To coil or not to coil? How to pick the right treatment of intracranial aneurysms.

Transcription

1 To coil or not to coil? How to pick the right treatment of intracranial aneurysms. Poster No.: C-2777 Congress: ECR 2018 Type: Educational Exhibit Authors: E. Y. A. Palkhi, K. Anand, J. Zhong, H. Nejadhamzeeigilani, T. Patankar, T. Goddard; Leeds/UK Keywords: Hemorrhage, Aneurysms, Stents, Embolisation, CT-Angiography, CT, Neuroradiology brain, Interventional vascular, Arteries / Aorta DOI: /ecr2018/C-2777 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Learning objectives To gain insight into the factors to consider when deciding to treat intracranial aneurysms (ICA) and how to select the most suitable device. To review all endovascular devices used for treating intracranial aneurysms To discuss the types of complications that may result from each treatment Background Endovascular techniques for treating intracranial aneurysms are now making treatment increasingly safer and more effective with multiple new devices and treatment combinations available. This can present a conundrum for the neuro-interventionist for selecting the best treatment option. Findings and procedure details Endovascular options should be considered based on anatomic considerations such as aneurysm geometry and morphology, peripheral access, and parent vessel anatomy. Clinical presentation, patient medical history and comorbidities, as well as operator experience are other important factors that must be evaluated. Endovascular treatment with coiling of saccular aneurysm with a favourable neck has been accepted as a safe procedure with better outcomes than surgical clipping as per the international subarachnoid haemorrhage trial (ISAT). However, treatment of complex aneurysms such as large, wide neck and fusiform ones remains technically challenging for coiling, with a poor occlusion and high recurrence rate of up to 80%. The use of novel devices including flow diverter devices (FDD) which include intrasaccular devices within the aneurysm and endoluminal devices placed in the parent vessel at the aneurysm neck has greatly increased the scope of treatment of ICAs to those with more complex anatomy where coiling or clipping on their own are difficult or impossible. The indications and contraindications to ensure that endovascular treatment is the most suitable initial or overall treatment must be carefully considered and are broadly covered in Fig. 1 on page 8. Page 2 of 17

3 Fig. 1: Indications and contraindications for endovascular treatment of intracranial aneurysms References: E. Palkhi SECTION 1: Anatomic and clinical considerations A) Anatomic considerations 1) Peripheral vascular anatomy, aortic arch and great vessel anatomy Access is commonly via the transfemoral route (transbrachial and transradial routes less commonly used), followed by navigating the aortic arch and selection of the desired carotid and vertebral artery. i) Aortic arch and great vessels: Increased tortuosity of the great vessels and aberrant branching patterns from the arch can make catheter access difficult II) Cervical portion of the carotid and vertebral arteries: high-grade cervical stenosis and excessive tortuosity may limit access and increase the risk of complications iii) Intracranial vessel anatomy: individual variability is high and therefore careful planning by the use of biplane angiography and roadmapping is necessary to increase procedural safety and reduce the risk perforation. Increased tortuosity within a closed configuration carotid syphon in the context of anterior circulation aneurysms, can also make catheter tracking challenging. 2) Route of access Most direct route available via ipsilateral carotid or vertebral artery, however it is important to assess the patency of the circle of Willis to consider potential alternative routes based on aneurysmal orientation and size; this is especially important in emergency situations where there is loss of access from the ipsilateral side during treatment. 3) Aneurysm anatomy Page 3 of 17

4 Aneurysms are often located branching points of parent arteries and where the course of a vessel takes a curve. I) Morphology and Geometry of the aneurysm Size: measured by maximum diameter dimension of the aneurysm dome (small, large, giant) Shape: Saccular (most common) or fusiform, presence of irregularities, presence of a daughter sac Neck size: wide neck >4mm or aspect ratio<2 (dome height to neck width). The aspect ratio helps determine the need for adjuncts Geometric ratios: Increased Aspect ratio (dome height to neck width) and size ratio (aneurysm size to parent artery size) are associated with a higher risk of rupture. II) Location and direction of the aneurysm relative to the parent artery This has important implications for strategy used to access the inside of the lesion. Major vessel bifurcation aneurysms (carotid or basilar) are usually entered with a straight or 45 angled microcatheter. Smaller branch vessel bifurcation (posterior communicating or ophthalmic o o artery) often require 90 or J-shaped microcatheter access. III) Presence of branch arteries in proximity to the aneurysm Branch vessel arising from parent artery or base of neck are usually safer to treat with caution Branch vessels arising from higher up the neck base or dome are associated with a high risk of ischaemic complications or with ineffective treatment with poor occlusion grades. B) Clinical considerations Patient comorbidity, age and performance status Presentation: ruptured or unruptured aneurysm (presence of SAH) or symptomatic SECTION 2: Types of Endovascular techniques, devices and delivery systems Page 4 of 17

5 Reconstructive techniques involve direct occlusion of the aneurysm using coils, bridging devices (balloons and stent remodelling) and novel standalone flow diverter devices (FDD). Deconstructive techniques are far less commonly utilised and involve parent artery occlusion hence stopping inflow at the origin of the aneurysm with or without revascularisation. 1) Coiling Used independently in treatment of saccular, narrow necked aneurysms with simple anatomy. They are often utilised in the emergency setting as well. Aneurysm occlusion is achieved by using gradually decreasing coil sizes. An adequate frame is initially obtained by careful selection of the first coil corresponding to the size of the aneurysm. The early and late complications of endovascular coiling are summarised in Fig. 2 on page 8. Fig. 2: Early and late complications of endovascular coiling References: E. Palkhi 2) Assistive/bridging neck devices These are not routinely used in ruptured aneurysms as they increase procedural duration and complexity, risk of complications and often require antiplatelet medication. i) Balloon remodelling These are used to assist in coiling of wide necked aneurysms. A temporary occlusion balloon is inflated across the aneurysm neck while embolization coils are introduced. The balloon offers may advantages including control of coil and catheter which prevents coil prolapse into the parent vessel, moulding of neck and origin of bifurcation, and rapid inflation of the balloon in front of the aneurysm also limits bleeding in the context of intraprocedural rupture. Balloon remodelling is technically challenging, requires many steps and is associated with high morbidity and mortality. ii) Intracranial stenting Page 5 of 17

6 These help to provide support for coils even after their introduction into the aneurysm as opposed to balloon remodelling. They are also used in increasingly complex lesions such as those with a very wide neck or no neck, such as dissecting aneurysms and 'blister like' aneurysms. They are associated with a relatively increased risk of thromboembolic complications (requiring long term dual antiplatelet) and haemorrhagic complications. 3) Flow Diverter Devices These can be broadly categorised into Endoluminal and Intra-saccular devices i) Endoluminal devices Endoluminal flow diverter devices are self-expanding, low porosity (high-mesh density metal coverage stents) devices deployed across the aneurysmal segment within the parent vessel with the intention of immediate change in regional circulation with diversion of blood away from the aneurysm. The resultant aneurysmal stasis promotes thrombosis within the aneurysm. Examples of endoluminal FDD are listed in Table 3. Endoluminal flow diverters avoid access into the aneurysm thus reducing risk of intraprocedural aneurysm rupture. They also provide better neck reconstruction and reduced long-term recanalisation. Other advantages over endosaccular coiling are the ability to treat the weakened abnormal arterial wall by providing a scaffold for neoendothelialisation to occur. These devices have demonstrated superior results with good long term compared to other treatment options for wide neck, complex aneurysms. ii) Intra-saccular devices (flow disrupter devices) Flow disrupters are flexible intrasaccular mesh devices suitable for treating complex aneurysms of the bifurcations with a wide neck. The first available flow disruptor device is the Woven Endobridge device (WEB) which is a self-expanding oblate braided mesh of nitonol wires that is deployed into the aneurysm sac itself. Once deployed, the WEB device induces thrombosis within the aneurysm. The initial WEB device had dual layer (DL) design with inner and outer braids, however this has since evolved to a single layer (SL) device with a higher density nitonol wires achieving similar flow disruption effects. Additional modifications to the WEB device include a spherical subtype (SLS) and enhanced visualisation due to platinum-coated nitolol wires (EV). Furthermore, miniaturisation of the WEB devices (WEB 17 and WEB 21) has enabled delivery of these devices through smaller catheters. Page 6 of 17

7 The advantages of intra-saccular device is the combination of an endosaccular approach with flow diversion thereby eliminating the need for dual antiplatelet therapy and therefore extending their use to the emergency setting of a ruptured aneurysm. One drawback of the WEB device is that it does not involve neck reconstruction. Examples of intra-saccular devices are listed in Fig. 3 on page 9. Fig. 3: Summary of types of FDD devices and novel neck reconstructive devices References: E. Palkhi Fig. 4: Case of a basilar artery aneurysm treated solely with an intra-saccular WEB device (blue arrow) with successful post-treatment occlusion. Illustrations of the WEB single and spherical subtype are also shown (right, Courtesy of Sequent Medical, see References) References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Fig. 5: CONTOUR device (blue arrow), an intra-saccular device currently offered on a trial basis in the UK. 3D rotational angiography pre-treatment and post-treatment DSA images show a case of basilar tip aneurysm (red arrow). Illustrations of the CONTOUR devices shown (right image, Courtesy of Cerus Endovascular, see References) References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Fig. 6: Case of a basilar artery tip aneurysm (red arrow) treated with coiling (yellow arrow) and a pconus adjunctive device (blue arrows) with successful occlusion postembolization. pconus illustration on the far right image (Courtesy of Phenox, see References) References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Fig. 7: Case of a basilar tip aneurysm (light green arrow) treated with coiling (yellow arrow) with a barrel stent (blue arrow). 3D rotational angiography (Left), DSA images of approach with corresponding part of the barrel stent (middle) and post-treatment DSA images with successful total occlusion demonstrated. (See references for illustration). References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Fig. 8: A case of an elective right supraclinoid internal carotid artery aneurysm (red arrow) treated with a pulserider stenting device (blue arrows) and 8 coils (yellow arrow) with complete occlusion demonstrated. Pulserider device illustration (image on far right, see references) References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 7 of 17

8 Fig. 9: A case of an incidental partially thrombosed basilar tip aneurysm (red arrows) treated with T-stenting using low profile self-expandable (LEO Baby stent, blue arrows) and coiling (yellow arrows). Pre-treatment, approach, post-treatment DSA images are demonstrated. No evidence of recurrence demonstrated at 2-year follow up. Illustration of the LEO baby stent demonstrated on image on the right (See References) References: Leeds Teaching Hospitals NHS Trust - Leeds/UK Images for this section: Fig. 1: Indications and contraindications for endovascular treatment of intracranial aneurysms E. Palkhi Page 8 of 17

9 Fig. 2: Early and late complications of endovascular coiling E. Palkhi Fig. 3: Summary of types of FDD devices and novel neck reconstructive devices E. Palkhi Page 9 of 17

10 Fig. 4: Case of a basilar artery aneurysm treated solely with an intra-saccular WEB device (blue arrow) with successful post-treatment occlusion. Illustrations of the WEB single and spherical subtype are also shown (right, Courtesy of Sequent Medical, see References) Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 10 of 17

11 Fig. 5: CONTOUR device (blue arrow), an intra-saccular device currently offered on a trial basis in the UK. 3D rotational angiography pre-treatment and post-treatment DSA images show a case of basilar tip aneurysm (red arrow). Illustrations of the CONTOUR devices shown (right image, Courtesy of Cerus Endovascular, see References) Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 11 of 17

12 Fig. 6: Case of a basilar artery tip aneurysm (red arrow) treated with coiling (yellow arrow) and a pconus adjunctive device (blue arrows) with successful occlusion postembolization. pconus illustration on the far right image (Courtesy of Phenox, see References) Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 12 of 17

13 Fig. 7: Case of a basilar tip aneurysm (light green arrow) treated with coiling (yellow arrow) with a barrel stent (blue arrow). 3D rotational angiography (Left), DSA images of approach with corresponding part of the barrel stent (middle) and post-treatment DSA images with successful total occlusion demonstrated. (See references for illustration). Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 13 of 17

14 Fig. 8: A case of an elective right supraclinoid internal carotid artery aneurysm (red arrow) treated with a pulserider stenting device (blue arrows) and 8 coils (yellow arrow) with complete occlusion demonstrated. Pulserider device illustration (image on far right, see references) Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 14 of 17

15 Fig. 9: A case of an incidental partially thrombosed basilar tip aneurysm (red arrows) treated with T-stenting using low profile self-expandable (LEO Baby stent, blue arrows) and coiling (yellow arrows). Pre-treatment, approach, post-treatment DSA images are demonstrated. No evidence of recurrence demonstrated at 2-year follow up. Illustration of the LEO baby stent demonstrated on image on the right (See References) Leeds Teaching Hospitals NHS Trust - Leeds/UK Page 15 of 17

16 Conclusion Although coiling remains the workhorse of ICA treatment, many complex ICAs which were previously untreatable can be definitely occluded in combination or independently with newer devices. Personal information References Eboli P, Ryan RW, Alexander MJ. General technical considerations for the endovascular management of cerebral aneurysms. Neurosurg Clin N Am Jul;25(3): Pierot L, Wakhloo AK. Endovascular treatment of intracranial aneurysms: current status. Stroke Jul;44(7): Anxionnat R, Tonnelet R, Derelle AL, Liao L, Barbier C, Bracard S. Endovascular treatment of ruptured intracranial aneurysms: Indications, techniques and results. Diagn Interv Imaging Aug;96(7-8): (Figure 5) CONTOUR illustration adapted from : Cerus-EndovascularContour-300x194.jpg ( ) [Internet]. [cited 2018 Jan 6]. Available from: sites/3/2016/07/cerus-endovascular-contour-300x194.jpg Intracranial aneurysm Archives - NeuroNews International [Internet]. [cited 2018 Jan 6]. Available from: Brouillard AM, Sun X, Siddiqui AH, Lin N. The use of flow diversion for the treatment of intracranial aneurysms: expansion of indications. Cureus Jan 28;8(1):e472. (Figure 9) Baby LEO stent illustration adapted from :Aydin K, Arat A, Sencer S, Barburoglu M, Men S. Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms Using Low-Profile LEO Baby Stents: Initial and Midterm Results. AJNR Am J Neuroradiol Oct;36(10): Page 16 of 17

17 (Figure 6) pconus illustration adapted from: phenox launches ptowin Study to assess efficacy of pconus Bifurcation Aneurysm Implant - Phenox [Internet]. [cited 2018 Jan 6]. Available from: Dumont TM, Eller JL, Mokin M, Sorkin GC, Levy EI. Advances in endovascular approaches to cerebral aneurysms. Neurosurgery Feb;74 Suppl 1:S (Figure 7) Barrel Stent Illustration adapted from: Almost no learning curve with Barrel reconstruction device - NeuroNews International [Internet]. [cited 2018 Jan 6]. Available from: Negrotto M, Crosa R, Casagrande W. Assisted coiling using LEO Baby or LVIS Jr stents: Report of six cases. Interv Neuroradiol Oct;21(5): Manhas A, Nimjee SM, Agrawal A, Zhang J, Diaz O, Zomorodi AR, et al. Comprehensive overview of contemporary management strategies for cerebral aneurysms. World Neurosurg Oct;84(4): Pipeline Device Guide neuroangio.org [Internet]. [cited 2018 Jan 6]. Available from: (Figure 8) Pulserider device illustration adapted from :Endovascular Today Endovascular Advances in the Treatment of Cerebral Aneurysms (February 2017) [Internet]. [cited 2018 Jan 6]. Available from: (Figure 4) Web Devices illustration adapted from Jiang B, Paff M, Colby GP, Coon AL, Lin L-M. Cerebral aneurysm treatment: modern neurovascular techniques. Stroke Vasc Neurol Sep;1(3): Page 17 of 17