- Email: [email protected]
Coiling as a Rescue Strategy for Flow Diverter Prolapse into a Giant Intracranial Aneurysm
Technical Note
Coiling as a Rescue Strategy for Flow Diverter Prolapse into a Giant Intracranial Aneurysm Ana S. Ferrigno, Enrique Caro-Osorio, Hector R. Martinez, Lourdes Martinez-Ordaz, Jose A. Figueroa-Sanchez
BACKGROUND: Up to 3.2% of the adult population has an unruptured intracranial aneurysm (IA). Flow diversion is a relatively new treatment technique that is especially useful for large and morphologically unfavorable IAs.
-
METHODS: A previously healthy woman aged 32 years presented with a 6-month history of ptosis and ophthalmoplegia of the left eye. A magnetic resonance imaging scan revealed a giant left internal carotid artery aneurysm. She was admitted for treatment using flow diversion. After delivery of the flow diverter (FD), prolapse of the proximal end of the stent into the aneurysmal sac was observed. FD stabilization was achieved by deploying multiple coils through a previously placed microcatheter to push the prolapsed end away from the aneurysmal lumen.
-
RESULTS: The patient had a favorable outcome, with reduction of preoperative mass effect symptoms and complete obliteration of the aneurysm persisting at the 3-month follow-up.
-
CONCLUSIONS: Giant IAs remain one of the most daunting clinical problems to treat. FD displacement is a rare (0.5%e0.75%) and possibly fatal complication. Currently, no clinical guidelines exist for its management. Adjunctive coiling is a possible rescue strategy for stabilizing an FD that foreshortened and prolapsed into the aneurysmal sac. Further studies are needed to identify the best approach to this complication.
-
Key words Coiling - Endovascular repair - Flow diverter - Intracranial aneurysm - Stent prolapse -
Abbreviations and Acronyms FD: Flow diverter FRED: Flow Redirection Endoluminal Device IAs: Intracranial aneurysms ICA: Internal carotid artery PED: Pipeline Embolization Device
WORLD NEUROSURGERY -: ---, MONTH 2019
INTRODUCTION
I
t is estimated that 3.2% of the healthy adult population has an unruptured intracranial aneurysm (IA),1 of which only the minority will become symptomatic. The most common presentation of unruptured IAs is as an incidental finding, but headache, nerve palsies, and stroke may occur.2
Currently, 3 main treatment modalities are available for IAs: surgical clipping, endovascular intervention, and observation.1 Of the endovascular treatment options, coil embolization is a technique that has been available since 1990 that may be superior to surgical clipping in terms of procedural morbidity and economic cost.1 However, fusiform, giant, and wide-neck aneurysms may be technically challenging to embolize using coils. Flow diversion is a relatively new endovascular treatment modality for IAs that may be used in such challenging cases.3 By using a flow diverter (FD), the aneurysmal lumen is isolated from circulation, thus inducing thrombosis of the aneurysmal sac.4 This reduces the risk for rupture while avoiding the mass effect associated with coiling.3 Flow diversion has a complete aneurysmal occlusion rate of 76%, with a morbidity rate of 5% and a mortality rate of 4%.5 The main complications of the procedure include hemorrhagic complications (at an estimated rate of 3%), thromboembolic complications (1.5%), and stent migration (0.5%).6
METHODS A previously healthy woman aged 32 years presented to our institution with a 3-month progressive history of cephalea, blurred vision, and ptosis of the left eye. Physical examination demonstrated total ophthalmoplegia of the left eye and anisocoria (left pupil had a 6 mm diameter with a sluggish
Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico To whom correspondence should be addressed: Jose A. Figueroa-Sanchez, M.D., M.B.A. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.08.141 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
1
TECHNICAL NOTE
pupillary reflex while the right pupil had a 4 mm diameter and was reactive). Magnetic resonance imaging was obtained, revealing a giant left internal carotid artery (ICA) aneurysm measuring 5.1 5.5 6.1 cm, with a calculated volume of 85.5 mL (Figure 1). Treatment using flow diversion with adjunctive coiling using the jailing technique was considered to be the best endovascular modality available to avoid the high mortality rates associated with surgical management, and to prevent causing further mass effect as reported with densely packed coil embolization. Premedication with steroids and dual antiplatelet therapy using aspirin and ticagrelor was initiated. After platelet inhibition was confirmed with the P2Y12 assay (VerifyNow, Accumetrics, Accriva, San Diego, California, USA), the patient was placed under general anesthesia. The procedure was performed through an 8F introducer sheath in the right femoral artery. Fluoroscopy demonstrated a giant unruptured left ICA (Figure 2A and B). A standard 8F guiding catheter (Cordis, Miami, Florida, USA) with continuous flush and a 0.038-inch hydrophilic guidewire (Terumo, Tokyo, Japan) was positioned in the left ICA to navigate 2 microcatheters. According to plan, a Headway 27 (MicroVention, Tustin, California, USA) would be used to deliver a 5.0 mm 35/28 (total length/working length) Flow Redirection Endoluminal Device (FRED) (MicroVention) while a Headway 21 microcatheter (MicroVention) was to be jailed into the aneurysm. The FRED size was selected according to the estimated aneurysmal neck size; it was the longest length FD available. In addition, a Traxcess 14 EX microguide (MicroVention) was positioned in the left middle cerebral artery for distal support. Once the proximal part of the aneurysm was identified, the FRED was deployed across the aneurysm neck to jail the
Figure 1. T2-weighted magnetic resonance imaging sequence demonstrating a giant aneurysm in the left
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Headway 21 microcatheter. However, after the delivery of the FRED, foreshortening of the FD and prolapse of the proximal end into the aneurysmal sac was observed (Figure 2C). Because of the spontaneous retraction of the Traxcess 14 EX microguide, telescoping the prolapsed stent in an attempt to divert blood flow away from the aneurysm was not possible. At that moment, it was decided to deploy multiple coils through the previously placed Headway 21 microcatheter (Figure 2D and E) to push the prolapsed end away from the aneurysmal lumen. FD stabilization was achieved by using a total of 10 coils (Figure 2F), and patent blood flow was verified in the distal middle cerebral artery (Figures 2C and D). The aneurysm was completely obliterated. A schematic version of the sequence of events is represented in Figure 3. RESULTS The patient had an uneventful postoperative course. At the 6month follow-up, a digital subtraction angiography confirmed continued complete obliteration of the aneurysm (Figure 4) and the patient’s ophthalmoplegia was completely resolved, the only sequela was mild ptosis of the left eye.
DISCUSSION Giant IAs are a relatively rare clinical entity, corresponding to approximately 5% of diagnosed IAs and arbitrarily defined as >25 mm.7 At present, giant IAs are considered as one of the most difficult cerebrovascular lesions to treat. They have an unfavorable prognosis, with a high rupture rate and mass effect.8 Given that surgical treatment is often associated with high rates of morbidity and coil embolization has high rates of incomplete aneurysm obliteration that often require
internal carotid artery measuring 5.1 5.5 6.1 cm. (A) Axial view. (B) Coronal view.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141
TECHNICAL NOTE
Figure 2. (A) Digital subtraction angiography (DSA) shows an unruptured giant left internal carotid artery (ICA) aneurysm stealing blood flow from the anterior cerebral artery (dashed arrow) and slow blood flow in the middle cerebral artery (solid arrow). (B) The ophthalmic artery (arrow) is observed distal to the aneurysm neck, and thus the location of the aneurysm is suspected to be in the cavernous portion of the left ICA. (C) After Flow Redirection Endoluminal Device deployment, foreshortening
and prolapse of the proximal end of the flow diverter into the aneurysm was observed (arrow) (D) Microcatheter jailed inside the aneurysm lumen. (E) Deployment of multiple coils through the jailed microcatheter to push the prolapsed end away from the aneurysmal lumen (arrows). (F) Final control DSA shows almost complete obliteration of aneurysm with remaining contrast (arrow).
retreatment, flow diversion has recently become an attractive option for giant IAs.9
to US Food and Drug Administration approval for PED use in large unruptured IAs.
FDs promote complete aneurysm occlusion by stimulating endoluminal reconstruction of the parent artery and preventing blood flow into the aneurysmal sac, thus encouraging thrombosis.8 The pipeline for uncoilable or failed aneurysm multicenter trial, which studied the Pipeline Embolization Device (PED) for the treatment of large and giant wide-necked unruptured IAs, showed that PED is a reasonably safe and effective treatment for large IAs, with 73.6% of the cases recorded showing complete aneurysm occlusion, and only 5.6% of patients experiencing adverse neurologic events.9 Angiographic cure was achieved in 92.1% of these patients at 3-years follow-up.10 This results led
Compared with coiling large unruptured IAs (10 mm), flow diversion has higher rates of complete aneurysm occlusion (86 vs. 41%) without a difference in procedure-related complications (7.5% in both groups) or clinical outcome.8 Given the effectiveness of flow diversion, it has been proposed that it should be considered a first choice for treating unruptured IAs and recurrent IAs after previous treatments.11
WORLD NEUROSURGERY -: ---, MONTH 2019
The complications associated with flow diversion are not negligible. A systematic review concluded that the use of flowdiverting devices had a low mortality (2.8%) and neurologic
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TECHNICAL NOTE
Figure 3. Schematic representation of sequence of events. (A) Unruptured left internal carotid artery giant aneurysm. (B) Flow diverter (FD) placement for flow diversion. (C) Foreshortening and prolapse of FD. (D)
morbidity rate (4.5%), with an overall complication rate of 17%.12 Technical complications were composed of poor stent opening (8.6%) and wire perforation (3.8%).13 Neurologic complications included ischemia (7.5%), rebleeding (1.8%), and intracranial hemorrhages (2.9%).13 Migration or poor position of the stent was observed in 5.8%.12 One of the most technically challenging complications of FD migration is the foreshortening of the device leading to prolapse into the aneurysm, an event that has been reported in up to 9.3% of large and giant aneurysms cases.14 The first case of device prolapse was described in 2010 by Lubicz et al.15 in a patient who presented with device migration complicated with
Prolapse of FD (arrow) and deployment of coils through the jailed microcatheter. (E) Coil embolization for complete obliteration of the aneurysm.
massive subarachnoid hemorrhage resulting in the patient’s death 13 days after flow diversion for a giant saccular carotidophthalmic aneurysm. Since then, multiple authors have published cases of device prolapse (Table 1). To date, no clinical guideline exists about the best treatment strategy to employ once device prolapse has occurred. FD migration has been managed by surgical removal,20 telescoping additional flow diverting stents,17 parent vessel sacrifice,24 endoscopic retrieval,25 using a balloon-anchoring technique,13 or observation.14 If navigation through the FD is feasible (by anterograde or retrograde access), telescoping a second FD device with adequate overlapping between the 2 FDs could be a relatively simple solution. However, if distal access is lost and anterograde reaccess through the prolapsed proximal end of the FD proves impossible but navigation to the aneurysmal sac is an option, we propose coiling as a possible rescue strategy before sacrifice of the parent artery or surgery for retrieval is considered. Adjunctive coiling has been previously used as a method to presumably improve clinical outcomes in PED-treated patients.24,25 The perceived benefits of coiling are immediate dome protection for a ruptured aneurysm and scaffolding during PED deployment. Some authors have reported that adjunctive coiling can improve occlusion rates without a significant increase in morbidity.4,8,17 However, some authors argue that adjunctive coiling might not be needed because a high rate of aneurysms achieve complete obliteration with PED without the need for additional coiling.8,26 To our knowledge, this is the first case report in which coiling is used as a rescue strategy after FD foreshortening and prolapse has occurred.
CONCLUSIONS
Figure 4. Digital subtraction angiography at the 6-month follow-up demonstrating complete obliteration of the aneurysm and adequate flow into the left middle cerebral artery (arrow).
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Giant IAs remain one of the most daunting clinical problems to treat. Flow diversion is a relatively new therapy that has been proven to be a reasonably safe and effective treatment. In this report, we present a case of FD foreshortening that lead to the prolapse of the proximal end into the aneurysmal sac. This complication was effectively treated with adjunctive coiling. It is our understanding that this is the first report in which FD stabilization was successfully achieved without the need for FD retrieval, telescoping, using a balloon, or sacrificing the parent
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141
TECHNICAL NOTE
Table 1. Published Cases of Prolapsed Flow Diverters into Intracranial Aneurysms Aneurysm Size
Flow Diverter Size
Prolapse of Flow Diverter
Prolapsed End
Management
28 mm
4 30
Delayed
-
No intervention
27.5 21 mm
4.25 20 mm
Immediate
Proximal
Telescoping of 5 additional PEDs through retrograde access
Chalouhi et al., 201317
18 13 mm
3.25 20 mm
Delayed
Distal
Telescoping a second PED
Chalouhi et al., 201318
12.7 11.6 mm
3 16 mm
Delayed
Proximal
Conservative
28 23 mm
4.25 30 mm
Delayed
Distal
Parent vessel occlusion
“Large”
-
Delayed
Distal
Telescoping a second PED
16.5 mm
4.5 18 mm
Delayed
Distal
Telescoping a second PED
Study Lubicz et al., 201015 16
Hauck et al., 2010
“Giant”
4 14 mm
Delayed
Proximal
No intervention*
Crowley et al., 201413
28 20 mm
4.5 35 mm
Immediate
Proximal
Realignment using a balloon-anchoring technique followed by telescoping a second PED
Bowers et al., 201520
30 22 mm
4.75 35-mm
Immediate
Distal
Microsurgery with bypass and stent removal
Kan et al., 201521
30 20 mm
4.5 35 mm followed by 4.5 20 mm with a 50% overlap
Immediate
Distal and proximal, respectively
Telescoping of 2 additional PEDs through retrograde access
4 18 mm
Immediate
Proximal
Realignment using a balloon-anchoring technique followed by telescoping 2 additional PEDs
4.5 20 mm
Delayed
Proximal
Conservative
21 29 mm
4.25 30 mm
Immediate
Proximal
Conservative
35 mm
Overlapping 5 24 mm (distal) and 5 26 mm (5 26)
Delayed
Proximal
Parent vessel occlusion
19
Navarro et al., 2014
Martínez-Galdámez et al., 201722 - Neck size: 14 mm
Srinivasan et al., 201714
Gawlitza et al., 201923
20 14 mm
PED, Pipeline Embolization Device. *Telescoping of a second PED was planned, but the patient died before the procedure.
artery. To prevent stent migration, the diameters of inflow and outflow vessels as well as aneurysmal neck size must be accurately determined for adequate FD length selection, thus
REFERENCES 1. Gregory TB, Brown RD, Amin-Hanjani S, et al. Guidelines for the management of patients with unruptured intracranial aneurysms. Stroke. 2015; 46:2368-2400. 2. Wiebers DO. Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003; 362:103-110. 3. Piano M, Valvassori L, Quilici L, Pero G, Boccardi E. Midterm and long-term follow-up of cerebral aneurysms treated with flow diverter devices: a single-center experience. J Neurosurg. 2013; 118:408-416.
undersizing with poor wall apposition leading to stent displacement can be averted. Further studies are needed to identify the best approach to this rare but potentially lethal complication.
4. Alderazi YJ, Shastri D, Kass-Hout T, Prestigiacomo CJ, Gandhi CD. Flow diverters for intracranial aneurysms. Stroke Res Treat. 2014;2014: 12.
8. Nohra C, Stavropoula T, Starke RM, et al. Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms. Stroke. 2013;44:2150-2154.
5. Waleed B, Murad MH, Giuseppe L, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters. Stroke. 2013;44: 442-447.
9. Becske T, Kallmes DF, Saatci I, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267: 858-868.
6. Nohra C, Badih D, Starke Robert M, et al. Abstract 8: the pipeline embolization device: midterm results and predictors of outcomes in 335 consecutive patients. Stroke. 2016;47:A8.
10. Becske T, Potts MB, Shapiro M, et al. Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg. 2017;127:81-88.
7. Parkinson RJ, Eddleman CS, Batjer HH, Bendok BR. Giant intracranial aneurysms: endovascular challenges. Neurosurgery. 2006;59:112.
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11. Yu SC, Kwok C, Cheng P, et al. Intracranial aneurysms: midterm outcome of pipeline embolization device–a prospective study in 143 patients with 178 aneurysms. Radiology. 2012;265:893-901.
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12. Zhou G, Su M, Yin YL, Li MH. Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus. 2017;42:E17. 13. Crowley RW, Abla AA, Ducruet AF, McDougall CG, Albuquerque FC. Novel application of a balloon-anchoring technique for the realignment of a prolapsed pipeline embolization device: a technical report. J Neurointerv Surg. 2014;6: 439-444. 14. Srinivasan VM, Carlson AP, Mokin M, et al. Prolapse of the pipeline embolization device in aneurysms: incidence, management, and outcomes. Neurosurg Focus. 2017;42:E16. 15. Lubicz B, Collignon L, Raphaeli G, et al. Flowdiverter stent for the endovascular treatment of intracranial aneurysms. Stroke. 2010;41:2247-2253. 16. Hauck EF, Natarajan SK, Langer DJ, Hopkins LN, Siddiqui AH, Levy EI. Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened pipeline embolization device: complication management. Neurosurgery. 2010;67(2 Suppl Operative):495-502. 17. Chalouhi N, Satti SR, Tjoumakaris S, et al. Delayed migration of a pipeline embolization device. Neurosurgery. 2013;72(2 Suppl Operative): ons229-ons234 [discussion: ons234]. 18. Chalouhi N, Tjoumakaris SI, Gonzalez LF, et al. Spontaneous delayed migration/shortening of the
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pipeline embolization device: report of 5 cases. Am J Neuroradiol. 2013;34:2326. 19. Navarro R, Cano EJ, Brasiliense LBC, Dabus G, Hanel RA. Fatal outcome after delayed pipeline embolization device migration for the treatment of a giant superior cerebellar artery aneurysm: technical note for complication avoidance. Open J Modern Neurosurg. 2014;4:163-168. 20. Bowers CA, Taussky P, Park MS, Neil JA, Couldwell WT. Rescue microsurgery with bypass and stent removal following pipeline treatment of a giant internal carotid artery terminus aneurysm. Acta Neurochir (Wien). 2015;157:2071-2075. 21. Kan P, Wakhloo AK, Mokin M, Puri A. Techniques in distal access of wide-necked giant intracranial aneurysms during treatment with flow diversion. Surg Neurol Int. 2015;6(suppl 7):S284-S288. 22. Martínez-Galdámez M, Ortega-Quintanilla J, Hermosín A, Crespo-Vallejo E, Ailagas JJ, Pérez S. Novel balloon application for rescue and realignment of a proximal end migrated pipeline flex embolization device into the aneurysmal sac: complication management. J NeuroIntervent Surg. 2017;9:e4. 23. Gawlitza M, Soize S, Manceau P, Pierot L. Delayed intra-aneurysmal migration of a flow diverter construct after treatment of a giant aneurysm of the cavernous internal carotid artery [e-pub ahead of print]. J Neuroradiol. https://doi.org/10.1016/j. neurad.2019.01.092, accessed April 15, 2019.
24. Lin N, Brouillard AM, Krishna C, et al. Use of coils in conjunction with the pipeline embolization device for treatment of intracranial aneurysms. Neurosurgery. 2015;76:142-149. 25. Bender MT, Jiang B, Campos JK, et al. Singlestage flow diversion with adjunctive coiling for cerebral aneurysm: outcomes and technical considerations in 72 cases. J Neurointerv Surg. 2018;10: 843-850. 26. Szikora I, Berentei Z, Kulcsar Z, et al. Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. Am J Neuroradiol. 2010;31:1139.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 3 July 2019; accepted 22 August 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.08.141 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141
Coiling as a Rescue Strategy for Flow Diverter Prolapse into a Giant Intracranial Aneurysm Ana S. Ferrigno, Enrique Caro-Osorio, Hector R. Martinez, Lourdes Martinez-Ordaz, Jose A. Figueroa-Sanchez
BACKGROUND: Up to 3.2% of the adult population has an unruptured intracranial aneurysm (IA). Flow diversion is a relatively new treatment technique that is especially useful for large and morphologically unfavorable IAs.
-
METHODS: A previously healthy woman aged 32 years presented with a 6-month history of ptosis and ophthalmoplegia of the left eye. A magnetic resonance imaging scan revealed a giant left internal carotid artery aneurysm. She was admitted for treatment using flow diversion. After delivery of the flow diverter (FD), prolapse of the proximal end of the stent into the aneurysmal sac was observed. FD stabilization was achieved by deploying multiple coils through a previously placed microcatheter to push the prolapsed end away from the aneurysmal lumen.
-
RESULTS: The patient had a favorable outcome, with reduction of preoperative mass effect symptoms and complete obliteration of the aneurysm persisting at the 3-month follow-up.
-
CONCLUSIONS: Giant IAs remain one of the most daunting clinical problems to treat. FD displacement is a rare (0.5%e0.75%) and possibly fatal complication. Currently, no clinical guidelines exist for its management. Adjunctive coiling is a possible rescue strategy for stabilizing an FD that foreshortened and prolapsed into the aneurysmal sac. Further studies are needed to identify the best approach to this complication.
-
Key words Coiling - Endovascular repair - Flow diverter - Intracranial aneurysm - Stent prolapse -
Abbreviations and Acronyms FD: Flow diverter FRED: Flow Redirection Endoluminal Device IAs: Intracranial aneurysms ICA: Internal carotid artery PED: Pipeline Embolization Device
WORLD NEUROSURGERY -: ---, MONTH 2019
INTRODUCTION
I
t is estimated that 3.2% of the healthy adult population has an unruptured intracranial aneurysm (IA),1 of which only the minority will become symptomatic. The most common presentation of unruptured IAs is as an incidental finding, but headache, nerve palsies, and stroke may occur.2
Currently, 3 main treatment modalities are available for IAs: surgical clipping, endovascular intervention, and observation.1 Of the endovascular treatment options, coil embolization is a technique that has been available since 1990 that may be superior to surgical clipping in terms of procedural morbidity and economic cost.1 However, fusiform, giant, and wide-neck aneurysms may be technically challenging to embolize using coils. Flow diversion is a relatively new endovascular treatment modality for IAs that may be used in such challenging cases.3 By using a flow diverter (FD), the aneurysmal lumen is isolated from circulation, thus inducing thrombosis of the aneurysmal sac.4 This reduces the risk for rupture while avoiding the mass effect associated with coiling.3 Flow diversion has a complete aneurysmal occlusion rate of 76%, with a morbidity rate of 5% and a mortality rate of 4%.5 The main complications of the procedure include hemorrhagic complications (at an estimated rate of 3%), thromboembolic complications (1.5%), and stent migration (0.5%).6
METHODS A previously healthy woman aged 32 years presented to our institution with a 3-month progressive history of cephalea, blurred vision, and ptosis of the left eye. Physical examination demonstrated total ophthalmoplegia of the left eye and anisocoria (left pupil had a 6 mm diameter with a sluggish
Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico To whom correspondence should be addressed: Jose A. Figueroa-Sanchez, M.D., M.B.A. [E-mail: [email protected]] Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.08.141 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
1
TECHNICAL NOTE
pupillary reflex while the right pupil had a 4 mm diameter and was reactive). Magnetic resonance imaging was obtained, revealing a giant left internal carotid artery (ICA) aneurysm measuring 5.1 5.5 6.1 cm, with a calculated volume of 85.5 mL (Figure 1). Treatment using flow diversion with adjunctive coiling using the jailing technique was considered to be the best endovascular modality available to avoid the high mortality rates associated with surgical management, and to prevent causing further mass effect as reported with densely packed coil embolization. Premedication with steroids and dual antiplatelet therapy using aspirin and ticagrelor was initiated. After platelet inhibition was confirmed with the P2Y12 assay (VerifyNow, Accumetrics, Accriva, San Diego, California, USA), the patient was placed under general anesthesia. The procedure was performed through an 8F introducer sheath in the right femoral artery. Fluoroscopy demonstrated a giant unruptured left ICA (Figure 2A and B). A standard 8F guiding catheter (Cordis, Miami, Florida, USA) with continuous flush and a 0.038-inch hydrophilic guidewire (Terumo, Tokyo, Japan) was positioned in the left ICA to navigate 2 microcatheters. According to plan, a Headway 27 (MicroVention, Tustin, California, USA) would be used to deliver a 5.0 mm 35/28 (total length/working length) Flow Redirection Endoluminal Device (FRED) (MicroVention) while a Headway 21 microcatheter (MicroVention) was to be jailed into the aneurysm. The FRED size was selected according to the estimated aneurysmal neck size; it was the longest length FD available. In addition, a Traxcess 14 EX microguide (MicroVention) was positioned in the left middle cerebral artery for distal support. Once the proximal part of the aneurysm was identified, the FRED was deployed across the aneurysm neck to jail the
Figure 1. T2-weighted magnetic resonance imaging sequence demonstrating a giant aneurysm in the left
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Headway 21 microcatheter. However, after the delivery of the FRED, foreshortening of the FD and prolapse of the proximal end into the aneurysmal sac was observed (Figure 2C). Because of the spontaneous retraction of the Traxcess 14 EX microguide, telescoping the prolapsed stent in an attempt to divert blood flow away from the aneurysm was not possible. At that moment, it was decided to deploy multiple coils through the previously placed Headway 21 microcatheter (Figure 2D and E) to push the prolapsed end away from the aneurysmal lumen. FD stabilization was achieved by using a total of 10 coils (Figure 2F), and patent blood flow was verified in the distal middle cerebral artery (Figures 2C and D). The aneurysm was completely obliterated. A schematic version of the sequence of events is represented in Figure 3. RESULTS The patient had an uneventful postoperative course. At the 6month follow-up, a digital subtraction angiography confirmed continued complete obliteration of the aneurysm (Figure 4) and the patient’s ophthalmoplegia was completely resolved, the only sequela was mild ptosis of the left eye.
DISCUSSION Giant IAs are a relatively rare clinical entity, corresponding to approximately 5% of diagnosed IAs and arbitrarily defined as >25 mm.7 At present, giant IAs are considered as one of the most difficult cerebrovascular lesions to treat. They have an unfavorable prognosis, with a high rupture rate and mass effect.8 Given that surgical treatment is often associated with high rates of morbidity and coil embolization has high rates of incomplete aneurysm obliteration that often require
internal carotid artery measuring 5.1 5.5 6.1 cm. (A) Axial view. (B) Coronal view.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141
TECHNICAL NOTE
Figure 2. (A) Digital subtraction angiography (DSA) shows an unruptured giant left internal carotid artery (ICA) aneurysm stealing blood flow from the anterior cerebral artery (dashed arrow) and slow blood flow in the middle cerebral artery (solid arrow). (B) The ophthalmic artery (arrow) is observed distal to the aneurysm neck, and thus the location of the aneurysm is suspected to be in the cavernous portion of the left ICA. (C) After Flow Redirection Endoluminal Device deployment, foreshortening
and prolapse of the proximal end of the flow diverter into the aneurysm was observed (arrow) (D) Microcatheter jailed inside the aneurysm lumen. (E) Deployment of multiple coils through the jailed microcatheter to push the prolapsed end away from the aneurysmal lumen (arrows). (F) Final control DSA shows almost complete obliteration of aneurysm with remaining contrast (arrow).
retreatment, flow diversion has recently become an attractive option for giant IAs.9
to US Food and Drug Administration approval for PED use in large unruptured IAs.
FDs promote complete aneurysm occlusion by stimulating endoluminal reconstruction of the parent artery and preventing blood flow into the aneurysmal sac, thus encouraging thrombosis.8 The pipeline for uncoilable or failed aneurysm multicenter trial, which studied the Pipeline Embolization Device (PED) for the treatment of large and giant wide-necked unruptured IAs, showed that PED is a reasonably safe and effective treatment for large IAs, with 73.6% of the cases recorded showing complete aneurysm occlusion, and only 5.6% of patients experiencing adverse neurologic events.9 Angiographic cure was achieved in 92.1% of these patients at 3-years follow-up.10 This results led
Compared with coiling large unruptured IAs (10 mm), flow diversion has higher rates of complete aneurysm occlusion (86 vs. 41%) without a difference in procedure-related complications (7.5% in both groups) or clinical outcome.8 Given the effectiveness of flow diversion, it has been proposed that it should be considered a first choice for treating unruptured IAs and recurrent IAs after previous treatments.11
WORLD NEUROSURGERY -: ---, MONTH 2019
The complications associated with flow diversion are not negligible. A systematic review concluded that the use of flowdiverting devices had a low mortality (2.8%) and neurologic
www.journals.elsevier.com/world-neurosurgery
3
TECHNICAL NOTE
Figure 3. Schematic representation of sequence of events. (A) Unruptured left internal carotid artery giant aneurysm. (B) Flow diverter (FD) placement for flow diversion. (C) Foreshortening and prolapse of FD. (D)
morbidity rate (4.5%), with an overall complication rate of 17%.12 Technical complications were composed of poor stent opening (8.6%) and wire perforation (3.8%).13 Neurologic complications included ischemia (7.5%), rebleeding (1.8%), and intracranial hemorrhages (2.9%).13 Migration or poor position of the stent was observed in 5.8%.12 One of the most technically challenging complications of FD migration is the foreshortening of the device leading to prolapse into the aneurysm, an event that has been reported in up to 9.3% of large and giant aneurysms cases.14 The first case of device prolapse was described in 2010 by Lubicz et al.15 in a patient who presented with device migration complicated with
Prolapse of FD (arrow) and deployment of coils through the jailed microcatheter. (E) Coil embolization for complete obliteration of the aneurysm.
massive subarachnoid hemorrhage resulting in the patient’s death 13 days after flow diversion for a giant saccular carotidophthalmic aneurysm. Since then, multiple authors have published cases of device prolapse (Table 1). To date, no clinical guideline exists about the best treatment strategy to employ once device prolapse has occurred. FD migration has been managed by surgical removal,20 telescoping additional flow diverting stents,17 parent vessel sacrifice,24 endoscopic retrieval,25 using a balloon-anchoring technique,13 or observation.14 If navigation through the FD is feasible (by anterograde or retrograde access), telescoping a second FD device with adequate overlapping between the 2 FDs could be a relatively simple solution. However, if distal access is lost and anterograde reaccess through the prolapsed proximal end of the FD proves impossible but navigation to the aneurysmal sac is an option, we propose coiling as a possible rescue strategy before sacrifice of the parent artery or surgery for retrieval is considered. Adjunctive coiling has been previously used as a method to presumably improve clinical outcomes in PED-treated patients.24,25 The perceived benefits of coiling are immediate dome protection for a ruptured aneurysm and scaffolding during PED deployment. Some authors have reported that adjunctive coiling can improve occlusion rates without a significant increase in morbidity.4,8,17 However, some authors argue that adjunctive coiling might not be needed because a high rate of aneurysms achieve complete obliteration with PED without the need for additional coiling.8,26 To our knowledge, this is the first case report in which coiling is used as a rescue strategy after FD foreshortening and prolapse has occurred.
CONCLUSIONS
Figure 4. Digital subtraction angiography at the 6-month follow-up demonstrating complete obliteration of the aneurysm and adequate flow into the left middle cerebral artery (arrow).
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Giant IAs remain one of the most daunting clinical problems to treat. Flow diversion is a relatively new therapy that has been proven to be a reasonably safe and effective treatment. In this report, we present a case of FD foreshortening that lead to the prolapse of the proximal end into the aneurysmal sac. This complication was effectively treated with adjunctive coiling. It is our understanding that this is the first report in which FD stabilization was successfully achieved without the need for FD retrieval, telescoping, using a balloon, or sacrificing the parent
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141
TECHNICAL NOTE
Table 1. Published Cases of Prolapsed Flow Diverters into Intracranial Aneurysms Aneurysm Size
Flow Diverter Size
Prolapse of Flow Diverter
Prolapsed End
Management
28 mm
4 30
Delayed
-
No intervention
27.5 21 mm
4.25 20 mm
Immediate
Proximal
Telescoping of 5 additional PEDs through retrograde access
Chalouhi et al., 201317
18 13 mm
3.25 20 mm
Delayed
Distal
Telescoping a second PED
Chalouhi et al., 201318
12.7 11.6 mm
3 16 mm
Delayed
Proximal
Conservative
28 23 mm
4.25 30 mm
Delayed
Distal
Parent vessel occlusion
“Large”
-
Delayed
Distal
Telescoping a second PED
16.5 mm
4.5 18 mm
Delayed
Distal
Telescoping a second PED
Study Lubicz et al., 201015 16
Hauck et al., 2010
“Giant”
4 14 mm
Delayed
Proximal
No intervention*
Crowley et al., 201413
28 20 mm
4.5 35 mm
Immediate
Proximal
Realignment using a balloon-anchoring technique followed by telescoping a second PED
Bowers et al., 201520
30 22 mm
4.75 35-mm
Immediate
Distal
Microsurgery with bypass and stent removal
Kan et al., 201521
30 20 mm
4.5 35 mm followed by 4.5 20 mm with a 50% overlap
Immediate
Distal and proximal, respectively
Telescoping of 2 additional PEDs through retrograde access
4 18 mm
Immediate
Proximal
Realignment using a balloon-anchoring technique followed by telescoping 2 additional PEDs
4.5 20 mm
Delayed
Proximal
Conservative
21 29 mm
4.25 30 mm
Immediate
Proximal
Conservative
35 mm
Overlapping 5 24 mm (distal) and 5 26 mm (5 26)
Delayed
Proximal
Parent vessel occlusion
19
Navarro et al., 2014
Martínez-Galdámez et al., 201722 - Neck size: 14 mm
Srinivasan et al., 201714
Gawlitza et al., 201923
20 14 mm
PED, Pipeline Embolization Device. *Telescoping of a second PED was planned, but the patient died before the procedure.
artery. To prevent stent migration, the diameters of inflow and outflow vessels as well as aneurysmal neck size must be accurately determined for adequate FD length selection, thus
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 3 July 2019; accepted 22 August 2019 Citation: World Neurosurg. (2019). https://doi.org/10.1016/j.wneu.2019.08.141 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.08.141