What Does A Middle Cerebral Artery Stent Look Size 24 Mm By 4mm

Abstract

Background

Different endovascular techniques be for treatment of cerebral wide-necked bifurcation aneurysms (WNBA). We nowadays the "shelf" technique with the novel woven LVIS EVO stent, which enables forming a buttress at the level of the aneurysm neck to preclude coil prolapse and additional stenting.

Methods

Single-center retrospective analysis of patients treated with the "shelf" technique by using LVIS EVO stent in incidental WNBAs betwixt Jan 2020 and March 2021. Inclusion criteria were saccular aneurysms with neck width ≥iv mm or a dome/cervix ratio ≤2. Primary endpoint was a favorable navigation to the target vessel and successful deployment of the LVIS EVO stent with forming a buttress that enables aneurysm apoplexy by subsequent coiling. Secondary endpoints were aneurysm occlusion on follow-upwardly, process-related complications and clinical outcome.

Results

A full of 15 patients were included. The primary end point was reached in 100% of cases. A complete aneurysm occlusion at the stop of the procedure was accomplished in 14/fifteen patients (93%). No intraprocedural complications occurred. All patients except one were discharged with an modified Rankin Calibration (mRS) of 0. Procedure-related morbidity was 7%. Median follow-up imaging was 115 days (7–419 days) and bachelor for 11/fifteen (73%) of the patients. Of those, 10 (91%) individuals had a complete aneurysm occlusion and 1 showed a residuum cervix. In all patients, the covered branch was patent and no ischemic complications occurred during follow-up.

Decision

This study demonstrates the "shelf" technique with LVIS EVO stents every bit a feasible and rubber handling choice for WNBAs with very good short-term apoplexy rates.

Introduction

The endovascular handling of cerebral wide-necked bifurcation aneurysms (WNBA) is technically challenging. Neither the exclusive use of coils (with or without airship remodeling) nor the boosted use of a single stent are suitable strategies equally risk of ringlet prolapse is high, especially for individuals with incorporation of the branch arteries into the aneurysm sac or an obtuse angle between an arising artery and the aneurysm. For this subgroup of patients, different options might be reasonable, e.chiliad. Y‑stent assisted coiling (Y-SAC) using laser-cut stents or flow diversion. Although long-term occlusion rates of Y‑SAC are promising, information technology is technically complex and one of the major concerns is occurrence of ischemic complications due to the increased metal density of the overlapping stents [1]. Ischemic complications are also a main business organisation of extra-aneurysmal flow diverter (FD) treatment as patency of the covered side branch cannot be guaranteed later on FD deployment [2]. Another treatment option might be intra-aneurysmal flow diversion, but aneurysm size, an inadequate morphology or an birdbrained angle between aneurysm and parent artery can impede device implantation.

An alternative strategy for WNBAs is the "shelf" or "barrel" technique past the utilise of a braided stent, e.1000. the low-contour visualized intraluminal back up junior device (LVIS Jr., MicroVention, Aliso Viejo, CA, USA) equally described previously [3, 4]. The primary principle is to create a "shelf" at the entry level of the aneurysm to prevent curlicue prolapse and avert the use of a second stent. Aneurysm occlusion can and then subsequently be achieved by coiling through a jailed microcatheter. The novel LVIS EVO stent (MicroVention-Terumo, Aliso-Viejo, CA, Us) was recently introduced and specifically designed for SAC [5, vi]. Advantages of the stent include a proper visibility and a high metal coverage for additional menstruum redirection [five].

In our study, we report the feasibility, safety and short-term apoplexy rate of the "shelf" technique by the utilise of the novel LVIS EVO stent in patients with cerebral WNBAs.

Methods

In this unmarried center study 27 patients non-consecutively treated with an LVIS EVO stent due to intracranial aneurysms were reviewed. The inclusion catamenia was from Jan 2020 through March 2021. Baseline demographics, aneurysmal characteristics (including size, morphology and angulation form between aneurysm and parent artery, alpha angle), technical issues, complications, and clinical outcome were noted. The institutional database was anonymized and analyzed retrospectively. Inclusion criteria were the handling of cognitive WNBA, including anterior communicating artery (AcomA), pericallosal artery, center cognitive artery (MCA) and internal carotid‑T, defined equally neck width ≥4 mm or a dome/neck ratio ≤2, with SAC exclusively using a single LVIS EVO stent. Only saccular aneurysms were included and only elective cases were analyzed. Pretreated aneurysms and patients with preceding subarachnoid hemorrhage were also included. All indications were based on an interdisciplinary decision-making between neurosurgeons and interventional neuroradiologists.

The design of the stent has been described previously [vii]. In cursory, the LVIS EVO is a cocky-expanding and unmarried wire-braided stent with four proximal and distal markers and has slightly flared ends. The device is available in a variety of lengths between 12 mm and 34 mm available with diameters of 2.5–four.0 mm. The stent tin exist recaptured upward to the point of no render, which is represented by the proximal radiopaque markers. The pick of the used equipment and the applied technique for those WNBAs was left to the discretion of the operator as some of them might have been treated with other devices (e.g. intra-aneurysmal period diversion) as well.

Co-ordinate to the guidelines of the respective local ethics committees, no approving was necessary for this anonymous retrospective study, which was conducted in accord with the Declaration of Helsinki. The primary end point was technical success, defined as favorable navigation to the target vessel and successful deployment of the LVIS EVO stent with forming a buttress that enabled aneurysm apoplexy past subsequent coiling with preservation of the jailed artery. The secondary end points were aneurysm occlusion rate (AOR) on follow-upward imaging using the Raymond–Roy occlusion classification (RROC) [viii], procedure-related complications and clinical outcome. Angiographic follow-up was exclusively assessed by digital subtraction angiography (DSA). Clinical effect was evaluated at discharge and during follow-up according to the modified Rankin calibration (mRS) score. Each patient's angiographic and clinical condition at the last follow-up was divers every bit the final outcome.

Endovascular Procedure

Patients received double antiplatelet medication (75 mg/day clopidogrel, 100 mg/mean solar day aspirin) starting five days before the intervention and maintained for 3 months later handling, followed by continuous single aspirin antiplatelet therapy for life if no intimal hyperplasia was detected on first angiographic follow-up. Otherwise, dual antiplatelet therapy was maintained at least for 12 months. Platelet function tests were routinely performed using ASA and P2Y12 assays (Multiplate, Roche, Basel, Switzerland).

All procedures were performed with the patient under general anesthesia by interventional neuroradiologists with at least v years of experience. Femoral access was obtained with a short 8F femoral sheath. Iii-dimensional rotational angiography was applied in all patients to identify an ideal working projection without superimposition of surrounding vessels. All LVIS EVO stents were deployed through a dedicated 0.017″ microcatheter (Headway, Microvention, Aliso Viejo, CA, USA) using a triaxial guide-catheter organization. At first, the microcatheter was navigated to a distal artery beyond the bifurcation. The choice of the branch artery was left to the operator and was dependent on vessel diameter, the bearing of the aneurysm entrance and bending betwixt afferent and distal artery. In cases of codominant branches, the artery was used which mainly incorporated the aneurysm. Otherwise, the dominant branch artery was accessed. Then, a 2d microcatheter was "jailed" inside the aneurysm. Afterward, the stent was deployed with the "shelf" technique as described previously [iii]. The cardinal of the technique is to apply forward tension intermittently on the stent pusher wire and microcatheter during stent deployment after half of the aneurysm neck is covered. This leads to a further opening with expanding of the stent beyond the maximum unconstrained diameter forming a "shelf" at the entry level of the aneurysm, which prevents coil prolapse. In our experience, a stent should be chosen, which is slightly over-dimensioned to enable forming of an optimal buttress. Later complete deployment of the stent, the aneurysm is occluded past the use of detachable coils.

Results

Overall, 27 patients were treated with LVIS EVO stent during the written report period; of those, fifteen individuals were treated with SAC due to a cognitive WNBA. Of the patients viii (53%) were female with a median aneurysm cervix width of 3.0 mm (range one.3–5.6 mm) and dome-to-neck ratio of ane.2 (range 0.7–1.7). Median angle between aneurysm and parent avenue (alpha angle) was 26° (range iv–72°) and median historic period was 56 years (range 38–67 years). Of the patients two had suffered from preceding subarachnoid hemorrhage and 4 aneurysms were pretreated with coiling. An overview of the individual data is given in Table ane.

Table 1 Individual overview of patients treated with LVIS EVO "shelf" technique

Full size tabular array

The master end point was reached in 100% of cases (Figs. 1 and ii). All stents could be deployed with forming a "shelf" equally intended and no coil prolapse was observed. A complete aneurysm occlusion (RROC ane) at the finish of the procedure was achieved in 14/15 patients (93%) with a residual cervix (RROC ii) in 1 (7%) private. No intraprocedural complications such as stent twisting or malfunctioning of stent deployment were observed. All covered branch arteries remained patent. In 12 (80%) patients, magnetic resonance imaging was performed at the post-obit day and 3 had silent improvidence-weighted imaging lesions. All patients except one were discharged with an mRS of 0. Procedure-related morbidity was 7% with i patient suffering from an AcomA aneurysm, who exhibited an isolated fornix infarction with an impaired retentiveness at discharge (mRS 1).

Median follow-upwardly imaging with DSA was 115 days (range 7–419 days) and available for xi/15 (73%) patients. Of those, 10 (91%) individuals had a complete aneurysm occlusion (RROC 1) and 1 still showed an unchanged residue neck (RROC 2) at the first follow-up afterwards 96 days. Clopidogrel was routinely discontinued but follow-up with a unmarried antiplatelet drug was non available to date. In all patients, the covered branch was patent and no ischemic complications occurred during follow-up. One intimal hyperplasia occurred subsequently 3 months but resolved after 1 year under maintenance of dual antiplatelet medication.

Give-and-take

In this written report, we nowadays the technical feasibility, safety and short-term apoplexy rate of the "shelf" technique for cognitive WNBAs using the novel LVIS EVO stent. As the intended stent deployment with subsequent coiling was feasible in all patients and the rate of complete aneurysm occlusion was high, the "shelf" technique seems to be a promising handling option in this patient cohort.

The construction of the braided wires allows a variation in cell size property, especially if forwards tension is applied during stent deployment. In a vessel bifurcation, this will lead to an expansion of the stent at the outer curve reaching a stent bore beyond the maximum unconstrained diameter. Thus, a "shelf" is created at the level of the aneurysm entrance if forcefulness is executed after half of the aneurysm neck is covered by the stent. This technique is not advisable for light amplification by stimulated emission of radiation-cut stents equally open up-cell stents tend to kink at the inner curve and might provoke cell entanglement [ix]. Closed-jail cell, laser-cut stents will not attain a comparable prison cell size mutability within the curvature and are therefore not suitable for edifice an adequate buttress [3]. For the detachment of coils, it is crucial to insert the microcatheter in a "jailing" technique within the aneurysm, equally navigation through the braided wires of a deployed stent is challenging and not recommended by the manufacturer. This is due to the metal coverage of the stent, which is higher compared to the LVIS and LVIS Jr. stent (28% vs. 23–27% and 17–23%, respectively) [10]. Therefore, in minor aneurysms special caution is required to go on the microcatheter tip stable inside the aneurysm sac during stent deployment. Some other novelty of the LVIS EVO stent is the fatigued filled tube technology, which makes all the wires visible under fluoroscopy and therefore facilitates stent deployment, which is helpful specially when the "shelf" is built.

In comparing to other endovascular treatment strategies the "shelf" technique seems to be an alternative option in cerebral WNBAs as in our report the technical success rate was 100% with an adequate aneurysm occlusion (RROC i and 2) in all patients during curt-term follow-upwardly. This is comparable to a contempo study of Ulfert et al., who demonstrated an adequate occlusion of 95% afterwards 6 months by the use of pCONUS-assisted coiling [11]; nevertheless, in our written report the complete apoplexy rate (RROC 1) was college with 91% in comparing to 55% in the aforementioned study. Furthermore, follow-upwards information were based on MRI, which delimitates bear witness of in-stent intimal hyperplasia and occlusion rates. The authors mentioned a limited utilise of the pCONUS in patients with high angulation grades between aneurysm and parent vessel ≥70°. Fifty-fifty for those aneurysms, LVIS EVO "shelving" seems appropriate as in our report one patient was successfully treated with an alpha bending of 72° (Fig. 3). The butt vascular reconstruction device was as well presented as an constructive device [12], but was meanwhile withdrawn from the market. The utilise of two stents with "Y" or "10" configuration is some other effective technique with complete AOR upwards to 88% on long-term follow-up [13], but might have a higher complexity rate due to increased metal density of the overlapping stents as described in a big study of Bartolini et al., who reported a procedure-related permanent neurologic deficits charge per unit of 10% [fourteen]; nonetheless, a recent meta-analysis of Y‑SAC in WNBAs also demonstrated high adequate AOR of 95% in mid-term follow-upwards, but a low morbidity of two.4% [one]. Similarly, the wide-neck bifurcation aneurysms of the middle cognitive artery and the basilar noon treated past endovascular techniques (Co-operative) trial recently showed complete and acceptable AOR in patients treated with coiling (including balloon-assisted and stent-assisted coiling) for unruptured WNBAs of thirty.six% and 63.0%, respectively, after a follow-up of 49 weeks [15].

Another concept is intra-aneurysmal flow diversion with the Woven EndoBridge (Spider web). Recently, a three-year analysis of the European Web Clinical Assessment of Intrasaccular Aneurysm Therapy (WEBCAST) and WEBCAST‑2 trials was published that showed adequate occlusion in 84% of cases with a low morbidity of 1.three% [16] and even our own experience with WEB is promising in unruptured, WNBAs with 78% adequate AOR at one twelvemonth [17]. This strategy is particularly advantageous in patients with contraindications to antiplatelet therapy; still, some aneurysms might be unfavorable for Web treatment due to very pocket-size or large aneurysm size, an inadequate morphology (e.g. girl sac) or an birdbrained angle between aneurysm and parent artery. Recently, initial results of the Contour Neurovascular Organisation (CNS) were published but is has to be proven in time to come studies whether this technique might be an culling option for WNBAs [eighteen].

The apply of extra-aneurysmal catamenia diversion is a matter of fence and might besides be an alternative option with an adequate AOR of 79% after one year, but the rate of treatment-related complications is loftier with 21% [2]. I reason is an occlusion or at least a flow reduction of jailed arteries in 10% and 26%, respectively. In our study, no compromising of period into jailed branches was observed.

One patient in our study suffered from fornix infarction and a balmy AcomA syndrome. This might be due to occlusion of the subcallosal artery, a known AcomA perforator, which usually remains angiographically occult [xix]. The perforator fifty-fifty in our patient was not determinable on DSA images and AcomA remained patent but distribution of the ischemic lesions suggests that the subcallosal artery was affected; yet, whether this was caused by the "shelf" and the blueprint of the LVIS EVO stent remains speculative. The procedure-related complication rate of Y‑SAC is up to ix% and is dependent on the applied stent type [1].

Long-term follow-up of aneurysms treated with the "shelf" technique is missing so far but is important with respect to definitive treatment success. As mentioned to a higher place, the high metal coverage of the braided wires provides additional flow-generating furnishings [5] but this will impede renavigation of a recurrent aneurysm, which might be challenging if retreatment is necessary. Renavigation might be more feasible if laser-cutting or depression-profile stents were primarily used; nonetheless, the rate of retreatment in SAC of cerebral WNBAs varies between two% and fourteen% depending on the number of stents and stent types used [xiv, 20].

A limitation of our report is the retrospective design with the expected choice bias. Furthermore, the pocket-sized sample size and the absence of a control group limits the validity of the data. Occlusion rates were self-assessed and results might be less favorable subsequently core laboratory adjudication.

Determination

This written report demonstrates the "shelf" technique with LVIS EVO stents as a feasible and safe treatment option for WNBAs with very good brusque-term apoplexy rates. Whether this technique may obviate the need for Y‑SAC in this patient accomplice remains to be proven when long-term information are available. Therefore, further studies are necessary.

Modify history

28 September 2021

A Correction to this paper has been published: https://doi.org/ten.1007/s00062-021-01084-four

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Funding

Open Admission funding enabled and organized by Projekt Bargain.

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Affiliations

Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, In der Schornau 23–25, 44892, Bochum, Germany

Volker Maus, Werner Weber & Sebastian Fischer

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Correspondence to Volker Maus.

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Conflict of interest

W. Weber reports personal fees for consultancy from Microvention, Stryker, Phenox. South. Fischer reports personal fees for consultancy from Microvention. V. Maus declares that he has no competing interests.

Ethical standards

Co-ordinate to the guidelines of the respective local ideals committees, no approval was necessary for this bearding retrospective study, which was conducted in accordance with the Declaration of Helsinki.

Additional information

The original online version of this article was revised: Table ane has been corrected.

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Maus, Five., Weber, West. & Fischer, S. "Shelf" Technique Using a Novel Braided Self-Expandable Stent for the Treatment of Wide-Necked Bifurcation Aneurysms. Clin Neuroradiol 31, 1187–1193 (2021). https://doi.org/x.1007/s00062-021-01032-2

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Received: 16 March 2021
Accustomed: 28 Apr 2021
Published: 20 July 2021
Consequence Date: December 2021
DOI : https://doi.org/ten.1007/s00062-021-01032-2

Keywords

Endovascular treatment
Aneurysm treatment
Aneurysm occlusion
Stent-assisted coilembolisation
LVIS EVO