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Abstract

Aim

Flow diverters are increasingly used to treat aneurysms, but treatment is not always effective. The management of aneurysms that fail to occlude following flow diversion is problematic. We aimed to reproduce failures in an animal model and study re-treatment with additional flow diverters alone or with flow diverters and liquid embolic agent.

Material and methods

Twenty wide-necked aneurysms were created at the carotid-lingual bifurcation in 10 dogs, and were treated with flow diverters 4–6 weeks later. Follow-up angiography was performed at three months. Suitable residual aneurysms were randomly allocated: re-treatment with flow diverters alone (n = 6), or with the injection of liquid embolic between two layers of flow diverters (n = 4) or no re-treatment (n = 2). Angiography was repeated three months later, followed by euthanasia, photography and pathology.

Results

Patent wide-necked aneurysms were produced in 17/20 attempts (85%); three months after flow diversion there were 15/17 (88%) residual aneurysms. In three cases, re-treatment was not possible because the flow diverter had prolapsed into the aneurysm, leaving 12 aneurysms to study. Re-treated aneurysms showed improved angiographic results at six months (median score of 2; P = 0.03), but residual aneurysms were present in all cases. Parent artery occlusion occurred in two aneurysms treated with flow diverter plus liquid embolic. At pathology, aneurysms were only partially filled with thrombus; leaks through the flow diverters were found in the neointima connecting the arterial lumen to residual aneurysms.

Conclusion

Re-treatment of residual flow-diverted experimental aneurysms with additional flow diverters did not lead to aneurysm occlusion.

Keywords

Experimental aneurysm flow diversion failure re-treatment animal models

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References

Becske

Kallmes

Saatci

et al.

Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 2013; 267: 858–868.

Brinjikji

Murad

Lanzino

et al.

Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 2013; 44: 442–447.

Kan

Srinivasan

Mbabuike

et al.

Aneurysms with persistent patency after treatment with the pipeline embolization device. J Neurosurg 2016; 126: 1–5.

Farzin

Brosseau

Jamali

et al.

Flow diverters: inter and intra-rater reliability of porosity and pore density measurements. J Neurointerv Surg 2015; 7: 734–739.

Chalouhi

Tjoumakaris

Starke

et al.

Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms. Stroke 2013; 44: 2150–2154.

Mattingly

Van Adel

Dyer

et al.

Failure of aneurysm occlusion by flow diverter: a role for surgical bypass and parent artery occlusion. J Neurointerv Surg 2015; 7: e13.

Darsaut

Salazkin

Gentric

et al.

Temporary surgical clipping of flow-diverted arteries in an experimental aneurysm model. J Neurosurg 2016; 125: 283–288.

Darsaut

Bing

Salazkin

et al.

Testing flow diverters in giant fusiform aneurysms: a new experimental model can show leaks responsible for failures. AJNR Am J Neuroradiol 2011; 32: 2175–2179.

Fahed

Gentric

Salazkin

et al.

Flow diversion of bifurcation aneurysms is more effective when the jailed branch is occluded: an experimental study in a novel canine model. J Neurointerv Surg 2017; 9: 311–315.

10.

Fahed

Raymond

Ducroux

et al.

Testing flow diversion in animal models: a systematic review. Neuroradiology 2016; 58: 375–382.

11.

Kilkenny

Browne

Cuthill

et al.

Animal research: reporting in vivo experiments – the ARRIVE guidelines. J Cereb Blood Flow Metab 2011; 31: 991–993.

12.

Darsaut

Bing

Salazkin

et al.

Flow diverters can occlude aneurysms and preserve arterial branches: a new experimental model. AJNR Am J Neuroradiol 2012; 33: 2004–2009.

13.

Kamran

Yarnold

Grunwald

et al.

Assessment of angiographic outcomes after flow diversion treatment of intracranial aneurysms: a new grading schema. Neuroradiology 2011; 53: 501–508.

14.

Gentric

Salazkin

Gevry

et al.

Compaction of flow diverters improves occlusion of experimental wide-necked aneurysms. J Neurointerv Surg 2016; 8: 1072–1077.

15.

Berenstein

. Treatment of experimental aneurysms with a new liquid embolic agent and a retrievable stent: proof of concept and feasibility study. J Neurointerv Surg 2016; 8: 934–939.

16.

Abla

Zaidi

Crowley

et al.

Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 2014; 14: 31–37.

17.

Raymond

Darsaut

Guilbert

et al.

Flow diversion in aneurysms trial: the design of the FIAT study. Interv Neuroradiol 2011; 17: 147–153.

18.

Szikora

Marosfoi

Salomvary

et al.

Resolution of mass effect and compression symptoms following endoluminal flow diversion for the treatment of intracranial aneurysms. AJNR Am J Neuroradiol 2013; 34: 935–939.

19.

Estrade

Makoyeva

Darsaut

et al.

In vitro reproduction of device deformation leading to thrombotic complications and failure of flow diversion. Interv Neuroradiol 2013; 19: 432–437.

20.

Fahed

Darsaut

Gentric

et al.

Flow diversion: what can clinicians learn from animal models?

Neuroradiology 2017; 59: 255–261.

21.

Raymond

Darsaut

Salazkin

et al.

Mechanisms of occlusion and recanalization in canine carotid bifurcation aneurysms embolized with platinum coils: an alternative concept. AJNR Am J Neuroradiol 2008; 29: 745–752.

22.

Raymond

Guilbert

Metcalfe

et al.

Role of the endothelial lining in recurrences after coil embolization: prevention of recanalization by endothelial denudation. Stroke 2004; 35: 1471–1475.

23.

Hampton

Walsh

Tolias

et al.

Mural destabilization after aneurysm treatment with a flow-diverting device: a report of two cases. J Neurointerv Surg 2011; 3: 167–171.

24.

Chow

McDougall

O’Kelly

et al.

Delayed spontaneous rupture of a posterior inferior cerebellar artery aneurysm following treatment with flow diversion: a clinicopathologic study. AJNR Am J Neuroradiol 2012; 33: E46–E51.

25.

Simon

Archer

Mericle

. Multicenter registry of liquid embolic treatment of cerebral aneurysms. World Neurosurg 2014; 82: e731–e738.

26.

Molyneux

Cekirge

Saatci

et al.

Cerebral Aneurysm Multicenter European Onyx (CAMEO) trial: results of a prospective observational study in 20 European centers. AJNR Am J Neuroradiol 2004; 25: 39–51.

27.

Mawad

Cekirge

Ciceri

et al.

Endovascular treatment of giant and large intracranial aneurysms by using a combination of stent placement and liquid polymer injection. J Neurosurg 2002; 96: 474–482.

28.

Struffert

Roth

Romeike

et al.

Onyx in an experimental aneurysm model: histological and angiographic results. J Neurosurg 2008; 109: 77–82.

29.

Murayama

Vinuela

Tateshima

et al.

Endovascular treatment of experimental aneurysms by use of a combination of liquid embolic agents and protective devices. AJNR Am J Neuroradiol 2000; 21: 1726–1735.

30.

Darsaut

Bing

Salazkin

et al.

Flow diverters failing to occlude experimental bifurcation or curved sidewall aneurysms: an in vivo study in canines. J Neurosurg 2012; 117: 37–44.

Re-treatment of residual aneurysms after flow diversion: An experimental study

Abstract

Aim

Material and methods

Results

Conclusion

Keywords

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References