Stent-assisted coiling of cerebral aneurysms: multi-center analysis of radiographic and clinical outcomes in 659 patients.
- 作者列表："Mokin M","Primiani CT","Ren Z","Piper K","Fiorella DJ","Rai AT","Orlov K","Kislitsin D","Gorbatykh A","Mocco J","De Leacy R","Lee J","Vargas Machaj J","Turner R","Chaudry I","Turk AS
INTRODUCTION:The endovascular stent-assisted coiling approach for the treatment of cerebral aneurysms is evolving rapidly with the availability of new stent devices. It remains unknown how each type of stent affects the safety and efficacy of the stent-coiling procedure. METHODS:This study compared the outcomes of endovascular coiling of cerebral aneurysms using Neuroform (NEU), Enterprise (EP), and Low-profile Visualized Intraluminal Support (LVIS) stents. Patient characteristics, treatment details and angiographic results using the Raymond-Roy grade scale (RRGS), and procedural complications were analyzed in our study. RESULTS:Our study included 659 patients with 670 cerebral aneurysms treated with stent-assisted coiling (NEU, n=182; EP, n=158; LVIS, n=330) that were retrospectively collected from six academic centers. Patient characteristics included mean age 56.3±12.1 years old, female prevalence 73.9%, and aneurysm rupture on initial presentation of 18.8%. We found differences in complete occlusion on baseline imaging, defined as RRGS I, among the three stents: LVIS 64.4%, 210/326; NEU 56.2%, 95/169; EP 47.6%, 68/143; P=0.008. The difference of complete occlusion on 10.5 months (mean) and 8 months (median) angiographic follow-up remained significant: LVIS 84%, 251/299; NEU 78%, 117/150; EP 67%, 83/123; P=0.004. There were 7% (47/670) intra-procedural complications and 11.5% (73/632) post-procedural-related complications in our cohort. Furthermore, procedure-related complications were higher in the braided-stents vs laser-cut, P=0.002. CONCLUSIONS:There was a great variability in techniques and choice of stent type for stent-assisted coiling among the participating centers. The type of stent was associated with immediate and long-term angiographic outcomes. Randomized prospective trials comparing the different types of stents are warranted.
引言: 随着新的支架设备的出现，血管内支架辅助弹簧圈治疗脑动脉瘤的方法正在迅速发展。每种类型的支架如何影响支架盘绕手术的安全性和有效性仍然是未知的。 方法: 本研究比较了使用Neuroform (NEU) 、Enterprise (EP) 和低剖面可视化腔内支持 (LVIS) 支架对脑动脉瘤进行血管内栓塞的结果。使用Raymond-Roy分级量表 (RRGS) 分析患者特征、治疗细节和血管造影结果，以及手术并发症。 结果: 我们的研究纳入了659例患者，其中670个脑动脉瘤接受支架辅助弹簧圈治疗 (NEU，n = 182; EP，n = 158; LVIS，n = 330)，这些患者是从6个学术中心回顾性收集的。患者特征包括平均年龄56.3 ± 12.1岁，女性患病率73.9%，初次出现动脉瘤破裂18.8%。我们发现三种支架在基线成像 (定义为RRGS I) 上的完全闭塞差异: LVIS 64.4%，210/326; NEU 56.2%，95/169; EP 47.6%，68/143; P = 0.008。血管造影随访10.5个月 (平均) 和8个月 (中位) 完全闭塞的差异仍然显著: LVIS 84%，251/299; NEU 78%，117/150; EP 67%，83/123; P = 0.004。在我们的队列中有7% 例 (47/670) 术中并发症和11.5% 例 (73/632) 术后相关并发症。此外，与手术相关的并发症，编织支架比激光切割更高，P = 0.002。 结论: 参与中心的支架辅助弹簧圈技术和支架类型的选择存在很大差异。支架类型与即刻和长期血管造影结果相关。需要进行比较不同类型支架的随机前瞻性试验。
METHODS:BACKGROUND:Due to recent advances in endograft design and percutaneous access, technical success could be increased during endovascular aneurysm repair (EVAR). Beside EVAR, endovascular aneurysm sealing (EVAS) provides an alternative procedure to treat aneurysms. To compare the two methods, additional benchmark criteria should be evaluated: Screening time, dose area product (DAP), procedure time and contrast use. In this study these technical variables are analyzed for EVAS vs. EVAR in comparable patient cohorts. METHODS:It is a retrospective, single-center study. Only elective cases of infrarenal aortic aneurysms were included, all treated by the same surgeon (D.B.). Procedures were performed within the instructions for use without additional procedures. All operations were undertaken in a hybrid operating theatre. For EVAR, only the Medtronic Endurant® and the Gore C3 Excluder® were included. For EVAS the Nellix® from Endologix was used. RESULTS:Between 2012 and 2016, 67 patients were treated with EVAS and 40 with EVAR; of these 20 and 16 could be introduced into the study respectively. Median age was 73 and 72 years respectively (only men). The two groups were comparable in terms of BMI, GFR and ASA-status. Screening time was reduced for EVAS (10.6 vs. 14.5 min., P<0.01), while the DAP was not significantly different. Procedural time and contrast use were increased for EVAS (120 vs. 96 min., 120 vs. 79 mL, P<0.01). CONCLUSIONS:Especially the younger EVAS-procedure requires ongoing review in order to further reduce contrast agent. Reduced screening time for EVAS does not have a significant impact on radiation dose.
METHODS:OBJECTIVE:To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. BACKGROUND:Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation. METHODS:All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage. RESULTS:In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation. CONCLUSIONS:Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage.
METHODS:BACKGROUND:Spinal cord ischemia (SCI) and paraplegia are complications of surgery for type A acute aortic dissection (TAAAD). Since the segmental arteries play a key role in SCI, this study evaluated the association between SCI and false lumen segmental arteries (FLSAs: segmental arteries originating from the false lumen). METHODS:The study included 101 consecutive TAAAD patients (mean age, 66±13; range, 34-89 years) who underwent surgery from January 2011 to April 2017. The diagnosis of TAAAD and the number of FSLAs were determined by preoperative computed tomography (CT). Patients were divided into two groups according to the number of FLSAs at the Th9-L2 level: Group A (N.=13), ≥8 FLSAs; and group B (N.=88), ≤7 FLSAs. Preoperative, perioperative, and postoperative findings were compared between the groups, and risk factors for SCI were evaluated. RESULTS:The frequency of preoperative paralysis was significantly higher in Group A than Group B (P=.0070). The overall incidence of postoperative SCI was 8% (8/101) and significantly higher in Group A than Group B (5/13 [45%] vs. 3/88 (4%), P<0.0001). Hospital mortality was 8% (8/101) and significantly higher in Group A than Group B (3/13 [23%] vs. 5/88 [6%], P=.0302). Multivariate analysis showed that the independent risk factors for SCI were ≥8 FLSAs at Th9-L2 (odds ratio [OR], 20.4; 95% confidence interval [95% CI], 3.34-124.9, P=0.0011) and diabetes mellitus (OR, 22.3; 95% CI, 1.69-294.5; P=0.0184). CONCLUSIONS:In patients who underwent surgery for TAAAD, ≥8 FLSAs at the Th9-L2 levels on preoperative CT was a risk factor for SCI.