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J Cerebrovasc Endovasc Neurosurg. 2015 Dec;17(4):331-333. English.
Published online December 31, 2015.  https://doi.org/10.7461/jcen.2015.17.4.331
© 2015 Journal of Cerebrovascular and Endovascular Neurosurgery
Endovascular Management of Intracranial Aneurysms: Advances in Stenting Techniques and Technology
Dale Ding
Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA.

Correspondence to Dale Ding. Department of Neurosurgery, University of Virginia Health System, P.O. Box 800212 Charlottesville, VA 22908, USA. Tel: 1-434-924-2203, Fax: 1-434-982-5753, Email: dmd7q@hscmail.mcc.virginia.edu
Received April 19, 2014; Revised February 21, 2015; Accepted December 16, 2015.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


Keywords: Endovascular procedures; Flow diversion; Intracranial aneurysm; Stents; Stroke; Subarachnoid hemorrhage

TO THE EDITOR

I have read, with interest, a recently published article in the Journal of Cerebrovascular and Endovascular Neurosurgery by Kim et al. titled 'A Self-expanding Nitinol Stent (Enterprise) for the Treatment of Wide-necked Intracranial Aneurysms: Angiographic and Clinical Results in 40 Aneurysms'.23) The authors report their outcomes with Enterprise (Codman, Raynham, MA, USA) stent-assisted coil embolization (SACE) of 40 wide-necked intracranial aneurysms in 39 patients. The mean neck width was 5.6 mm, and 30% were located in the posterior circulation. At the initial treatment, the rates of Raymond class 1, 2 and 3 angiographic outcomes were 20%, 15%, and 65%, respectively. The rate of overall complications was 12.5%, and the rate of symptomatic complications was 2.5%. The modified Rankin Scale (mRS) score was 3 or higher in six patients (15.4%), although four of the six patients (66.7%) presented with subarachnoid hemorrhage (SAH). Of the 18 patients with available angiographic follow-up (mean duration 11.3 months, range 6 to 23 months), the rates of Raymond class 1, 2, and 3 outcomes were 72.2%, 22.2%, and 5.6%, respectively. Of note, 11 of 16 aneurysms with neck or sac remnants at initial treatment progressed to complete occlusion at follow-up (68.8%), and only one of those aneurysms developed recanalization (6.3%). Additionally, there were no cases of in-stent stenosis at follow-up. In the following discussion, we highlight recent advances in endovascular stenting techniques and technologies for the treatment of intracranial aneurysms.

Wide-necked (dome to neck ratio < 2 or neck width ≥ 4 mm) or large (diameter ≥ 10 mm) aneurysms are difficult to treat with endovascular coiling alone.30) Intracranial stents significantly expanded the endovascular armamentarium by providing a scaffold for coil support and promoting endothelialization across the neck of large, wide-necked aneurysms.27) An analysis of 552 aneurysms (508 patients) treated with SACE, 91% electively and 9% in the setting of SAH, reported a 7% procedural complication rate.3) After a mean follow-up of 26 months, the aneurysm recanalization and retreatment occurred in 12% and 6%, respectively. The past few years have seen a transition from the use of stenting techniques from SACE, such as was used in the present series, to flow-diverting stents, such as the Pipeline Embolization Device (PED; ev3 Neurovascular, Irvine, CA, USA) and SILK stent (Balt Extrusion, Montmorency, France).1), 15), 16), 17), 18), 20), 25) A matched cohort study comparing PED flow diversion to coiling (including coiling alone, SACE, and balloon-assisted coiling) large, unruptured saccular aneurysms reported a significantly higher occlusion rate in the PED cohort (86% vs. 41%, p < 0.001), with similar rates of complications and favorable outcome (modified Rankin Scale score 0-2).

A meta-analysis of 1,654 aneurysms (1,451 patients) treated with flow diverters reported complete occlusion in 76%, ischemic stroke in 6%, procedural morbidity in 5%, mortality in 4%, and postoperative subarachnoid hemorrhage, intraparenchymal hemorrhage, and perforator infarction each in 3%.2) Patients with posterior circulation aneurysms were significantly more prone to ischemic stroke (p < 0.0001) and perforator infarction (p < 0.0001) compared to those with anterior circulation aneurysms. An international, multicenter retrospective cohort study of 906 aneurysms (793 patients) treated with the PED at 17 centers reported a combined neurological morbidity and mortality rate of 8%, which was highest in posterior circulation aneurysms (16%) and lowest in internal carotid artery aneurysms < 10 mm in diameter (5%).22) The overall rates of ischemic stroke, intracranial hemorrhage, and spontaneous aneurysm rupture were 5%, 2%, and 0.6%, respectively. Although our understanding of the typical complication profile of flow diversion is becoming more established, the optimal management of uncommon complications remains poorly defined.11), 19), 21)

Stents continue to play a crucial role in the treatment of intracranial aneurysms, as well as numerous cerebrovascular disorders.4), 5), 7), 8), 9), 12), 14), 26), 32) Conventional high-porosity stents have given way, in recent years, to low-porosity flow diverters. Our understanding of the indications for SACE and flow diversion continues to evolve as evidence mounts for stent-based techniques and devices. An improved understanding of aneurysm biology may improve our ability to develop and employ emerging stent technologies for the treatment of complex aneurysms.6), 10), 13), 24), 28), 29), 31)

Notes

Disclosure:The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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