12. 12
Pipeline (PUFS trial)
• Outcomes at 180 days
– Complete occlusion: 73.6%
– Major stroke or death: 5.6%
• Outcomes at 5 years
– 95.2% occlusion rate
– No additional major strokes or death
– No reports of delayed recanalization
24. 24
Not just coiling anymore
• In next 3-5 years we will have available
– MANY types of coils
– 3 types of balloons
– 3 low-profile stents
– 3 intra-vascular flow diverters (FD)
– 2 intra-saccular FDs
– 1 coil / intra-saccular FD hybrid
27. 27
Ruptured brain aneurysms at Abbott
• 778 treated endovascularly since 1995
• Outcomes at discharge
– mRS 0 to 2: 389 (50%)
– mRS 3: 196 (25%)
– mRS 4 to 6: 193 (25%)
28. 28
Neurointerventional clinic at Abbott
• Evidence-based patient counseling
• Pre-operative medical management
– Dual antiplatelet therapy
– Optimize management of comorbidities
• Vigilant post-operative management
• Short, medium and long term follow-up
31. 31
Brain aneurysm follow-up
• After treatment, dependent on stability & occlusion
– 30 days
– 6 months
– 2 years
– 5 years
– 10 years
– 5 to 10 year intervals
32. 32
• Coiling is an important component of our toolkit,
but is only part of the story
• A variety of devices have expanded what can be
done endovascularly
– Balloons, stents, flow diverters, intra-saccular flow
diverters
• Periprocedural medical management and long-
term follow-up are vital
Summary
Editor's Notes
PROCEDURE:
1. Transarterial embolization with the WEB device: Basilar tip aneurysm.
2. Cerebral angiography: Left vertebral artery.
3. Rotational angiography with 3D reconstructions: Left vertebral artery.
4. Angioseal hemostatic closure device placement.
DATE: 11/12/2014.
HISTORY: 47 year-old female with an incidentally-discovered basilar tip aneurysm presents for endovascular treatment with the WEB device.
PRIMARY PHYSICIAN: Dr. Delgado.
FIRST ASSIST: Dr. Kadkhodayan.
MEDICATIONS: 1% buffered Lidocaine (local), Heparin 11,000 units IV bolus; additional medications as per anesthesiology record.
SAMPLES: None.
POST-PROCEDURE DIAGNOSIS: Status post endovascular treatment of a basilar tip aneurysm with the WEB device.
PROCEDURE AND FINDINGS:
The procedure was explained in its entirety to the patient and family prior to transport to the neuroangiography suite. This included a discussion of the risks, benefits, and alternatives to cerebral angiography with endovascular embolization. Risks discussed included vascular perforation, rupture, or dissection, stroke or transient neurologic deficit (TIA), distal embolization, allergic reaction, pain, bleeding, and infection. The patient gave both verbal and written consent to proceed. Prior to beginning the procedure, a "time out" was performed to confirm the patient's identity and the planned procedure. General anesthesia was initiated and monitored by the staff from the anesthesia department.
Both groins were prepped and draped in the usual sterile fashion with Betadine. Next, the right femoral head was localized fluoroscopically and buffered 1% lidocaine was injected for local anesthesia.
The common femoral artery was then accessed with a micropuncture needle and a 5 French sheath advanced over a 0.035 J-wire. The sheath was connected to a regulated, pressurized infusion of heparinized saline.
The baseline ACT was 128 seconds. A 6,000 unit bolus of intravenous heparin was administered. Two additional boluses totaling 5,000 units of intravenous heparin were administered later in the case to maintain the ACT at 2x baseline.
A 5F H1 catheter was advanced over the glidewire to the aortic arch. Utilizing this catheter/wire combination, the left vertebral artery was selectively cannulated. Rotational angiography via the catheter was then performed with 3D reconstructions obtained at an independent workstation in order to obtain optimal working projections for treatment of the known basilar tip aneurysm measuring 8mm in maximum dimension. Then, we exchanged the 5 French catheter for a 6 Fr NeuronMax sheath over an exchange-length wire, with the sheath positioned in the mid cervical segment of the left vertebral artery.
Then, we introduced an 058 Navien distal access catheter inside the NeuronMax and advanced it to the distal cervical segment of the left vertebral artery over a glidewire.
Then, under digital roadmapping guidance, we introduced an 033 VIA catheter with an Echelon 10 microcatheter inside it and carefully advanced the VIA catheter over a Synchro 14 microwire until the via catheter was inside the basilar tip aneurysm and then removed the Echelon 10 microcatheter and microwire.
Next, we proceeded with embolization of the aneurysm by carefully deploying a 9mm x 6mm WEB device inside the aneurysm sac. However, a contrast injection revealed that this device was too large for the aneurysm. We then retrieved the device via the VIA catheter and then introduced a 9mm x 5mm WEB device. However, a repeat contrast injection revealed that this device was also too large for the aneurysm with >50% narrowing of the proximal P1 segments bilaterally. Hence, we then retrieved the device via the VIA catheter and finally introduced a 8mm x 5mm WEB device. A contrast injection demonstrated that this device provide stasis of contrast inside the aneurysm without narrowing of the P1 segments. Given this, we proceeded to detach this device and removed the VIA microcatheter.
We performed a final dual-volume 3D angiogram via the Navien catheter.
Post-embolization angiography was then performed via the guide catheter in the standard posteroanterior and lateral views as well as the working projections. This demonstrated significant contrast stasis in the aneurysm sac without narrowing of the P1 segments. There was no change in cerebral perfusion in comparison to the pre-embolization images.
The final ACT was 203 seconds.
At the conclusion of the study, the catheter was retracted to the external iliac artery. Contrast was injected at this site to evaluate the common femoral artery puncture site prior to placement of the Angioseal hemostatic device.
There were no immediate complications. The patient was awakened from anesthesia and transported to the post-procedure monitoring area in stable condition.
IMPRESSION:
Successful embolization of a basilar tip aneurysm with the WEB device.
Josser E. Delgado, M.D.Neurointerventionalist
Abbott Northwestern Hospital
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