Endovascular treatment of cerebral aneurysms

DR SHARIQ A SHAH RADIODIAGNOSIS SKIMS SRINAGAR

1. ENDOVASCULAR TREATMENT
OF CEREBRAL ANEURYSMS
MODERATOR: PROF. SHEIKH RIAZ
S/R INCHARGE: DR. GM WANI
PRESENTER: DR. SHARIQ SHAH

2. 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

3. 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

4. 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) .

5. THE PRESENT
•IN 1991 GUIDO GUGLEILMI INTRODUCED GUGLEILMI DETACHABLE COILS
(GDCs).

6. THE PRIMARY ANATOMIC IMPEDIMENT TO COIL EMBOLIZATION IS
WIDE NECKED ANEURYSM

7. 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

8. MID BASILAR
ANEU
BALOON
SUBT
IMG
NATIVE IMG COIL
MASS
COIL
MASS

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

10. POST COILING SUBT IMG POST TREAT

11. COILING Vs CLIPPING
ISAT ( INTERNATIONAL SUBARACHNOID ANEURYSM TRIAL)

13. 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)

14. 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..??

15. COILING FAILURE
S
I
X
M
T
RETREATMENT WITH Y STENT TECQ
NATIVE SUBT

16. BIOACTIVE AND COATED COILS


POLYGLYCOLIC-
POLYLACTIC ACID
(PGPLA) COILS
MATRIX, CERECYTE


HYDROGEL COATED
COILS
HYDROCOIL, MICROVENTION

17. •
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%.

18. 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

19. PARENT VESSEL RECONSTRUCTION WITH COMMERCIALLY
AVAILABLE SELF-EXPANDING INTRACRANIAL MICROSTENT

NEUROFORM STENT
CORDIS ENTERPRISE
STENT

20. 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.

21. ICA ANEU
FLOW DIVERTER
6 MONTH
DSA
3 D

22. FLOW DISRUPTION
THE MESH OF THE FLOW DISRUPTOR IS PLACED WITHIN THE ANEURYSM
POUCH AND CREATES BLOOD FLOW STASIS WITH SUBSEQUENT
THROMBOSIS
WEB DEVICE

23. MCA
ANEU
1 YEAR

24. 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)

26. THANKS