PowerPoint Presentation

Endovascular treatment of brain aneurysms:Beyond coiling

Yasha Kayan, MDJosser E. Delgado, MD

Abbott Northwestern HospitalNeuroscience Institute

#Surgical clipping 1937

#Coil embolization

First in human: 1991GDC FDA approved: 1995

#Neurointerventional suite

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#Embolization procedure

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Coiling (framing coil)

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Coiling (clotting, endothelialization)

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Balloon-assisted coilingFirst described in 1997

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Balloon-assisted coiling

#Stent-assisted coiling

Neuroform stent FDA approved in 2002

#Flow diversion

Pipeline approved in 2011

#Pipeline (PUFS trial)Outcomes at 180 daysComplete occlusion: 73.6%Major stroke or death: 5.6%Outcomes at 5 years95.2% occlusion rateNo additional major strokes or deathNo reports of delayed recanalization

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37 year-old male with HIV-related dilating vasculopathy

Pipeline case 34

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2.5 x 14mm Pipelines37 year-old male with HIV-related dilating vasculopathyPipeline case 34

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6-month FU angiogram37 year-old male with HIV-related dilating vasculopathyPipeline case 34

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Higher complication rate?

#Continuing the conversation

#Intra-saccular flow diversion

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47 y/o woman with an incidental basilar tip aneurysmAbbotts 1st WEB case

#PROCEDURE:

1. Transarterial embolization with the WEB device: Basilar tip aneurysm.

2. Cerebral angiography: Left vertebral artery.

3. Rotational angiography with 3D reconstructions: Left vertebral artery.

4. Angioseal hemostatic closure device placement.

DATE: 11/12/2014.

HISTORY: 47 year-old female with an incidentally-discovered basilar tip aneurysm presents for endovascular treatment with the WEB device.

PRIMARY PHYSICIAN: Dr. Delgado.FIRST ASSIST: Dr. Kadkhodayan.

MEDICATIONS: 1% buffered Lidocaine (local), Heparin 11,000 units IV bolus; additional medications as per anesthesiology record.SAMPLES: None.POST-PROCEDURE DIAGNOSIS: Status post endovascular treatment of a basilar tip aneurysm with the WEB device.

PROCEDURE AND FINDINGS:

The procedure was explained in its entirety to the patient and family prior to transport to the neuroangiography suite. This included a discussion of the risks, benefits, and alternatives to cerebral angiography with endovascular embolization. Risks discussed included vascular perforation, rupture, or dissection, stroke or transient neurologic deficit (TIA), distal embolization, allergic reaction, pain, bleeding, and infection. The patient gave both verbal and written consent to proceed. Prior to beginning the procedure, a "time out" was performed to confirm the patient's identity and the planned procedure. General anesthesia was initiated and monitored by the staff from the anesthesia department.

Both groins were prepped and draped in the usual sterile fashion with Betadine. Next, the right femoral head was localized fluoroscopically and buffered 1% lidocaine was injected for local anesthesia.

The common femoral artery was then accessed with a micropuncture needle and a 5 French sheath advanced over a 0.035 J-wire. The sheath was connected to a regulated, pressurized infusion of heparinized saline.

The baseline ACT was 128 seconds. A 6,000 unit bolus of intravenous heparin was administered. Two additional boluses totaling 5,000 units of intravenous heparin were administered later in the case to maintain the ACT at 2x baseline.

A 5F H1 catheter was advanced over the glidewire to the aortic arch. Utilizing this catheter/wire combination, the left vertebral artery was selectively cannulated. Rotational angiography via the catheter was then performed with 3D reconstructions obtained at an independent workstation in order to obtain optimal working projections for treatment of the known basilar tip aneurysm measuring 8mm in maximum dimension. Then, we exchanged the 5 French catheter for a 6 Fr NeuronMax sheath over an exchange-length wire, with the sheath positioned in the mid cervical segment of the left vertebral artery.

Then, we introduced an 058 Navien distal access catheter inside the NeuronMax and advanced it to the distal cervical segment of the left vertebral artery over a glidewire.

Then, under digital roadmapping guidance, we introduced an 033 VIA catheter with an Echelon 10 microcatheter inside it and carefully advanced the VIA catheter over a Synchro 14 microwire until the via catheter was inside the basilar tip aneurysm and then removed the Echelon 10 microcatheter and microwire.

Next, we proceeded with embolization of the aneurysm by carefully deploying a 9mm x 6mm WEB device inside the aneurysm sac. However, a contrast injection revealed that this device was too large for the aneurysm. We then retrieved the device via the VIA catheter and then introduced a 9mm x 5mm WEB device. However, a repeat contrast injection revealed that this device was also too large for the aneurysm with >50% narrowing of the proximal P1 segments bilaterally. Hence, we then retrieved the device via the VIA catheter and finally introduced a 8mm x 5mm WEB device. A contrast injection demonstrated that this device provide stasis of contrast inside the aneurysm without narrowing of the P1 segments. Given this, we proceeded to detach this device and removed the VIA microcatheter.

We performed a final dual-volume 3D angiogram via the Navien catheter.

Post-embolization angiography was then performed via the guide catheter in the standard posteroanterior and lateral views as well as the working projections. This demonstrated significant contrast stasis in the aneurysm sac without narrowing of the P1 segments. There was no change in cerebral perfusion in comparison to the pre-embolization images.

The final ACT was 203 seconds.

At the conclusion of the study, the catheter was retracted to the external iliac artery. Contrast was injected at this site to evaluate the common femoral artery puncture site prior to placement of the Angioseal hemostatic device.

There were no immediate complications. The patient was awakened from anesthesia and transported to the post-procedure monitoring area in stable condition.

IMPRESSION:

Successful embolization of a basilar tip aneurysm with the WEB device.

Josser E. Delgado, M.D.NeurointerventionalistAbbott Northwestern HospitalConsulting Radiologists, Ltd Pager: (612) 526-0719Office/Appointments: (612) 863-4808Answering Service: (952) 285-3797OneCall Transfer Center: (612) 863-1000www.consultingradiologists.com19

Post-detachment

8mm x 5mm WEB DL post-detachment run47 y/o woman with an incidental basilar tip aneurysm

#Abbotts 1st WEB case1-year follow-up

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WEB-ITFDA IDE study150 patients, 25 US sites8 patients from Abbott1 primary safety event: 0.67% (1/150)Ipsilateral parenchymal hemorrhage

#Stent alternatives

#Not just coiling anymoreIn next 3-5 years we will have availableMANY types of coils3 types of balloons3 low-profile stents3 intra-vascular flow diverters (FD)2 intra-saccular FDs1 coil / intra-saccular FD hybrid

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Complex access

#Endovascular aneurysm treatment at Abbott Northwestern

#Ruptured brain aneurysms at Abbott778 treated endovascularly since 1995Outcomes at dischargemRS 0 to 2: 389 (50%)mRS 3: 196 (25%)mRS 4 to 6: 193 (25%)

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Neurointerventional clinic at AbbottEvidence-based patient counselingPre-operative medical managementDual antiplatelet therapyOptimize management of comorbiditiesVigilant post-operative managementShort, medium and long term follow-up

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Lancet Neurol. 2014;13:59-66Patient counseling

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373Aneurysms