The DERIVO 2heal embolisation device: A technical report using single antiplatelet therapy for intracranial pseudoaneurysm treatment

Abstract

The novel DERIVO 2heal Embolisation Device (Acandis, Pforzheim, Germany) is a flexible, fully radiopaque flow-diverter with a fibrin-based nano-coating, which is supposed to make the device inert to the coagulation cascade. We report a case of pseudoaneurysm treatment with this device under single anti-platelet therapy (SAPT). A female patient underwent endoscopic surgery for chronic rhinosinusitis. During surgery, the lateral wall of the sphenoid wall and the adjacent internal carotid artery was injured, leading to massive hemorrhage, which was treated with compression and tamponades. Eleven days after the procedure, the patient developed a rapidly growing pseudoaneurysm at the injury site with a relevant risk of upcoming aneurysm rupture. The aneurysm was treated by implantation of a DERIVO 2heal. A SAPT regimen was chosen due to the recent massive hemorrhage and anticipating enhanced progressive aneurysm occlusion. There were no thromboembolic complications and there was no morbidity. After 5 days, the pseudoaneurysm was completely occluded. The observations of the presented case are promising and warrant further investigation of this device.

Keywords: Aneurysm; angiography; derivo embolisation device; flow diverter; internal carotid artery.

Figure 1.

(A) The DERIVO 2heal embolisation device (Acandis Pforzheim, Germany) consists of 48, 52 or 64 (shown left to right) densely woven nitinol composite wires available in diameters between 3.5 and 8.0 mm for treatment of vessel diameters ranging between 1.5 and 8.0 mm. The device diameters ≤ 3.5 mm are compatible with a low-profile (0.017”) microcatheter. The ends of the DERIVO 2heal are flared of 25° in order to improve wall apposition. The nitinol wires of the DERIVO 2heal exhibit a higher amount of platinum than the conventional DED 2 resulting in increased fluoroscopic visibility of the entire device contour, as demonstrated by unsubtracted angiograms in (B). In return, the additional radiopaque markers at the ends of the DED 2 were left out. The photograph in (A) was provided by courtesy of Acandis. .

Figure 2.

The DERIVO 2heal received a surface finishing with fibrin-based nano-coating (“heal” technology). This surface technology converts fibrinogen molecules to fibrin and covers the entire surface of the flow-diverter with a fibrin network mimicking the final step of the coagulation cascade. Electron microscopy (500- and 1000-fold magnification) shows increased fibrin and platelet deposits at the stent wires of an uncoated compared to a fibrin-coated DERIVO stent after exposure to thrombin/antithrombin III complex and platelets. The images were provided by courtesy of Acandis. .

Figure 3.

A 72-year old female underwent endoscopic sinus surgery for chronic rhinosinusitis. During the intervention, massive arterial bleeding from the right sphenoid sinus occurred, which was temporarily stopped with a nasal tamponade. Computed tomography with angiography showed an osseous defect at the lateral sinus wall adjacent to the clinoid segment of the internal carotid artery (A). Also, there were no signs of active bleeding in digital subtraction angiography and the vessel wall seemed regular (B). The tamponade was carefully removed under angiographic control without complications. Control CTA after 11 days showed a pseudoaneurysm (3 mm) of the ICA that protruded through the osseous defect into the sphenoid wing (C). On the following day, the aneurysm measured 5 mm on DSA (D). The aneurysm was treated with a DERIVO 2heal flow-diverter under single anti-platelet therapy. The non-subtracted angiogram shows the radiopaque contour of the device at its full length (E). Immediately after flow-diverter implantation, contrast stasis was seen inside the pseudoaneurysm (OKM A2, F). On 5-day angiographic follow-up, the aneurysm was completely occluded (G) and there was no in-stent stenosis, as shown in the rotational angiography scan (H).