2. Disclosures
Boris Pabon MD, has received research support through Boston
Scientific, Cordis and Microvention, and has served as a consultant to
Chestnut Medical. Currently, perform proctoring activities to COVIDIEN.
4. Introduction
Endovascular treatment of intracranial aneurysms has
evolved substantially over the past two
decades, transitioning from an investigational therapy into routine clinical
practice and ultimately emerging as the treatment of choice for many lesions.
Despite this tremendous evolution in endovascular
therapy, some important limitations remain, particularly in
the treatment of wide- necked, large and giant, or “nonsaccular” fusiform
aneurysms.
10. Why are Flow-Diverter so exciting?
…This device does not function as previous self –
expanding stents (i.e. Neuroform ,Enterprise) in that it
is not designed to provide support to keep material
within an aneurysm dome; instead it appear to
function by excluding the aneurysm from the
circulation.
15. What is the PED ?
The PED is a flexible, microcatheter- delivered, self-
expanding, endovascular “stent- like” construct engineered
specifically for the treatment of cerebral aneurysms . The
device consists of a braided mesh cylinder composed of 48
individual platinum and cobalt chromium microfilaments.
18. Pre procedure
• Accurate Images ( DSA – 3DRA – CT angio/ MRI )
• Gastric protection
• Ranitidine better than Omeprazol
• Check the individual response to antiplatelets
(Verify now)
• Check your PED’s Stock
• If you have any concern, then ASK !
• Confirm the presence of a 2nd Operator
• Corticoids load , to Giant or partially thrombosed lesions
19. Pre procedure
• Antiplatelets (Electively) :
ASA 100mg qd PO and, Clopidrogrel 75mg qd PO , Five
days before the procedure.
• Antiplatelets (Urgency) :
ASA 300mg PO and, if NGT available, Load dosis of
Clopidrogrel 600mg fractioned with almost 1h of interval.
• Antiplatelets (Emergency):
We recommend to use IIb-IIIa GP Inhibitors.
20. Procedure
• Check again all Images (Last time Findings …)
• Check again your PED’s Stock (avoid a heart attack !...)
• Confirm if the antiplatelet protocol is OK
Always be ready
for surprises….
22. Procedure
• Accepting a suboptimal material (guide, catheter, Micro wire)
can turn a 20 minutes case into a 4 hour nightmare.
• Put the Microcatheter more distally than you think would be right !
• Avoid to leave the Microcatheter tip near to the sharp curved
vessel : during PED implantation you will have a system backward
and the microwire would advance suddenly. (Perforation risk)
• Maintain constantly the forward tension of the PED, using the
torque device and, avoiding the kinking of the PED pusher.
23. Procedure
• keep in mind the PED foreshortening, again, it’s better to be
distally to avoid misplacement.
• For telescoping technique, never undersize the next device, you will
affect the construct. Try it not oversized !
• If the distal end of the stent remain close, you can rotate the wire
gently (no more than 3 cycles) or, you can try to advance the
microcatehter ; this simple maneuver would be enough to open it.
• Once you sure about the distal position , delivery the stent slowly
and gradually , specially at sharp angles.
24. Procedure
• Value the Hemodynamic effect , using a 25Fr/sec acquisition.
• Verify PED conformability. ( X-per CT / Dyna CT)
• Safeguard the distal access with the stent-wire at the end of the
procedure. Only, if you are satisfied with the result, so, pullback the
wire.
• Determine your strategy (1 or >1 PED)
29. Pipeline Deployment
• Continue
deployment of PED
by slowly pushing
out delivery wire
• To avoid
unexpected
movements, load
catheter while
pushing delivery
wire by applying
slight forward
tension
37. After procedure
• Be cautious with femoral access (Risk of retroperitoneal hematoma
and pseudoaneurysms)
• Clinical and radiological follow up 3, 6, 12
• Continue the gastric protection
• Dual antiplatelet regime (i.e. ASA + Clopidrogrel) for 6 m
• ASA lifetime
• Corticoids scheme in cases selected (Large/Giant lesions)
89. Conclusions
The PED constituted easier strategy for treatment of selected
aneurysms than coiling. Essentially, eliminating the risk of
procedural rupture and complications related to the introduction
and manipulation of microcatheters or coils.
There are limitations related to existence of SAH and treatment of
bifurcation aneurysms. Specific trials are required to evaluate
this topic.
PED Experience is early. However, the existing clinical data have
been very encouraging. Based on our clinical experience, PED may
significantly improve the endovascular treatment of complex
aneurysms.
90. Take Home Messages
• Know the patient.
• Treat the patient; not only the artery.
• Learn from other people’s mistakes, better than
learning from your own.
• Learn techniques from different people and then
come up with your own.
• Keep it simple.
• Risk free Intracranial Stenting is not doing it.
• Recognize your limits; don’t push your luck
