Reconstructive endovascular treatmet of fusiform intracranial aneurysms with Leo Plus and Silk stents.

Reconstructive endovascular treatmet of fusiform intracranial aneurysms with Leo Plus and Silk stents. Poster No.: C-2177 Congress: ECR 2011 Type: Scientific Exhibit Authors: J. M. Pumar Cebreiro, P. Sucasas Hermida, M. Ares, G. 1 2 1 2 1 1 1 Romero, V. Lázaro, R. García Dorrego, M. Pérez Alarcón ; 1 2 Santiago de Compostela/ES, Pontevedra/ES Keywords: Aneurysms, Embolisation, Catheter arteriography, Neuroradiology brain, Interventional vascular DOI: 10.1594/ecr2011/C-2177 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. www.myesr.org Page 1 of 33

Purpose We report our experience with endovascular treatment of fusiform intracranial aneurysms (Leo Plus) and flow diverters (SILK system) Methods and Materials A retrospective review of our prospectively maintained database identified 18 fusiform aneurysms located in posterior territory (PCA, basilar/vertebral) in 60% of the cases and, less frequently, ophthalmic carotid cavernous region and anterior-middle region (Fig 1). A fusiform aneurysm consists in a circumferencial dilatation without any ostium or neck that involves, at least, 180º of the parent artery. Unlike sacular aneurysms, fusiform aneurysms have a different wall and arterial branches arise from it more frequently. Clinical findings usually consist in transient ischemic attacks, mass effect and rarely subarachnoid hemorrhage. In our therapeutic strategy, all patients with unruptured aneurysms who will undergo an endovascular procedure receive clopidogrel (75 mg/day) and aspirine (300 mg/day) 7 days before. Afterwards, stent placement across the aneurysm is performed in order to reconstruct the parent artery depending on the characteristics of the aneurysms (coiling prior existence of perforating branches, thrombosis,...) were selected or the stent Leo Plus or flow diverter SILK (Fig 2). Post-stent treatment is made with double antiagregation for 3 months and aspirine all life long. Follow-up included conventional angiography at 6 and 12 months post-procedure. These studies were compared to angiograms obtained immediately after embolization analyzing the degree of aneurysm occlusion. Adverse effects such as complete embolization or neurological damage were found (see Fig 3). Page 2 of 33

Some of the reasons why we choose Leo Plus stent among the flexible intracranial stent available nowadays are: Length >2 cm (full length visible), increased flexibility in tight and tortuous vessels, even tighter fit to parent vessel walls, facilitate re-access, recapturable when up to 90% deployed that facilitates reposition the stent, TiO2 passivation layer (avoids nickel ions migration in the blood, and rounded ends which reduces traumaticity in the vessel wall. Flow diverters (SILK) have a mecanical anatomic effect which affects both inflow and outflow allowing to redirect the flow, a physiological effect with thrombus formation and inflammatory transmural and mural changes and a biological effect that favors endothelization and begining of thrombus reabsorption. We show here some of the fusiform intracraneal aneurysms treated in our Unit of Neuroradiology (Fig 4-26). After our preliminary experience, we recommend the therapeutic strategy shown on Figure (Fig 27) Images for this section: Page 3 of 33

Fig. 1: Location of fusiform aneurysms Page 4 of 33

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Results Although the treatment of fusiform aneurysms remains unclear, our study shows that these aneurysms can be treated by vascular reconstruction using self-expandable stents and opens the door to the start of treatment with flow diverters Conclusion Leo stent represents a significant advanced in the vascular treatment of intracranial aneurysms in terms of high radial force and ease of delivery. In most cases the Leo stent can be deployed accurately even within the most tortuous segments of the cerebral vasculature. It is a feasible, secure, and effective system in treating wide-necked intracranial aneurysms and in combination with coiling embolization offers a promising therapeutic alternative in the treatment of these aneurysms. The use of flow diverters may be beneficial sometimes; this is when arterial branches arise from the parent artery. References 1. Fiorella D, Woo HH, Albuquerque FC, Nelson, PK. Definitive reconstruction of circumferential fusiform intracranial aneurysms with the pipeline embolization device. Neurosurgery 62(5):1115-20; discussion 1120-1; 2008 2. Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, Berez AL, Tran Q, Nelson PK, Fiorella D. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64(4):632-42; discussion 642-3; quiz N6; 2009 3. Lavine SD, Meyers PM. Application of new techniques and technologies: stenting for cerebral aneurysm. Clin Neurosurg 54:64-9; 2007 4. Pumar JM, Blanco M, Vázquez F, Castiñeira JA, Guimaraens L, Garcia-Allut A. Preliminary experience with Leo self-expanding stent for the treatment of intracranial aneurysms. AJNR Am J Neuroradiol 26(10):2573-7; 2005 Page 31 of 33

5. Sadasivan C, Cesar L, Seong J, Rakian A, Hao Q, Tio FO, Wakhloo AK, Lieber BB. An original flow diversion device for the treatment of intracranial aneurysms: evaluation in the rabbit elastase-induced model. Stroke 40(3):952-8; 2009 6. Wanke I, Doerfler A, Schoch B, Stolke D, Forsting M. Treatment of widw-necked intracranial aneurysms with a self-expanding stent system: Initial clinical experience. AJNR Am J Neuroradiol 24: 1192-1199; 2003 7. Fiorella D, Kelly M, Albuquerque F, Nelson P. Curative reconstruction of a giant midbasilar trunk aneurysm with the pipeline embolization device. Neurosurgery 64: 212-217; 2009 8. Nelson P.K, Lylyk P, Szikora I, Wetzel S.G, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 32: 34-40; 2011 9. Pumar JM, García-Dorrego R, Nieto A, Vazquez-Herrero F, Blanco-Ulla M, VazquezMartin A. Vascular reconstruction of a fusiform basilar aneurysm with the Silk embolization system. J NeuroIntervent Surg 2010. doi: 10.1136/jnis.2010.002725 10. Lubicz B, Collignon L, Lefranc F, Bruneau M, Brotchi J, Balériaux D, De Witte O. Circumferencial and fusiform intracranial aneurysms: reconstructive endovascular treatment with self-expanded stents. Neuroradiology 50: 499-507; 2008 Personal Information Address correspondence to: J.M. Pumar Cebreiro Unit of Neuroradiology Hospital Clínico Universitario Travesía da Choupana s/n 15706 Santiago de Compostela (Spain) E-mail: Jose.Manuel.Pumar.Cebreiro@sergas.es Page 32 of 33

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