Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters

Abstract

Background: The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter.

Methods: A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O'Kelly-Marotta grading scale), patency of jailed branch(es), and in-stent stenosis.

Results: Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O'Kelly-Marotta grading scale A, 3 (37.5%) O'Kelly-Marotta grading scale B, 1 (12.5%) O'Kelly-Marotta grading scale C, and 3 (37.5%) O'Kelly-Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient.

Conclusion: Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.

Keywords: TuBridge flow diverter; endovascular treatment; middle cerebral artery aneurysm.

Figure 1.

Photograph of the TFD. The flared ends of the TFD improve wall apposition and the double-helix platinum–iridium radiopaque microfilaments increase device visibility under fluoroscopy.

Figure 2.

(a) CTA demonstrated a left MCA bifurcation giant aneurysm involving distal M1 and the superior trunk of M2. The inferior trunk of M2 was not visible. (b) Post-clipping CTA demonstrated the reconstructed aneurysm with stenotic M1 and patent distal vessels. The inferior trunk of M2 emerged (white arrow). (c) Six-month follow-up angiogram demonstrated a major recurrence of the aneurysm with a daughter sac in the proximal part (white arrowhead). (d) Post-procedure un-subtracted image showed the TFD landed in M1 and the superior trunk of M2 and loose packing of the aneurysm with coils. (e) Immediate postoperative angiogram demonstrated decreased flow of the inferior trunk of M2 (black arrows). (f) Angiogram six months after surgery showed the proximal part of the aneurysm was thrombosed, M1 was stenotic, and the inferior trunk of M2 was invisible. (g) On 18-month follow-up angiogram, the aneurysm was completely occluded; the distal M1 and the superior trunk of M2 were reconstructed. However, the distal M1 was still moderately stenotic and the inferior trunk of M2 was occluded (black arrowheads). (h) Eighteen-month follow-up angiogram of the external carotid artery showed that a collateral blood supply was established from the middle meningeal artery to the distal vessels of inferior trunk of M2 (hollow arrows).

Figure 3.

(a and b) Pre-procedure angiogram demonstrated a right proximal M1 fusiform aneurysm involving part of the ICA bifurcation. (c and d) When the TFD was passing through the acute angle of the vessel, the aneurysm was temporally filled with a coil to support the stent. (e) After the stent passed the acute angle, the coil was retrieved to inspect the wall apposition of the TFD. (f) Lateral view of the TFD deployed with support of a coil in the aneurysm. (g and h) Post-procedure angiogram demonstrated decreased filling of the aneurysm and patent jailed artery of A1. (i and j) Angiogram at six months after surgery showed the filling of aneurysm was decreased, the blood flow of the jailed A1 was decreased, and ICA was mildly stenotic.

Figure 4.

(a and b) CTA and DSA demonstrated a left M1 perforator artery aneurysm of 3 mm (white arrow). (c) After stent deployment, the wall apposition of the proximal end was not sufficient (white arrowhead). (d) Balloon angioplasty was performed to improve wall apposition of the proximal end of the stent. (e and f) Immediate postoperative angiogram demonstrated improved wall apposition (black arrow) and patent jailed perforators. (g and h) Angiogram at six months after surgery demonstrated that the aneurysm was completed occluded (black arrowhead), the blood flow of the jailed perforators was unchanged, and M1 was mildly stenotic.