Elsevier

World Neurosurgery

Volume 118, October 2018, Pages e575-e583
World Neurosurgery

Original Article
The Use of Flow Diversion in Vessels ≤2.5 mm in Diameter–A Single-Center Experience

https://doi.org/10.1016/j.wneu.2018.06.245Get rights and content

Highlights

  • Flow diversion in arteries <2.5 mm in diameter is technically feasible.

  • The aneurysm occlusion rate is similar to that seen in larger vessels.

  • Existing devices can be used and newer devices dedicated to smaller vessels have begun to enter the market.

Background

Flow diversion has become an accepted treatment strategy for aneurysms; however, there are limited data on the use of these devices in small vessels ≤2.5 mm in diameter.

Methods

We performed a retrospective review of our prospectively maintained database to identify all patients treated with flow diversion between September 2009 and January 2018. We identified all patients in whom the average parent artery was ≤2.5 mm in diameter. Ruptured aneurysms were excluded from the analysis as were patients who had adjunctive coiling at the time of flow diversion.

Results

We identified 29 patients (22 female, 76%) with average age 56.2 ± 15.9 years (range, 21–83 years). Most aneurysms were classified as saccular (n = 21, 72.4%), with 7 fusiform aneurysms (24.2%) and 1 presumed dissecting aneurysm (3.4%). The average parent artery diameter was 2.1 ± 0.37 mm (range, 1.3–2.5 mm). Delayed angiographic follow-up was available for 18 patients at an average of 19.4 months after treatment. Fifteen patients showed Raymond-Roy classification grade 1 occlusion (94%) and 1 patient with complete filling showed Raymond-Roy classification grade 3 (6%). Four patients (13.7%) underwent repeat treatment with implantation of another flow-diverting stent in a telescoping manner. At 90 days, 2 patients had a modified Rankin Scale (mRS) score of 6, 1 from an unrelated cause and 1 from the enlarging compressive dissecting aneurysm and intraparenchymal hemorrhage. All the remaining patients had an mRS score ≤2 at 90 days, with 24 patients (83%) with an mRS score of 0.

Conclusions

Flow diverters can be implanted into small vessels with a high rate of technical success and good rates of aneurysm occlusion. Dedicated devices to target these vessels should be developed.

Introduction

Since their introduction, flow-diverting stents (FDS) have gained a broad acceptance as a viable treatment option for intracranial aneurysms. The PUFS (Pipeline for Uncoilable or Failed Aneurysms) study1 showed an aneurysm occlusion rate of 73.6% at 6 months and major ipsilateral stroke or neurologic death rate of 5.5%, whereas the PITA (Pipeline Embolization Device for the Intracranial Treatment of Aneurysms) study2 showed a 6-month aneurysm occlusion rate of 93.3% and ischemic stroke risk of 6.5%. More recently, the 5-year follow-up data for the PUFS study were reported and showed good long-term safety, with most patients having a good clinical outcome.3 Numerous meta-analyses and systematic reviews from a variety of different groups have also showed similar results.4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 However, despite the wealth of data, there is limited evidence on the use of these stents in small arteries (≤2.5 mm), with only 1 study addressing this question directly.23

We present our data on the use of FDS to treat aneurysms arising from parent vessels with maximum diameter ≤2.5 mm.

Section snippets

Patient Population

We performed a retrospective analysis of a prospectively maintained database to identify all patients with an aneurysm arising from a vessel ≤2.5 mm in diameter. Patients with both saccular and fusiform aneurysms were included. Ruptured aneurysms were excluded from the analysis as were patients who had adjunctive coiling at the time of flow diversion. We searched our database between September 2009 and January 2018.

For each patient, we recorded demographic data, clinical presentation, location

Results

We identified 29 patients (22 female, 76%) with average age of 56.2 ± 15.9 years (range, 21–83 years). Seventeen aneurysms (59%) were located on the right, with the remainder of the aneurysms located on the left. Most aneurysms were classified as saccular 21 (72.4%), with 7 fusiform aneurysms (24.2%) and 1 presumed dissecting aneurysm (3.4%). Of the saccular aneurysms, the average dome width was 5.3 ± 3.9 mm (range, 1.2–16 mm), the dome was 8.5 ± 9.7 mm (range, 1.3–39 mm), and the average neck

Discussion

Good aneurysm exclusion rates and long-term outcomes have been seen for aneurysms treated with flow diversion; however, the results for the use of these devices in small vessels is limited. We are aware of only a single study that has looked specifically at the use of the PED in vessels ≤2.5 mm in diameter. Puri et al.23 presented their results of aneurysms, all arising from the anterior circulation, with parent artery vessel diameter of ≤2.5 mm. They identified 7 patients (6 female) with a

Conclusions

The use of FDS in vessels ≤2.5 mm is technically feasible, with good aneurysm exclusion rates. The introduction of FDSs specifically designed for small vessels may help to make the treatment of distal aneurysms more feasible.

Acknowledgments

Author contributions: P.B., data gathering, manuscript preparation, study design, review, and editing; J.C., data gathering, data collection, and manuscript preparation; C.B., data gathering, data collection, and manuscript preparation; I.L., data gathering, data collection, and manuscript preparation; N.P., data gathering, data collection, and manuscript preparation; H.H., manuscript preparation and study design; and P.L., data gathering, editing, review, and guarantor.

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      This null stroke rate, which was comparable to the studies in the literature review (pooled rate = 0.1 %), in addition to the 0 % mortality rate, highlights the safety profile of the FRED Jr. [5,10–15] This high rate of favorable clinical outcomes in our case series (100 %) compared to the literature (pooled rate= 90.1 %) may be attributed to the small sample size of our case series. 5,10–15Moreover, feasibility of FRED Jr was apparent in the 100 % rate of successful deployment in both our case series and the literature review [5,10–15]. With respect to outcomes, the rates of pooled complete occlusion (69.9 %) and complications (0 %) in our meta-analysis were comparable to those of other flow diverting stents in the literature ranging from 62 % to 100 % and 0–30 % respectively [16–19].

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    Conflict of interest statement: P.B. serves as a consultant and proctor for phenox and consultant for Neurvana Medical; J.C., I.L., C.B., and N.P. have no conflicts to declare; H.H. is cofounder and shareholder of phenox; and P.L. serves as a consultant for phenox.

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