Efficacy and Safety of Flow-Diverter Therapy for Recurrent Aneurysms after Stent-Assisted Coiling

Abstract

Background and purpose: Flow-diverter treatment for previously stented aneurysms has been reported to be less effective and prone to complications. In this study, we evaluated the effectiveness and safety of flow diverters for recurrent aneurysms after stent-assisted coiling.

Materials and methods: Patients who underwent flow-diverter placement for recurrent aneurysms after stent-assisted coiling between March 2015 and March 2019 were recruited. Clinical and radiographic characteristics and clinical and angiographic outcomes were retrospectively evaluated.

Results: Among 133 patients who underwent flow-diverter insertion, 17 (male/female ratio = 5:12; mean age, 53.8 years) were treated for recurrent aneurysms after stent placement with (n = 16) or without (n = 1) coiling. Eight patients initially presented with subarachnoid hemorrhage; 7, with headache; and 2, with visual field defects. Angiographic morphology included large/giant saccular in 12 patients, dissecting in 2, fusiform in 1, traumatic pseudoaneurysm in 1, and ruptured blood blister-like aneurysm in 1. The duration between the first treatment and flow-diverter placement ranged from 2 weeks to 15 months (median, 6 months). Flow-diverter placement was successful in all cases without any complications. All patients had favorable outcomes (mRS, 0-2), without any newly appearing symptoms. Aneurysms were followed up with conventional angiography at least once in 6-18 months. Sixteen aneurysms showed complete occlusion, and 1 aneurysm was enlarged.

Conclusions: Results from this case series investigating flow-diverter placement for recurrent aneurysms after stent-assisted coiling suggested that the procedure is safe and effective. Further study in a larger population may be warranted.

Fig 1.

A 54-year-old man with subarachnoid hemorrhage. A, A nonenhanced CT image shows a diffuse subarachnoid hemorrhage in the basal cistern. B, A 3D volume-reconstruction image shows a fusiform aneurysm of the left distal ICA. Both the anterior choroidal (solid arrow) and posterior communicating (dashed arrow) arteries arise from the fusiform aneurysm. C, Three LVIS Blue devices are deployed in a telescopic manner from the ICA cavernous segment to the middle cerebral artery M1 segment. D, Coil embolization performed using the balloon-in-stent technique. E, Immediate postembolization shows near-complete embolization. Both the anterior choroidal (solid arrow) and posterior communicating (dashed arrow) arteries are saved. F, One-year follow-up angiogram shows a major recurrence. Note that the left anterior cerebral artery is tented due to the mass effect of the fusiform aneurysm. G, One-year follow-up angiogram after Pipeline Embolization Device implantation shows complete occlusion. H, Subtracted 3D reconstruction image shows a well-remodeled ICA with both anterior choroidal (solid arrow) and posterior communicating (dashed arrow) arteries saved.

Fig 2.

A 67-year-old woman with a partially thrombosed giant aneurysm at the anterior communicating artery. A, Angiogram immediately after LVIS Jr–assisted coiling shows complete occlusion of the aneurysm sac. B, The 14-month follow-up angiogram shows a major recurrence with occlusion of the stent. The left anterior cerebral artery A2 segment is supplied through the recurrent aneurysm sac. Note blood flow from the A1 segment through the aneurysm sac to the A2 segment. The solid arrow indicates the inflow from A1 into the aneurysm sac, and the dashed arrow indicates the outflow from the aneurysm sac to A2. C, The A2 segment is navigated through the inside of the stent using a 0.0165-inch microcatheter and a 0.014-inch microwire. Next, balloon angioplasty is performed to open the occluded stented segment of the anterior cerebral artery using a Gateway balloon (Stryker, Kalamazoo, Michigan). D, The Pipeline Flex is deployed spanning the entire stented segment. E, An angiogram immediately after PED implantation shows complete occlusion of the recurrent aneurysm. F, The 10-month follow-up angiogram shows complete occlusion of the aneurysm. MR image before PED implantation (G) and at 10-month follow-up (H) show the decreased size of the thrombosed giant aneurysm (solid arrow).