Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent

doi:10.1016/j.jstrokecerebrovasdis.2015.02.016

Journal of Stroke and Cerebrovascular Diseases

Volume 24, Issue 6, June 2015, Pages 1357-1362

https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.02.016 Get rights and content

Background

Middle cerebral artery (MCA) aneurysms often occur in small parent vessels and are incorporated with the orifice of acute-angled efferent branch vessels. Endovascular treatment for these aneurysms remains technically challenging. This study aimed to assess the clinical safety and efficacy of the Low-profile Visualized Intraluminal Support Junior (LVIS Jr) stent for embolization of MCA aneurysms.

Methods

Eighteen intracranial aneurysms, including 13 unruptured and 5 ruptured aneurysms, were treated with LVIS Jr stent–assisted coil embolization. The clinical data and technical results are presented.

Results

A total of 18 stents were successfully delivered to the target aneurysms, and the technical success rate was 100%. There was complete occlusion in 8 (44.4%) of 18 cases, neck remnants in 7 (38.9%) cases, and partial occlusion in 3 (16.7%) cases. In-stent thrombosis occurred in 1 case, and the symptoms disappeared after transvenous tirofiban injection. The modified Rankin Scale score at discharge was 0 in 14 patients, 1 in 3 patients, and 2 in 1 patient.

Conclusions

The LVIS Jr stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked MCA aneurysms with tortuous and smaller parent vessels.

Section snippets

Patient Population

Between December 2013 and May 2014, 56 MCA aneurysms were treated in our department, 19 (33.9%) aneurysms were treated by neck clipping, whereas 37 (66.1%) aneurysms underwent endovascular embolization. The strategy of stent deployment was planned before procedure in 12 aneurysms, of the 25 MCA aneurysms treated with simple coils embolization, 6 cases (including 4 narrow-neck cases) encountered protrusion of coils into the parent artery during procedure, then stenting was considered as a

Immediate Angiographic Results and Complications

Stents were successfully implanted in all 18 patients and were deployed in position as expected, which resulted in 100% technical success. No significant difficulty was encountered during stent delivery and deployment. All stents were fully opened under fluoroscopy. Immediate postprocedural angiograms showed a total occlusion of the aneurysm in 8 (8 of 18, 44.4%) patients, a neck remnant in 7 (7 of 18, 38.9%), and partial occlusion in 3 (3 of 18, 16.7%). The angle between the afferent vessels

Discussion

Since the International Subarachnoid Aneurysm Trial results were published, endovascular embolization has become an important treatment modality for intracranial aneurysms.⁵ However, conventional coiling for wide-necked aneurysms remains a technical challenge and its long-term stability outcome remains controversial. Although MCA aneurysms are considered more suitable for craniotomy clipping, there are a growing number of neurosurgeons or interventional neuroradiologists who have adopted

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Impact of individual intracranial arterial aneurysm morphology on initial obliteration and recurrence rates of endovascular treatments: a multivariate analysis
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Cited by (32)

Trends in the Age of Patients Treated for Unruptured Intracranial Aneurysms from 1990 to 2020
2023, World Neurosurgery
The decision for treatment for unruptured intracranial aneurysms (UIAs) is often difficult. Innovation in endovascular devices have improved the benefit-to-risk profile especially for elderly patients; however, the treatment guidelines from the past decade often recommend conservative management. It is unknown how these changes have affected the overall age of the patients selected for treatment. Herein, we aimed to study potential changes in the average age of the patients that are being treated over time.
A systematic search of the literature was performed to identify all studies describing the age of the UIAs that were treated by any modality. Scatter diagrams with trend lines were used to plot the age of the patients treated over time and assess the presence of a potential significant trend via statistical correlation tests.
A total of 280 studies including 83,437 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. Mean age of the patients was 55.5 years, and 70.7% were female. There was a significant increasing trend in the age of the treated patients over time (Spearman r: 0.250; P < 0.001), with a 1-year increase in the average age of the treated patients every 5 years since 1987.
The present study indicates that based on the treated UIA patient data published in the literature, older UIAs are being treated over time. This trend is likely driven by safer treatments while suggesting that re-evaluation of certain UIA treatment decision scores may be of great interest.
Coiling Variations for Treatment of Ruptured Intracranial Aneurysms: A Meta-Analytical Comparison of Comaneci-, Stent-, and Balloon-Coiling Assistance Techniques
2023, World Neurosurgery
Wide-necked aneurysms represent a challenge for treatment in the setting of acute subarachnoid hemorrhage. Stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) are well-known techniques for treating wide-necked aneurysms. Comaneci-assisted coiling (CAC) is a newer technique involving temporary stent deployment to assist aneurysm coiling. We aim to present the first meta-analysis comparing these treatments of ruptured aneurysms.
Following PRISMA guidelines, PubMed and Embase databases were queried from earliest records to July 2022 for literature reporting SAC, BAC, or CAC of ruptured intracranial aneurysms. A meta-analysis of identified articles was performed.
Of the 571 articles queried, 64 articles were included. One study reported BAC and SAC, 8 reported BAC, 52 reported SAC, and 3 reported CAC. These studies comprised 3153 patients with 3207 ruptured aneurysms treated with CAC (161 patients and aneurysms), BAC (330 patients and aneurysms), and SAC (2662 patients, 2716 aneurysms). Rates of periprocedural thromboembolic or hemorrhagic complications, overall or procedure-related mortality, immediate complete occlusion, retreatment, and length of angiographic follow-up did not differ significantly between SAC and BAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P = 0.01) complication rates were higher with BAC than CAC. Periprocedural thromboembolic (P = 0.03) and hemorrhagic (P < 0.0001) complication rates were higher with SAC than CAC. Complete aneurysm occlusion rates (P = 0.033) were higher with CAC than BAC. No significant differences were present in CAC versus BAC or SAC retreatment rates.
CAC was associated with lower hemorrhagic and thromboembolic complication rates and demonstrated similar complete occlusion and residual retreatment rates to those for BAC and SAC.
Flow diverter devices in the treatment of complex middle cerebral artery aneurysms when surgical and endovascular treatments are challenging
2022, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Since their appearance in clinical practice the indication for FDDs have been extended, in terms of age, ruptured status and location.9,15 Only a few studies have reported the clinical safety and the efficacy of the treatment of MCA aneurysms with FDDs and with disparate results.3,16–28 In the above-mentioned series, most of the MCA aneurysms treated with FDD are saccular and small.29
In this study, the authors retrospectively evaluated the effectiveness and the safety of non-surgical middle cerebral artery (MCA) aneurysms treated via the implantation of a flow diverter device (FDD).
Clinical, procedural and follow-up data were analyzed in order to evaluate the safety and effectiveness of the treatment with the FDD in complex MCA aneurysms. Safety was assessed recording (intra-procedural, peri-procedural and delayed) complications in order to determine the morbidity and mortality rates. Functional outcome was evaluated with modified Rankin Scale (mRS) prior and after the endovascular procedure. To assess the efficacy, midterm and long-term clinical, angiographic and cross-sectional imaging follow-ups were recorded.
47 patients (21 males; 26 females) with MCA aneurysms were treated with FDD. 7 were ruptured. 21 aneurysms were saccular, 19 dissecting, 3 fusiform, 2 blood blister-like and 2 were pseudo-aneurysms. 14 aneurysms were small, 23 large and 10 giant, with a mean size of 15.3 mm. 8 aneurysms were recurrent (Raymond-Roy class III): 2 patients had an aneurysmal sac recanalization after being treated with simple coiling and 6 after being treated with microsurgical clipping. In 4 cases (8.5%), more than one FDD was telescopically positioned in order to treat the aneurysm, for a total of 54 FDDs used.
The overall mortality rate was 2.1% (1/47) and the overall morbidity rate was 8.6% (4/47). Midterm neuroimaging follow-ups showed the complete occlusion of the aneurysm in 63% cases, which became 91% at the end of the follow-up.
FDD is a safe and effective tool that can be used in the treatment of complex MCA aneurysms, where conventional neurosurgical treatments can be challenging or ineffective.
Microsurgical Clipping Compared with New and Most Advanced Endovascular Techniques in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis in the Modern Era
2020, World Neurosurgery
Citation Excerpt :
The search flow diagram is shown in Figure 1. A total of 29 studies and 1552 patients with unruptured saccular middle cerebral artery (MCA) were included in our review.4-32 Overall, 464 patients were treated with endovascular strategies (endovascular group), whereas 1088 patients (surgical group) were treated with surgical clipping.
Analyzing occlusion, complications rate, and clinical results in unruptured saccular middle cerebral artery aneurysms (MCAAs) comparing clipping with the most advance and newer endovascular techniques.
We conducted a literature research from January 2009 to December 2018 to evaluate the efficacy and safety of microsurgical clipping or endovascular treatment with new devices (such as Flow-diverter or Woven EndoBridge) in patients with unruptured MCAAs. We extracted data involved: study and intervention features, occlusion rate; time of occlusion assessment; and clinical outcome.
A total of 29 studies and 1552 patients with unruptured saccular MCAAs were included in our analysis (464 patients included in the endovascular group, 1088 patients in the surgical group). Overall, the rate of long-term complete/near-complete occlusion was 78.1% (311/405, 95% confidence interval [CI], 69%–87.1%) and 95.7% (113/118, 95% CI, 92%–99.3%) after endovascular and surgical treatments, respectively (P = 0.001). The long-term complete occlusion rate was 60% (153/405, 95% CI, 45%–74%) and 95% (112/118, 95% CI, 90%–98%) after endovascular and surgical treatments, respectively (P = 0.001). The overall rate of treatment-related complications was 5.6% (33/464, 95% CI, 3.6%–7.7%) and 2.9% (37/1088, 95% CI, 0.8%–5%) among the endovascular and surgical groups, respectively (P = 0.001). Endovascular treatments were associated with higher rates of good neurologic outcome (283/293 [97%], 95% CI, 95%–98% vs. 570/716 [84%], 95% CI, 67%–98%; P = 0.001). No difference was found for the mortality (3/464 [1.5%], 95% CI, 0.4%–2.6% vs. 1/1088, 95% CI, 0.1%–0.6%; P = 0.5).
Treatment-related complication and mortality are comparable among these techniques and the risk of aneurysm rupture seems very low for both strategies. The endovascular approach seems to increase the probability of good functional outcome after treatment, compared with surgery.
Outcome and Prognostic Factors of Ruptured Middle Cerebral Artery Aneurysms Treated via Endovascular Approach: A Single-Center 11-Year Experience
2020, World Neurosurgery
Citation Excerpt :
In recent years, we have preferred braided stents such as LVIS stents to treat these complex aneurysms. These stents showed excellent trackability and deliverability and offered smaller mesh compared with laser-cutting stents and hence provided better protection for aneurysm neck and side branches of wide-necked MCA aneurysms with tortuous vessels.21,22 Tirofiban is another factor that helps improve patient's outcome, because it reduced the occurrence of intrastent thrombosis.
To investigate outcomes and prognostic factors of ruptured middle cerebral artery (MCA) aneurysms, treated via endovascular approach, with improving treatment materials and techniques.
A total of 185 consecutive patients, admitted with acutely ruptured MCA aneurysms and treated by endovascular methods between 2006 and 2016, were retrospectively reviewed. Their baseline characteristics, procedure-related complications, and angiographic and clinical outcomes were collected. Univariate analysis and logistic regression analysis were completed to identify any association between procedure-related complications or clinical outcomes and potential risk factors.
Procedure-related complications occurred in 28 patients (15.1%), including aneurysm rebleeding in 7 (3.8%), hematoma expansion in 10 (5.4%), and ischemia in 13 (7.0%) (concurrent hemorrhage and ischemia in 2 patients), which resulted in morbidity/mortality of 7% and 1.4%. Final evaluations indicated that 153 patients (82.7%, 153/185) had a good outcome (modified Rankin Scale score 0–2). Among 120 (69.4%) who underwent angiographic follow-up, 89 (74.2%) were completely occluded and 20/120 (16.7%) were recanalized. Multivariate analysis of clinical outcome indicated that a high preoperative Hunt and Hess grade (IV–V), intrasylvian/intracerebral hematoma, and early period treatment (2006–2013) were associated with unfavorable outcomes.
Endovascular treatment for patients with ruptured middle cerebral artery aneurysms may offer favorable clinical and angiographic outcomes. With the evolution of treatment materials and updated techniques, treatment complications have become less common than previously reported in literature, and clinical outcomes have been improved in recent years.
Effect Analysis of Microsurgical Clipping and Endovascular Embolization for the Treatment of Middle Cerebral Artery Aneurysms
2019, World Neurosurgery
Citation Excerpt :
The incidence of middle cerebral artery aneurysms (MCAAs) is third in intracranial aneurysms and the therapeutic strategies of MCAAs mainly include microsurgical clipping and endovascular embolization.1 With the development of interventional endovascular techniques and the publication of the findings from International Subarachnoid Aneurysmal Hemorrhage Trial (ISAT), more and more medical centers are adopting endovascular embolization as the preferred treatment for intracranial aneurysms.2 However, despite the fact that middle cerebral arteries (MCAs) can be easily catheterized, MCAAs are usually difficult for endovascular therapy because of their unfavorable morphology and location.
To evaluate the safety and effectiveness of microsurgical clipping and endovascular embolization for the treatment of middle cerebral artery aneurysm (MCAA).
The clinical data of 482 patients with MCAA treated with microsurgical clipping or endovascular embolization were analyzed retrospectively. According to whether the aneurysms were ruptured, patients were divided into a ruptured group and an unruptured group. Demographics, clinical manifestation, and postoperative complications were recorded.
In the microsurgical clipping group (257 patients), there were 114 male and 143 female patients. The mean age was (55 ± 10) years and the mean course of disease was 3 (1, 36) days. The total numbers of MCAA were 274, including 179 ruptured aneurysms and 95 unruptured aneurysms. In the endovascular embolization group (225 patients), there were 98 male and 127 female patients. The mean age was (54 ± 11) years and the mean course of disease was 10 (1, 55) days. The total numbers of MCAA were 234, including 126 ruptured aneurysms and 108 unruptured aneurysms. There was no difference between the incidence of complications in the ruptured and unruptured groups. The outcome of the endovascular embolization group was better than the microsurgical clipping group in ruptured aneurysms (P = 0.000). The recurrence rate of the endovascular embolization group was greater than the microsurgical clipping group in ruptured aneurysms (P = 0.023).
Both microsurgical clipping and endovascular embolization were safe and effective methods for the treatment of MCAA, but patients with ruptured MCAAs treated with endovascular embolization were more likely to experience recurrence.

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: This study has received funding by the National Natural Science Foundation of China (Grant No. 81171092), Shanghai Education Commission Innovation Fund (Grant No. 14ZZ081), and Scientific Research 1255 Project of Changhai Hospital (Grant No. CH125520100). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

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Original ArticleEndovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent

Background

Methods

Results

Conclusions

Section snippets

Patient Population

Immediate Angiographic Results and Complications

Discussion

Lancet

Neuroform stent-assisted coil embolization of wide-neck intracranial aneurysms: strategies in stent deployment and midterm follow-up

Neurosurgery

Retractable self expandable stent for endovascular treatment of wide-necked intracranial aneurysms: preliminary experience

Neurosurgery

Stenting and angioplasty of small cerebral arteries in symptomatic intracranial atherosclerotic disease

Interv Neurol

Impact of individual intracranial arterial aneurysm morphology on initial obliteration and recurrence rates of endovascular treatments: a multivariate analysis

J Neurosurg

Endovascular treatment of wide-neck middle cerebral artery aneurysms with stents: a review of 16 cases

Am J Neuroradiol

Endovascular treatment for saccular aneurysms of the proximal (M1) segment of the middle cerebral artery

Acta Neurochir (Wien)

Original Article
Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent