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AJNR. American Journal of Neuroradiology Apr 2019Uptake of flow-diverting technology is rapidly outpacing the availability of clinical evidence. Most current usage is off-label, and the endovascular community is nearer... (Review)
Review
Uptake of flow-diverting technology is rapidly outpacing the availability of clinical evidence. Most current usage is off-label, and the endovascular community is nearer the beginning than the end of the learning curve, given the number of devices in development. A comprehensive overview of technical specifications alongside key outcome data is essential both for clinical decision-making and to direct further investigations. Most-studied has been the Pipeline Embolization Device, which has undergone a transition to the Pipeline Flex for which outcome data are sparse or heterogeneous. Alternative endoluminal devices do not appear to be outperforming the Pipeline Embolization Device to date, though prospective studies and long-term data mostly are lacking, and between-study comparisons must be treated with caution. Nominal technical specifications may be unrelated to in situ performance, emphasizing the importance of correct radiologic sizing and device placement. Devices designed specifically for bifurcation aneurysms also lack long-term outcome data or have only recently become available for clinical use. There are no major studies directly comparing a flow-diverting device with standard coiling or microsurgical clipping. Data on flow-diverting stents are too limited in terms of long-term outcomes to reliably inform clinical decision-making. The best available evidence supports using a single endoluminal device for most indications. Recommendations on the suitability and choice of a device for bifurcation or ruptured aneurysms or for anatomically complex lesions cannot be made on the basis of current evidence. The appropriateness of flow-diverting treatment must be decided on a case-by-case basis, considering experience and the relative risks against standard approaches or observation.
Topics: Adult; Aged; Blood Vessel Prosthesis; Embolization, Therapeutic; Endovascular Procedures; Female; Humans; Intracranial Aneurysm; Male; Middle Aged
PubMed: 30894358
DOI: 10.3174/ajnr.A6006 -
Journal of Medical Imaging and... Jun 2023High-flow priapism is a rare condition with limited data in the literature, particularly in Australia. There is therefore no clear consensus regarding treatment. We aim...
INTRODUCTION
High-flow priapism is a rare condition with limited data in the literature, particularly in Australia. There is therefore no clear consensus regarding treatment. We aim to present our institutional network experience in managing this condition over the last decade with super-selective gelatin sponge (Gelfoam) embolisation of the internal pudendal artery.
METHODS
We retrospectively searched for and reviewed the patient records of all cases of priapism encountered within our multicentre institutional network over the last 10 years. Of these, the cases of high-flow priapism treated with embolisation were analysed in depth and compared with the current literature.
RESULTS
Overall, 93 patients in our network were diagnosed with priapism from 1 January 2012 to 1 January 2022. And 89 of these patients (96%) had low-flow priapism and four patients (4%) had high-flow priapism. Of these four patients, two were treated within our network with super-selective Gelfoam embolisation of the internal pudendal artery. Following embolisation, both patients achieved rapid detumescence and returned to baseline premorbid erectile function. There was no report of recurrence or erectile dysfunction on follow-up.
CONCLUSION
Super-selective embolisation of the internal pudendal artery should be considered as a treatment option for high-flow priapism, with Gelfoam as an appropriate temporary embolic agent of choice. We show that it was a safe and effective option for the patients treated in this series, enabling quick and long-term return to baseline erectile function. Our results support data provided by the limited number of cases in the literature.
Topics: Male; Humans; Priapism; Erectile Dysfunction; Gelatin Sponge, Absorbable; Retrospective Studies; Penis; Embolization, Therapeutic
PubMed: 36203271
DOI: 10.1111/1754-9485.13482 -
Journal of Neurointerventional Surgery May 2020Wide-necked bifurcation aneurysms (WNBAs) make up 26-36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major... (Review)
Review
Wide-necked bifurcation aneurysms (WNBAs) make up 26-36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major bifurcation vessels while achieving a durable occlusion of the aneurysm. Intrasaccular flow disruption is an innovative technique for the treatment of WNBAs. The Woven EndoBridge (WEB) device is the only United States Food and Drug Administration approved intrasaccular flow disruption device. In this review article we discuss various aspects of treating WNBAs with the WEB device, including indications for use, aneurysm/device selection strategies, antiplatelet therapy requirement, procedural technique, potential complications and bailouts, and management strategies for residual/recurrent aneurysms after initial WEB treatment.
Topics: Embolization, Therapeutic; Endovascular Procedures; Female; Humans; Intracranial Aneurysm; Male; Self Expandable Metallic Stents; Treatment Outcome
PubMed: 32005760
DOI: 10.1136/neurintsurg-2019-015506 -
Acta Biomaterialia Oct 2022Cerebral aneurysms (CA), an abnormal bulge in the arteries that supply blood to the brain, are prone to rupture and can cause hemorrhagic stroke. Physicians can treat CA...
Cerebral aneurysms (CA), an abnormal bulge in the arteries that supply blood to the brain, are prone to rupture and can cause hemorrhagic stroke. Physicians can treat CA by blocking blood flow to the aneurysmal sac via clipping of the aneurysm neck via open procedure, or endovascular occlusion of the aneurysm with embolic materials to promote thrombus formation to prevent further inflow of blood into the aneurysm. Endovascular treatment options for CA still have significant limitations in terms of safety, usability in coagulopathic patients, and risks of device migration. Bioactive embolic therapies, consisting of non-toxic bioresorbable materials that encourage the growth of neointima across the aneurysm neck, are needed to improve the healing of CA. In this work, the bioinspired silk-elastinlike protein-based polymer (SELP 815K), was used to embolize aneurysms in a rabbit elastase model. SELP 815K effectively embolized the model aneurysms in vivo, achieving >90% occlusion, using commercial microcatheters. No device-associated adverse effects were observed in any of the animals, and SELP 815K showed no cytotoxicity. SELP embolization did not show any deleterious effects to local tissues, and features consistent with reendothelialization of the aneurysm neck were noted in histological examination one-month post-embolization. SELP 815K shows promise as an embolic treatment for unruptured CA. STATEMENT OF SIGNIFICANCE: Unruptured cerebral aneurysms are present in approximately 3% of the population, with a fatality rate of up to 65% upon rupture. In this work a silk-elastinlike protein polymer (SELP) is explored as a liquid embolic for occlusion of cerebral aneurysms. This embolic exists as a liquid at room temperature before rapidly forming a gel at physiological temperature. This shape filling property was used to successfully occlude cerebral aneurysms in rabbits, with stable occlusion persisting for over thirty days. SELP occlusions show evidence for reendothelialization of the aneurysm sac and provide an opportunity for delivery of bioactive agents to further improve treatments.
Topics: Animals; Embolization, Therapeutic; Intracranial Aneurysm; Pancreatic Elastase; Polymers; Rabbits; Silk; Treatment Outcome
PubMed: 35948175
DOI: 10.1016/j.actbio.2022.08.003 -
Neurosurgery Jan 2020Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of... (Review)
Review
Flow diverters have drastically changed the landscape of intracranial aneurysm treatment and are now considered first-line therapy for select lesions. Their mechanism of action relies on intrinsic alteration in hemodynamic parameters, both at the parent artery and within the aneurysm sac. Moreover, the device struts act as a nidus for endothelial cell growth across the aneurysm neck ultimately leading to aneurysm exclusion from the circulation. In silico computational analyses and investigations in preclinical animal models have provided valuable insights into the underlying biological basis for flow diverter therapy. Here, we review the present understanding pertaining to flow diverter biology and mechanisms of action, focusing on stent design, induction of intra-aneurysmal thrombosis, endothelialization, and alterations in hemodynamics.
Topics: Animals; Blood Vessel Prosthesis; Embolization, Therapeutic; Endovascular Procedures; Hemodynamics; Humans; Intracranial Aneurysm
PubMed: 31838528
DOI: 10.1093/neuros/nyz324 -
Journal of Neurointerventional Surgery May 2021Wide-necked bifurcation aneurysms (WNBAs) present unique challenges for endovascular treatment. The Woven EndoBridge (WEB) device is an intrasaccular braided device,...
BACKGROUND
Wide-necked bifurcation aneurysms (WNBAs) present unique challenges for endovascular treatment. The Woven EndoBridge (WEB) device is an intrasaccular braided device, recently approved by the FDA for treatment of WNBAs. While treatment of intracranial aneurysms with the WEB device has been shown to yield an adequate occlusion rate of 85% at 1 year, few data have been published for patients with ruptured aneurysms.
OBJECTIVE
To present a multi-institutional series depicting the safety and efficacy of using the WEB device as the primary treatment modality in ruptured intracranial aneurysms.
METHODS
A multi-institutional retrospective analysis was conducted, assessing patients presenting with aneurysmal subarachnoid hemorrhage treated with the WEB between January 2014 and April 2020. Baseline demographics, aneurysm characteristics, adverse events, and long-term outcomes (occlusion, re-treatment, functional status) were collected. A descriptive analysis was performed, and variables potentially associated with aneurysm recurrence or re-treatment were assessed.
RESULTS
Forty-eight patients were included. Anterior communicating artery aneurysms were the most common (35.4%) location for treatment, followed by middle cerebral artery (20.8%) and basilar apex (16.7%). Procedural success was noted in 95.8% of patients, and clinically significant periprocedural adverse events occurred in 12.5%. After a median follow-up of 5.5 months, 54.2% of patients had follow-up angiographic imaging. Complete occlusion was seen in 61.5% of cases with adequate occlusion in 92.3%. Re-treatment was required in only 4.2% of patients during the study period. Tobacco use was significantly higher in patients with aneurysm recurrence (88.9% vs 35.7%; p=0.012). No other characteristics were associated with recurrence/re-treatment. At 30 days, 81.1% were functionally independent (modified Rankin Scale score ≤2).
CONCLUSION
Treatment of acutely ruptured aneurysms with the WEB device demonstrates both safety and efficacy on par with rates of conventional treatment strategies.
Topics: Adult; Aged; Aneurysm, Ruptured; Cohort Studies; Embolization, Therapeutic; Endovascular Procedures; Female; Follow-Up Studies; Humans; Intracranial Aneurysm; Male; Middle Aged; Recurrence; Retrospective Studies; Self Expandable Metallic Stents; Treatment Outcome
PubMed: 32719167
DOI: 10.1136/neurintsurg-2020-016405 -
Cardiology in the Young Oct 2023Device embolisation is a serious adverse event during transcatheter duct closure. This study analyses risk factors for embolisation.
BACKGROUND
Device embolisation is a serious adverse event during transcatheter duct closure. This study analyses risk factors for embolisation.
METHODS
Demographic parameters, echocardiographic anatomy, haemodynamics, and procedural characteristics of consecutive duct closures in a tertiary centre over 8 years were analysed. Procedures complicated by embolisation were compared to uncomplicated procedures.
RESULTS
Fifteen embolisations occurred during 376 procedures. All except one embolisation were in infants. The pulmonary artery: aortic pressure ratio was 0.78 ± 0.22. Embolisation was seen significantly more commonly in Type C tubular ducts. Vascular plugs were more significantly associated with embolisations. Logistic regression analysis showed device embolisation was significantly higher in age group of < 6 months compared to 6-12 months (p = 0.02), higher in those with tubular ducts versus conical ducts (p = 0.003), use of vascular plugs compared to conventional duct occluders (p = 0.05), and in duct closure with undersized devices (p = 0.001). There was no in-hospital mortality. Three patients needed surgical retrieval while others were successfully managed in catheterisation laboratory.
CONCLUSIONS
Device embolisation complicates 4% of transcatheter duct closures, with need for surgery in one-fifth of them. Larger ducts with high pulmonary artery pressures in younger and smaller infants are more often associated with device embolisation. Tubular ducts are more prone for embolisation compared to usual conical ducts. Softer vascular plugs are often associated with embolisations. Intentional device undersizing to avoid vascular obstruction in small patients is a frequent risk factor for embolisation. Precise echocardiographic measurements, correct occluder choice, proper technique and additional care in patients with high pulmonary artery pressures are mandatory to minimise embolisations.
Topics: Infant; Humans; Ductus Arteriosus, Patent; Treatment Outcome; Cardiac Catheterization; Embolization, Therapeutic; Risk Factors; Septal Occluder Device
PubMed: 36515000
DOI: 10.1017/S1047951122003973 -
Journal of Neurointerventional Surgery Jul 2016Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached... (Review)
Review
Flow-diverting stents, including the Pipeline embolization device (PED) and Silk, have been beneficial in the treatment of aneurysms previously unable to be approached via endovascular techniques. Recurrent aneurysms for which stent-assisted embolization has failed are a therapeutic challenge, given the existing intraluminal construct with continued blood flow into the aneurysm. We report our experience using flow-diverting stents in the repair of 25 aneurysms for which stent-assisted embolization had failed. Nineteen (76%) of these aneurysms at the 12-month follow-up showed improved Raymond class occlusion, with 38% being completely occluded, and all aneurysms demonstrated decreased filling. One patient developed a moderate permanent neurologic deficit. Appropriate stent sizing, proximal and distal construct coverage, and preventing flow diverter deployment between the previously deployed stent struts are important considerations to ensure wall apposition and prevention of endoleak. Flow diverters are shown to be a reasonable option for treating previously stented recurrent cerebral aneurysms.
Topics: Adult; Aged; Cerebral Angiography; Embolization, Therapeutic; Endovascular Procedures; Female; Follow-Up Studies; Humans; Intracranial Aneurysm; Male; Middle Aged; Retrospective Studies; Salvage Therapy; Stents; Treatment Failure; Treatment Outcome
PubMed: 26041098
DOI: 10.1136/neurintsurg-2015-011672 -
The Journal of Cardiovascular Surgery Dec 2016Percutaneous, catheter-directed embolotherapy is an established interventional technique for the management of many vascular disorders. For more than three decades,... (Review)
Review
Percutaneous, catheter-directed embolotherapy is an established interventional technique for the management of many vascular disorders. For more than three decades, typical embolization devices included macro and microcoils, polyvinyl alcohol microparticles, glue and certain liquids such as absolute alcohol. In the past decade, however, several new embolic devices and refinements of existing embolic devices have arrived on the market and a number of clinical studies have demonstrated their added value. In this review article, these new embolic devices and their typical indications will be discussed, as well as the results of studies involving the embolic devices.
Topics: Adult; Animals; Chemoembolization, Therapeutic; Embolization, Therapeutic; Equipment Design; Female; Humans; Male; Middle Aged; Sclerosing Solutions; Sclerotherapy; Tissue Adhesives; Treatment Outcome; Vascular Access Devices; Young Adult
PubMed: 27647339
DOI: No ID Found -
Techniques in Vascular and... Sep 2020In the last decade, prostatic artery embolization (PAE) established itself as a safe and effective treatment option for lower urinary tract symptoms (LUTS) attributed to... (Review)
Review
In the last decade, prostatic artery embolization (PAE) established itself as a safe and effective treatment option for lower urinary tract symptoms (LUTS) attributed to benign prostate hyperplasia (BPH), with reproducible results across multiple centers and endorsement by important international societies. However, PAE is also known to be a technically demanding procedure. Accompanying the prevalence of benign prostate hyperplasia, the procedure is usually performed in older patients, in whom atherosclerosis and comorbidities are common features. Also, prostatic vascular anatomy is described to be complex and variable, and pelvic structures are deeply interconnected by anastomosis. Thus, PAE demands a deep familiarization with materials and devices, intraprocedure imaging techniques, microcatetherization skills and with the pelvic vascular anatomy. Especially in the beginning of the learning curve, the procedure can be time-consuming and related to high radiation exposure for both medical team and the patient. In this article, the main points of technical concern during PAE are described and discussed, such as the equipment needed, the effect of different embolic materials, patient's preparation for the procedure, arterial access sites, identifying and catheterizing the prostatic arteries, the embolization techniques, among others. Finally, the most frequent technical challenges are presented, and the possible strategies to overcome them are exemplified and discussed.
Topics: Catheters; Embolization, Therapeutic; Equipment Design; Humans; Lower Urinary Tract Symptoms; Male; Prostate; Prostatic Hyperplasia; Radiography, Interventional; Risk Factors; Treatment Outcome
PubMed: 33308534
DOI: 10.1016/j.tvir.2020.100691