with a crossing Y-configuration14. Of note, in these 10 cases, the Neuroform Atlas stent was deployed first because of its larger cell size, to avoid the more difficult re-crossing of the LVIS EVO stent with its smaller cell size. In one case, a second LVIS EVO was implanted with a H-configuration for an aneurysm at the anterior communicating artery. In the H-stent configuration, two stents are each inserted on one side from ipsilateral A2 to ipsilateral A1 without crossing the anterior communicating artery, which is usually sacrificed as a result15. Coiling of the target aneurysm was performed in 108 cases (92.5%), in 57 cases more than 50% of administered coils were hydrogel coils. A WEB device (MicroVention, Aliso Viejo, CA, USA) was used in 7 cases (5.9%). Stenting in combination with WEB device was used in this context either as a bail-out technique when the WEB was oversized, to push the WEB into the aneurysm, or for unusually complex aneurysms. In one case only a LVIS EVO stent was placed as part of a staged treatment before coiling in a second intervention, in one case, a coil could not be placed in the aneurysms due to the small size of 1.9mm, so only a LVIS EVO stent was implanted with a pushing technique to condense the cell sizes of the stent and in another case the stent was used for bail-out after the placement and incomplete opening of a flow diverter.

The jailing technique was used in 98 of 108 cases for coiling and in 2 of 7 cases for placing the WEB device. In 3 cases, the stent was re-crossed to gain access to the aneurysm. However, this approach was complicated by the narrow cell size of the stent and led in one case to a re-rupture of an already ruptured aneurysm of the anterior communicating artery. In 15 cases, the stent was deployed either as a second step after coil or WEB device placement or as a bail-out for coil or WEB protrusion in the parent vessel.

Complete occlusion immediately after intervention (RROC 1) was achieved in 85 aneurysms (72.0%), a residual neck (RROC 2) was present in 25 aneurysms (21.2%) and 8 aneurysms (6.8%) showed a residual or complete filling of the aneurysm (RROC 3).

In 7 cases angiographic apparent thromboembolic complications were observed, all of which were treated with intravenous Tirofiban or Eptifibatide. In 6 cases the complication resolved without clinical sequelae, in one case a hemiparesis persisted until discharge, resulting in a mRS of 4. Intraprocedural rupture of the target aneurysm occurred in 4 cases, in one of these cases after re-crossing of the stent in a patient with SAH. All intraprocedural ruptures were successfully treated with coiling, two cases without clinical sequelae and in two cases with new minor strokes.

Of the 13 patients with acute SAH, 4 developed vasospasms during hospitalization. Three of these patients were treated with intra-arterial spasmolysis, and 2 of the 4 patients died of their vasospasm-induced infarcts during their stay. All vasospasm occurred remotely from the implanted stents and were considered to be SAH-related, not device-related. One patient with SAH had a transient loss of vision after treatment of an aneurysm of the posterior inferior cerebellar artery.

One patient had 4days after intervention a hemineglect and was treated after exclusion of hemorrhage with intravenous Tirofiban. Ticagrelor was changed to Prasugrel due to assumed non- or partial responder status to Ticagrelor without further symptoms. One patient with an aneurysm of the ophthalmic segment of the ICA suffered a postprocedural occlusion of the central retinal artery which vision loss, which persisted in spite of intraarterial administration of rtPA. The two patients with symptomatic, partially thrombosed aneurysms were also symptomatic in the short-term. The first patient with an aneurysm of the posterior communicating artery showed a new palsy of the third cranial nerve which partially regressed until discharge. The second patient had an acute stent occlusion 8days after intervention and was treated with thrombectomy. On discharge she still had a left sided hemiparesis with a mRS of 2.

A patient with a symptomatic giant aneurysm of the P1 segment of the posterior cerebral artery experienced acute headache with perifocal edema on MRI 49days after treatment, which was presumably due to acute thrombosis of the aneurysm and was successfully treated with steroids.

One patient presented with a TIA and new infarcts on MRI 2month after treatment in the territory of the aneurysm at the bifurcation of the middle cerebral artery, which was treated with Y-stenting. DSA showed no in-stent-stenosis. All symptoms resolved completely, ASA was continued for life. No further treatment was required.

In summary treatment with the new LVIS EVO device led to technical complications in 13 patients (11.6%) and to a device related permanent morbidity and mortality in 6 patients (5.3%) and 0 patients (0%), respectively.

Follow-up was available for 84 patients with 86 aneurysms (72.9%). Mean time between intervention and last follow-up was 224days (11672days) or about 7.4months. DSA as follow-up was performed in 62 of these patients (73.8%), the other patients had an MRI with MRA in most cases and in 3 cases a flat detector CT-angiography or conventional CT-angiography, and one patient no vascular imaging at all. Of 26 patients with initially incomplete occlusion 17 progressed to complete occlusion (RROC1) on short-term follow-up (in 12 patients documented by DSA, in 4 patients by MRI with MR-angiography and in one case by CT-angiography), 9 of these patients were treated with hydrogel coils. Another 3 patients progressed to complete occlusion on mid-term follow-up (in 2 patients documented by DSA and in one case by MRI and MR-angiography); one patient progressed from RROC3 to RROC2. Partial recanalization was observed in 7 aneurysms. Occlusion rate and shift in occlusion rate are summarized in Fig.2 and Table 2.

Shift of occlusion rates (percentage and absolute numbers) from treatment to 6month (Follow-up 1) and 1218month follow-up (Follow-up 2).

3 patients were re-treated due to residual aneurysms between 6 and 8months after the first intervention. One patient had an asymptomatic stent occlusion. Beyond that, no in-stent-stenoses were observed on follow-up imaging. Procedural complications and outcome are summarized in Table 3.

The impact of the COVID-19 pandemic on follow-up was small. In 3 cases, intravenous flat detector CT angiography was performed rather than DSA because of restrictions in patient admission. In 4 cases, follow-up appointments were postponed. For these patients instead of 6months after treatment, follow-up visits were performed between 7.5 and 17months after the procedure.

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Treatment of broad-based intracranial aneurysms with the LVIS EVO ... - Nature.com