Editorial: What is the future of the endovascular treatment of intracranial aneurysms?
Abstract
Intracranial aneurysms rapture is a common cause of mortality or morbidity worldwide. For this reason, in case of rupture, early treatment of the aneurysm is mandatory. The evaluation of unruptured intracranial aneurysms continue to increased due to the improvements in invasive and non-invasive neuroimaging. Securing of this life-threatening condition, considering all demographical and procedural factors is necessary for improving treatment results and patients outcome. The endovascular treatment has become frontline therapy of cerebral aneurysms treatment during the last 20 years, and without a doubt its recent advances shifted this boundary even further. Nowadays endovascular armamentarium continues to grow rapidly. Neuro-interventional procedures have tremendously improved their efficiency and continue to improve device’s safety. However some types of aneurysms are not really easy to treat with ordinary endovascular technique as it can result in devastating consequence, Firstly, it is not always applicable to complex aneurysms or very large neck aneurysms. Secondly, durability of the of the aneurysm occlusion is not guaranteed in all cases even after usage of the remodeling technique or regular stenting. New devices are introduced to decrease these limits. Two new innovative techniques that are increasingly used for endovacular occlusion of the complex aneurysms are flow diversion and intrasaccular flow disruption. The objective of this review is to provide a comprehensive overview of novel paradigms and latest research of flow diversion and intrasaccular flow disruption devices, its current application, limitation and future prospective. The obvious advantages of these new technologies proved progressive expansion of their utilization to the extent that they will ultimately replace standard coiling in an increasing number of cases going forward.
The future of the endovascular treatment of intracranial aneurysms is bright. Fast gro-wing improvement in vascular access, treatment modalities and device delivery continue to increase number of patients with intracranial aneurysms treated with endovascular approach versus surgical clipping.
Downloads
References
Vlak MHM, Algra A, Brandenburg R, Rinkel GJE. Prevalence of unruptured intracranial aneurysms with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol. 2011;10:626-36. PMID: 21641282 https://doi.org/10.1016/S1474-4422(11)70109-0
Niewcamp DJ, Setz LE, Algra A et al. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009;8:635-42. PMID: 19501022 https://doi.org/10.1016/S1474-4422(09)70126-7
Molyneux AJ, Kerr RSC, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R; International Subarachnoid Aneurysm Trial (ISAT) Colaborative Group: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360:1262-3. PMID: 12414200 https://doi.org/10.1016/s0140-6736(02)11314-6
Conard C, Pierot L, Anxionnat R, Ricolfi F, Clarity Study Group. Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: Clinical results of the Clarity GDC study. Neurosurgery. 2011;69:837-41. PMID: 21623247 https://doi.org/10.1227/NEU.0b013e3182257b30
Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. ISUIA investigators. Lancet. 2003;362:103-10. PMID: 12867109 https://doi.org/10.1016/s0140-6736(03)13860-3
Pierot L, Barbe C, Ferré JC et al. Patient and aneurysm factors associated with aneurysm rupture in the population of the ARETA study. J Neuroradiol. 2020 Jun;47(4):292-300. PMID: 31539582 https://doi.org/10.1016/j.neurad.2019.07.007.
Pierot L, Gawlitza M, Soize S. Unruptured intracranial aneurysms: management strategy and current endovascular treatment options. Expert Rev Neurother. 2017;17:977-86. https://doi.org/10.1080/14737175.2017.1371593
Pierot L, Gawlitza M, Soize S. Unruptured intracranial aneurysms: It’s not a bomb! Rev Neurol. 2017;173:530-1. PMID: 29031554 https://doi.org/10.1016/j.neurol.2017.05.018.
Pierot L, Wakhloo AK. Endovascular treatment of intracranial aneurysms: current status. Stroke. 2013;44:2046-54. PMID: 23798560 https://doi.org/10.1161/STROKEAHA.113.000733
Pierot L, Spelle L, Leclerc C et al. Endovascular treatment of Unruptured Intracranial Aneurysms : Compa-rison of Safety of remodeling technique and standard treatment with coils. Radiology. 2009;251:846-55. PMID: 19318586 https://doi.org/10.1148/radiol.2513081056
Pierot L, Cognard C, Anxionnat R, Ricolfi F, for the CLARITY group. The remodelling technique for endovascular treatment of ruptured intracranial aneurysms had a higher rate of adequate occlusion than did conventional coil embolization with comparable safety. Radiology. 2011;258:546-53. PMID: 21131582 https://doi.org/10.1148/radiol.10100894
Pierot L, Cognard C, Spelle L, Moret J. Safety and efficacy of balloon remodeling technique during endovascular treatment of intracranial aneurysms: critical review of the literature. AJNR Am J Neuroradiol. 2012;33:12-5. https://doi.org/10.3174/ajnr.A2403
Piotin M, Blanc R, Spelle L et al. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010;41:110-5. PMID: 19959540 https://doi.org/10.1161/STROKEAHA.109.558114
Cagnazzo F, Cappucci M, Lefevre PH et al. Treatment of intracranial aneurysms with self-expandable braided stents: a systematic review and metaanalysis. AJNR Am J Neuroradiol. 2018;39:2064-9. https://doi.org/10.3174/ajnr.A5804
Ferns SP, Sprengers MES, von Rooij WJ at al. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates. Stroke. 2009;40:e523-9. PMID: 19520984 https://doi.org/10.1161/STROKEAHA.109.553099
Pierot L. Flow diverters stents in the treatment of intracranial aneurysms: Where are we? J Neuroradiol. 2011;38:40-6. PMID: 21257202https://doi.org/10.1016/j.neurad.2010.12.002
Beckse T, Kallmes DF, Saatci I et al. Pipeline for Uncoilable or failed aneurysms: Results from a multicenter, clinical trial. Radiology. 2013;267:858-68. PMID: 23418004 https://doi.org/10.1148/radiol.13120099
Benaissa A, Januel AC, Herbreteau D et al. Endovascular treatment with flow diverters of recanalized and multitreated aneurysms initially treated by endovascular approach. J Neurointerv Surg. 2015;7:44-9. PMID: 24449174 https://doi.org/10.1136/neurintsurg-2013-011046
Pierot L, Spelle L, Berge J et al. Feasibility, complications, morbidity, and mortality results at 6 months for aneurysm treatment with the Flow-Redirection Endoluminal Device: Report of SAFE study. J Neurointerv Surg. 2018;10:765-70. PMID: 29352057 PMCID: PMC6204937 https://doi.org/10.1136/neurintsurg-2017-013559
Limbucci N, Leone G, Renieri L et al. Expanding indications for flow diverters: distal aneurysms, bifurcation aneurysms, small aneurysms, previously coiled aneurysms and clipped aneurysms, and carotid cavernous fistulas. Neurosurgery 2020;86:S85-S94. PMCID: PMC6911737 PMID: 31838532 https://doi.org/10.1093/neuros/nyz334
Kan P, Sweid A, Srivatsan A, Jabbour P. Expanding indications for flow diverters: ruptured aneurysms, blister aneurysms, and dissecting aneurysms. Neurosurgery. 2020;86:S96-S103. PMID: 31838529 https://doi.org/10.1093/neuros/nyz304
Pierot L, Barbe C, Nguyen HA, et al. Intraoperative complications of endovascular treatment of intracranial aneurysms with coiling or balloon-assisted coiling in a prospective multicenter cohort of 1088 patients (Analysis of Recanalization after Endovascular Treatment of intracranial Aneurysm [ARETA] study). Radiology. 2020;295:381-9. https://doi.org/10.1148/radiol.2020191842
Kulcsar Z, Houdart E, Bonafe A et al. Intraaneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow diversion treatment. AJNR Am J Neuroradiol. 2011;32:20-5. PMID: 21071538 https://doi.org/10.3174/ajnr.A2370
Benaissa A, Tomas C, Clarençon F et al. Retrospective analysis of delayed intraparenchymal hemorrhage after flow diverter treatment: presentation of a retrospective multicenter trial. AJNR Am J Neuroradiol. 2016;37:475-80. PMID: 26514605 https://doi.org/10.3174/ajnr.A4561
Guédon A, Clarençon F, Di Maria F et al. Very late ischemic complications in flow diverter stents: A retrospective analysis of a single-center series. J Neurosurg. 2016;125:929-35. PMID: 26824382 https://doi.org/10.3171/2015.10.JNS15703
Pierot L, Barbe C, Herbreteau D et al. Delayed thromboembolic events after coiling of unruptured intracranial aneurysms in a prospective cohort of 335 Patients. Stroke (in press)
Gory B, Berge J, Bonafé A et al. Flow diverters for intracranial aneurysms: The Diversion national prospective cohort study. Stroke. 2019;50:3471-80. PMID: 31765296 https://doi.org/10.1161/STROKEAHA.119.024722
Kallmes DF, Brinjikji W, Cekirge S et al. Safety and efficacy of the Pipeline embolization device for treatment of intracranial aneurysms. J Neurosurg. 2017;127:775-80. PMID: 27791519 https://doi.org/10.3171/2016.8.JNS16467
Meyers PM, Coon AL, Kan PT, Wakhloo AK, Hanel RA. SCENT Trial. Stroke. 2019;50:1473-9. https://doi.org/10.1161/STROKEAHA.118.024135
Pierot L, Spelle L, Vitry F. Immediate clinical outcome of patients harboring unruptured intracranial aneurysms treated by endovascular approach: Results of the ATENA Study. Stroke. 2008;39:2497-504. PMID: 18617659 https://doi.org/10.1161/STROKEAHA.107.512756
Pierot L, Spelle L, Berge J et al. SAFE study (Safety and efficacy analysis of FRED embolic device in aneurysm treatment): 1-Year clinical and anatomical results. J Neurointerv Surg. 2019;11:184-9. PMID: 30297539 PMCID: PMC6582717 https://doi.org/10.1136/neurintsurg-2018-014261
Fischer S, Aguilar-Pérez M, Henkes E et al. Initial experience with p64: a novel mechanically deta-chable flow diverter for the treatment of intracranial saccular sidewall aneurysms. AJNR Am J Neuroradiol. 2015;36:2082-9. PMID: 26272970 https://doi.org/10.3174/ajnr.A4420
Briganti F, Leone G, Ugga L et al. Mid-term and long-term follow-up of intracranial aneurysms treated with the p64 flow modulation device: a multicenter experience. J Neurointerv Surg. 2017;9:70-6. PMCID: PMC5264236 PMID: 27439887 https://doi.org/10.1136/neurintsurg-2016-012502
Morais R, Mine B, Bruyère PJ, Naeije G, Lubicz B. Endovascular treatment of intracranial aneurysms with the p64 flow diverter: mid-term results in 35 patients with 41 aneurysms. Neuroradiology. 2017;59:263-69. PMID: 28236050 https://doi.org/10.1007/s00234-017-1786-2
De Beule T, Boulanger T, Heye S et al. P64 flow diverter: results in 108 patients from a single center. Interv Neuroradiol. 2020 Jun 6;1591019920932048. PMID: 32506988 https://doi.org/10.1177/1591019920932048
Bhogal P, Bleise C, Chudyk J et al. The p48MW flow diverter: initial human experience. Clin Neuroradiol. 2019 PMID: 31435722 https://doi.org/10.1007/s00062-019-00827-8
Becske T, Brinjikji W, Potts MB et al. Long-term clinical and angiographic outcomes following Pipeline embolization device of complex internal carotid artery aneurysms: Five-year results of the Pipeline for Uncoilable or Failed Aneurysms Trial. Neurosurgery. 2017;80:40-8. PMID: 28362885 https://doi.org/10.1093/neuros/nyw014
Martinez-Galdamez M, Lamin SM, Lagios KG et al. Periprocedural outcomes and early safety with the use of Pipeline Flex embolization device with Shield technology for unruptured intracranial aneurysms: Preliminary results from a prospective clinical study. J Neurointerv Surg. 2017;9:772-6. PMID: 28223428 PMCID: PMC5583676 https://doi.org/10.1136/neurintsurg-2016-012896
Rice H, Martinez-Galdamez M, Holtmannspötter M et al. Periprocedural to 1-year safety and efficacy outcomes with the Pipeline Embolization Device with Shield technology for intracranial aneurysms: a prospective, post-market, multicenter study. J Neurointerv Surg. 2020. http://dx.doi.org/10.1136/neurintsurg-2020-015943
Atasoy D, Kandasamy N, Hart J et al. Outcome study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU). AJNR Am J Neuroradiol. 2019;40:2094-101. PMCID: PMC6911729 EMSID: EMS84586 PMID: 31727754 https://doi.org/10.3174/ajnr.A6314
Manning MW, Cheung A, Phillips TJ, Wenderoth JD. Pipeline Shield with single antiplatelet therapy inaneurysmal subarachnoid hemorrhage: multicenter experience. J Neurointerv Surg. 2019;11:694-8. PMCID: PMC6582735 PMID: 30552166 https://doi.org/10.1136/neurintsurg-2018-014363
Lenz-Habijan T, Bhogal P, Peters M et al. Hydrophilic stent coating inhibits platelet adhesion on stent surface: Initial results in vitro. Cardiovasc Intervent Radiol. 2018;41:1779-85. PMCID: PMC6182755 PMID: 30039502 https://doi.org/10.1007/s00270-018-2036-7
Aguilar-Perez M, Hellstern V, AlMatter M et al. The p48 flow modulation device with Hydrophilic Polymer Coating (HPC) for the treatment of acutely ruptured aneurysms: early clinical experience using single antiplatelet therapy. Cardiovasc Intervent Radiol. 2020;43:740-7. PMID: 32030488 PMCID: PMC7196938 https://doi.org/10.1007/s00270-020-02418-4
Pierot L, Liebig T, Sychra V et al. Intrasaccular flow-disruption treatment of intracranial aneurysms: preliminary results of a multicenter clinical study. AJNR Am J Neuroradiol. 2012;33:1232-8. PMID: 22678844 https://doi.org/10.3174/ajnr.A3191
Pierot L, Klisch J, Cognard C et al. Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study. Neurosurgery. 2013;73:27-35. https://doi.org/10.1227/01.neu.0000429860.04276.c1
Lubicz B, Klisch J, Gauvrit JY et al. WEB-DL Endovascular treatment of wide-neck bifurcation aneurysms: short- and midterm results in a European study. AJNR Am J Neuroradiol. 2014;35:432-8. https://doi.org/10.3174/ajnr.A3869
Mine B, Pierot L, Lubicz B. Intrasaccular flow-diversion for treatment of intracranial aneurysms. Expert Rev Med Devices. 2014;11:315-25. PMID: 24694000 https://doi.org/10.1586/17434440.2014.907741
Papagiannaki C, Spelle L, Januel AC et al. WEB intrasaccular flow disruptor—prospective, multicenter experience in 83 patients with 85 aneurysms. AJNR Am J Neuroradiol. 2014;35:2106-11. https://doi.org/10.3174/ajnr.A4028
Pierot L, Klisch J, Liebig T et al. WEB-DL endovascular treatment of wide-neck bifurcation aneurysms: long-term results in a European series. AJNR Am J Neuroradiol. 2015,36:2314-9. https://doi.org/10.3174/ajnr.A4445
Pierot L, Moret J, Turjman F et al. WEB® treatment of intracranial aneurysms: Indications, Feasibility, Complications, and One-month Safety Results with WEB-DL and WEB-SL/SLS in the French Observatory. AJNR Am J Neuroradiol. 2015;36:922-7. pmid:25655876 https://doi.org/10.3174/ajnr.A4230
Pierot L, Costalat V, Moret J, et al. Safety and efficacy of aneurysm treatment with WEB®: Results of WEBCAST Study. J Neurosurg. 2016 ;124:1250-6. PMID: 26381253 https://doi.org/10.3171/2015.2.JNS142634
Pierot L, Moret J, Turjman F, et al. WEB treatment of intracranial aneurysms: Clinical and anatomical results in the French Observatory. AJNR Am J Neuroradiol. 2016;37:655-9. doi: https://doi.org/10.3174/ajnr.A4578
Pierot L, Spelle L, Molyneux A, Byrne J. Clinical and anatomical follow-up in patients with aneurysms treated with WEB device: one-year follow-up report in the cumulated population of 2 prospective, multicenter series (WEBCAST, French Observatory). Neurosurgery. 2016;78:133-41. PMID: 26552042 PMCID: PMC6975162 https://doi.org/10.1227/NEU.0000000000001106
Pierot L, Gubucz I, Buhk JH, et al. Safety and efficacy of aneurysm treatment with WEB®: Results of WEBCAST 2 Study. AJNR Am J Neuroradiol. 2017;38:1151-5. https://doi.org/10.3174/ajnr.A5178
Pierot L, Moret J, Barreau X, et al. Safety and efficacy of aneurysm treatment with WEB in the cumulative population of three prospective, multicenter series. J NeuroIntervent Surg. 2018;10:553-9. PMID: 28965106 PMCID: PMC5969386 https://doi.org/10.1136/neurintsurg-2017-013448
Fiorella D, Molyneux A, Coon A, et al. Demographic, procedural, and 30-day safety results from the WEB Intra-saccular Therapy Study (WEB-IT). J NeuroIntervent Surg. 2017;9:1191-6. https://doi.org/10.1136/neurintsurg-2016-012841
Pierot L, Biondi A, Narata AP, et al. Should indications for WEB aneurysm treatment be enlarged? Report of a series of 20 patients with aneurysms in “atypical” locations for WEB treatment. J Neuroradiology. 2017;44:203-9. https://doi.org/10.1016/j.neurad.2016.12.011
Van Rooij SB, van Rooij WJ, Peluso JP, Sluzewski M. The Wowen EndoBridge (WEB) as primary treatment for unruptured intracranial aneurysms. Interv Neuroradiol. 2018; 24:475-81. PMID: 29768963 PMCID: PMC6116134 https://doi.org/10.1177/1591019918772174
Pierot L, Moret J, Barreau X, et al. Aneurysm treatment with woven endobridge in the cumulative po-pulation of 3 prospective, multicenter series: 2-year follow-up. Neurosurgery. 2020 Aug 1;87(2):357-367. https://doi.org/10.1093/neuros/nyz557.
Pierot L, Szikora I, Barreau X, et al. Aneurysm treatment with WEB in the cumulative population of 2 prospective, multicenter series: 3-year follow-up. J NeuroIntervent Surg. 2020 https://doi.org/10.1136/neurintsurg-2020-016151
This work is licensed under a Creative Commons Attribution 4.0 International License.
