endovascular treatment of cerebral aneurysms

ENDOVASCULAR TREATMENT OF CEREBRAL ANEURYSMS

MODERATOR: PROF. SHEIKH RIAZ S/R INCHARGE: DR. GM WANIPRESENTER: DR. SHARIQ SHAH

INTRACRANIAL ANEURYSM

• PEVELANCE OF 0.5% - 6%

• ASYMPTOMATIC - NEVER DETECTED OR INCIDENTALLY DETECTED

• SYMPTOMATIC

• RUPTURE AND SAH : OF THOSE SUFFERING SAH 15% ARE KNOWN

TO DIE BEFORE REACHING HOSPITAL. 50% DIE WITHIN ONE

MONTH OF THOSE WHO SURVIVE 50% REMAIN DEPENDENT FOR

THEIR NORMAL ACTIVITIES OF DAILY LIVING

INDICATIONS OF TREATMENT• RUPTURED ANEURYSM :

ALMOST ALWAYS TREATED PROVIDED PATIENT IS NEUROLOGICALLY

AND PHYSIOLOGICALLY WELL ENOUGH TO UNDERGO THERAPY EITHER

SURGICAL CLIPPING OR ENDOVASCULAR COILING.

TREATMENT IS TYPICALLY CARRIED OUT URGENTLY RATHER THAN

EMERGENTLY WITHIN 24 HRS OF ARRIVAL TO HOSPITAL.

• UNRUPTURED ANEURYSM:

CONSERVATIVE MANAGEMENT

OPEN SURGICAL CLIPPING

ENDOVASCULAR COIL EMBOLIZATION

THE PAST• SERBINENKO IN 1970 FIRST DESCRIBED USE OF IMPLANTABLE LATEX

BALOONS

• ORIGINAL TECHNIQUE INVOLVED OCCLUSION OR DECONSRUCTION OF

PARENT VESSEL AND ANEURYSM.

• FURTHER DEVELOPMENT OF CATHETER AND BALOON TECHNOLOGY

ALLOWED FOR PLACEMENT OF DETACHABLE SILICONE AND LATEX BALLON

(CONSTRUCTIVE OCCLUSION) .

THE PRESENT• IN 1991 GUIDO GUGLEILMI INTRODUCED GUGLEILMI DETACHABLE COILS

(GDCs).

THE PRIMARY ANATOMIC IMPEDIMENT TO COIL EMBOLIZATION IS

WIDE NECKED ANEURYSM

BALOON REMODELLING A TEMPORARY OCCLUSION BALOON IS INFLATED ACROSS THE NECK OF

ANEURYSM EMBOLIZATION COILS ARE INTRODUCED

BALOON IS DEFLATED………WATCH FOR PROLAPSE

COIL STABLE

DETACH THE COIL AND REINFLATE THE BALOON

REPEAT

MID BASILAR ANEU

BALOON

SUBT IMG

NATIVE IMG COIL MASS

COIL MASS

STENT ASSISTED TECHNIQUE IN 2003 NEUROFORM , A MICRO CATHETER DELIVERED MICROSTENT WAS

DEVELOPED

POST COILING SUBT IMG POST TREAT

COILING Vs CLIPPINGISAT ( INTERNATIONAL SUBARACHNOID ANEURYSM TRIAL)

SHORT COMINGS OF COILING !!!

INCOMPLETE TREATMENT:

• ONLY 38% RATE OF COMPLETE ANGIOGRAPHIC OCCLUSION AT 12 MONTH

FOLLOW UP …….Raymond et al

• < 50% RATE OF COMPLETE ANGIOGRAPHIC OCCLUSION AT F/U

ANGIOGRAPHY …….. Rivet et al

• CARAT STUDY : RISK OF REBLEED INCREASED DRASTICALLY WITH

DECREASING LEVELS OF OCCLUSION…… 0.6% IN COMPLETELY OCCLUDED Vs

15% FOR PARTIALLY OCCLUDED (per 100 person years)

ANEURYSM RECANALIZATION

• RECANALIZATION RATE OF 33% WAS OBSERVED [ 50% FOR LARGE

AND WIDE NECKED ANEURYSM]……… Raymond etal

• RECANALIZATION OF 35% FOR LARGE ANEURYSMS AND 60% FOR

GAINT ANEURYSMS……..Murayama et al

• ONCE ANEURYSMS RECUR AND REQUIRE RETREATMENT, THEY

FREQUENTLY RECUR A SECOND OR THIRD TIME WITH A RECURRENCE

RATE OF ~ 50%

LONG TERM DURABILITY AND EFFICACY..??

COILING FAILURE

SIX MT

RETREATMENT WITH Y STENT TECQ NATIVE SUBT

BIOACTIVE AND COATED COILS

POLYGLYCOLIC-POLYLACTIC ACID (PGPLA) COILS

MATRIX, CERECYTE

HYDROGEL COATED COILS

HYDROCOIL, MICROVENTION

• PGPLA-CONATINING COILS : DESIGNED TO STIMULATE AN INFLAMMATORY REACTION WITHIN THE

ANEURYSM THAT INDUCES AN ACCELERATED ORGANIZATION OF THROMBUS

AND ULTIMATELY FIBROSIS AND SUBSEQUENTLY ELICITS A FASTER AND MORE

COMPLETE NEOINTIMAL OVERGROWTH OF THE ANEURYSM NECK.

• HYDROGEL-COATED COILS : COATED WITH A DESICCATED HYDROGEL THAT ABSORBS WATER AND SWELLS

CONSIDERABLY UPON INTRODUCTION INTO THE BLOOD ENVIRONMENT. AS

SUCH, THESE COILS SUBSTANTIALLY INCREASE THE VOLUMETRIC FILLING WITH

PACKING DENSITIES BETWEEN 50% AND 100%.

THE FUTURE !! PARENT VESSEL RECOSTRUCTION This procedure is achieved through the implantation of

stents or stent-like devices within the parent artery, which

function to achieve several important hemodynamic and

biological effects:

• Change in parent vessel configuration

• Flow redirection

• Tissue overgrowth

PARENT VESSEL RECONSTRUCTION WITH COMMERCIALLY

AVAILABLE SELF-EXPANDING INTRACRANIAL MICROSTENT

NEUROFORM STENTCORDIS ENTERPRISE STENT

PARENT VESSEL RECONSTRUCTION WITH THE PIPELINE EMBOLIZATION DEVICE (FLOW DIVERTER)

• The PED is a self-expanding, microcatheter-

delivered,cylindrical mesh device composed of 48 individual

braided cobalt chromium and platinum strands.

• The device has a 30% to 35% metal surface area when

fully deployed, which is far greater than the 6.5% to 9%

metal surface area coverage provided by the commercially

available microstents routinely used in practice.

• Multiple devices can be deployed within each other

(telescoped) to create a composite endovascular construct.

ICA ANEU

FLOW DIVERTER

6 MONTH

DSA 3 D

FLOW DISRUPTION THE MESH OF THE FLOW DISRUPTOR IS PLACED WITHIN THE ANEURYSM

POUCH AND CREATES BLOOD FLOW STASIS WITH SUBSEQUENT

THROMBOSIS

WEB DEVICE

MCA ANEU

1 YEAR

EMBOLIZATION WITH LIQUID EMBOLIC AGENTS

• ONYX WAS THE PRODUCT WHOSE DEVELOPMENT WAS THE MOST

IMPORTANT AND CLINICAL EVALUATION THE LARGEST.

• UNDER THE CONTROL OF A REMODELING BALLOON THE PRODUCT IS

PROGRESSIVELY INJECTED IN THE ANEURYSM TO FILL ALL THE ANEURYSM

FROM THE DOME TO THE NECK.

CONCERNS !! MASS EFFECT OF LARGE AND GIANT ANUERYSM POST FILLING

STENOSIS OF THE PARENT VESSEL (DUE TO LEAK)

THANKS