Elsevier

Surgical Neurology

Volume 66, Issue 6, December 2006, Pages 603-610
Surgical Neurology

Aneurysm
Balloon-expandable stenting with and without coiling for wide-neck and complex aneurysms

https://doi.org/10.1016/j.surneu.2006.05.058Get rights and content

Abstract

Background

Wide-necked, saccular, dissecting, and fusiform intracranial aneurysms are poor coil retainers. Retention can be improved by parent-artery stenting across the aneurysm.

Methods

We used a balloon-expandable stent and delivery system, intending to treat 38 aneurysms in 36 patients. Stents could not be advanced across the neck of 2 aneurysms near the ophthalmic artery origin. These cases were managed by temporary balloon remodeling and coiling. Stenting alone was done for 15 aneurysms, including 7 in vertebral artery V4 segments. Stenting with immediate or delayed coiling was done in 21 aneurysms.

Results

Stenting alone caused immediate and complete obliteration of 1 treated aneurysm (7%), subtotal obliteration in 13 treated (86%) aneurysms, and was associated with 1 failure. Stenting and coiling yielded a significantly better 57% complete obliteration rate, 43% subtotal obliteration, and no failures. There were 5 complications: 1 wire perforation, 2 cavernous-carotid-sinus fistulae, and 2 partial in-stent thromboses. All were controlled or cleared with no long-term sequelae or deaths. Contrast imaging at 1 to 12 months was available for 30 patients (13 stent-only, 17 stent-plus-coiling), demonstrating complete obliteration in 25 (83%) and subtotal obliteration in 5. A total of 7 stent-only aneurysms (4 V4s) were completely obliterated, and 3 (all V4s) were ≥90% obliterated.

Conclusion

Stenting and coiling through the wall of the stent resulted in 88% (15/17) complete obliteration when imaged 1 to 12 months after treatment. Stenting alone effectively closed off V4-segment wide-necked aneurysms but was inferior to stenting and coiling in less mobile vessels.

Introduction

Subarachnoid hemorrhage from intracranial aneurysm rupture accounts for less than 8% of all strokes, but has a disproportional impact because of its relatively young age of onset and poor outcomes, which renders it comparable to cerebral infarction in terms of loss of productive life years [7], [23]. It is potentially associated with lifestyle modifications, particularly in women, as it is associated with smoking, hypertension, and excessive alcohol intake [7], [8]. The data on treatment of most of these aneurysms are unusually robust. An international, prospective, randomized trial of endovascular coiling versus surgical clipping composed of more than 2000 patients with ruptured aneurysms, for which there was equipoise for either treatment, showed a significant 7.4%, absolute 1-year disability-free survival advantage, favoring coiling, which has persisted for 7 years [20]. The results are thought to be pertinent, by implication, to treating unruptured aneurysms, but the necessity for equipoise caused middle cerebral artery (prevailing opinion—surgery) and posterior circulation aneurysms (prevailing opinion—coiling) to be underrepresented and, hence, probably beyond the purview of the study's generalizeability [4].

Although not specifically stated, wide-neck (>4 mm neck or dome-to-neck ratio <2) aneurysms and fusiform aneurysms, which were problematic for both treatments, were typically not included [19]. The geometry of both is unfavorable for coil retention, hazarding protrusion into the parent artery, and, potentially, embolization [22]. Several strategies have been put forth for managing this hazard, but stenting of the parent vessel and then filling the aneurysm with coils through the stent's interstices, “stent-assisted coiling,” appears to be the most adaptable strategy [2], [6], [10], [11], [12], [13], [14], [15], [17], [18]. Initially, this was done with balloon-expandable stents designed for coronary arteries, but the recent trend has been to use self-expanding stents with their lesser radial strength. There are at least 4 reports of 95% or higher technical success [2], [10], [13], [17]. We have differed and have chosen to use the coronary artery, balloon-expandable, Lekton and subsequently available Lekton Motion stent system (Biotronik, AG, Bülach, Switzerland) for low-retentive-geometry aneurysms to achieve permanent aneurysm-parent-vessel junction remodeling and/or coil retention. We prefer this stent system because of its ease of navigation; its open structure facilitating coil delivery and coil retention; its ability to remodel the aneurysm entrance; its easily visualized markers; its limited shortening during expansion; and its smooth, antithrombogenic coating shown in in vitro and in vivo studies [11].

Section snippets

Patients

This was a longitudinal multicenter, observational study held at 4 centers throughout Brazil and Mexico. Between January 2003 and November 2005, 36 patients were recruited into the study. Patients were included if they had an incidental wide-neck or fusiform aneurysm (n = 14) or if they had bled within the previous 7 days (n = 12) and were willing and capable of giving informed consent in accordance with the treaty of Helsinki and laws of the respective countries. There were 26 women (72%) and

Technical failures

We defined the inability to navigate the device to the site of the aneurysm as a technical failure. Navigation of the balloon-expandable stent could not be accomplished in 2 patients. A second attempt with a self-expanding stent (Neuroform, Boston Scientific) was also not possible. Both aneurysms were located in the ophthalmic segment of the internal carotid artery and were successfully coiled using temporary balloon remodeling. These patients were counted as technical failures but were not

Discussion

Several strategies have been devised to improve immediate and permanent coil retention in wide-necked aneurysms. In 1997, Moret et al [21] introduced a technique using balloon remodeling of the parent artery, temporarily blocking the neck during coiling of the sac. Soon thereafter, 3D Guglielmi coils that expand into a basket shape with loops at 90° angles [3] were developed. The next logical step was to combine 3D coiling and temporary balloon remodeling, accepting a small but definite risk of

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