Endovascular treatment of brain aneurysms:Beyond coiling Presented by Yasha Kayan, MD and Josser E. Delgado, MD

1. Endovascular treatment of brain
aneurysms:
Beyond coiling
Yasha Kayan, MD
Josser E. Delgado, MD
Abbott Northwestern Hospital
Neuroscience Institute

2. 2
Surgical clipping – 1937

3. 3
Coil embolization
First in human: 1991
GDC FDA approved: 1995

4. 4
Neurointerventional suite
4

5. 5
Embolization procedure
5

6. 6
Coiling (framing coil)

7. 7
Coiling (clotting, endothelialization)

8. 8
Balloon-assisted coiling
First described in 1997

9. 9
Balloon-assisted coiling

10. 10
Stent-assisted coiling
Neuroform stent FDA approved in 2002

11. 11
Flow diversion
Pipeline approved in 2011

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

13. 13
37 year-old male with HIV-related dilating vasculopathy
Pipeline case 34

14. 14
2.5 x 14mm Pipelines
37 year-old male with HIV-related dilating vasculopathy
Pipeline case 34

15. 15
6-month FU angiogram
37 year-old male with HIV-related dilating vasculopathy
Pipeline case 34

16. 16
Higher complication rate?

17. 17
Continuing the conversation

18. 18
Intra-saccular flow diversion

19. 19
47 y/o woman with an incidental basilar tip aneurysm
Abbott’s 1st WEB case

20. 20
Post-detachment
8mm x 5mm WEB DL post-detachment run
47 y/o woman with an incidental basilar tip aneurysm

21. 21
Abbott’s 1st WEB case
1-year follow-up

22. 22
WEB-IT
• FDA IDE study
• 150 patients, 25 US sites
• 8 patients from Abbott
• 1 primary safety event: 0.67% (1/150)
– Ipsilateral parenchymal hemorrhage

23. 23
Stent alternatives

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

25. 25
Complex access

26. 26
Endovascular aneurysm treatment at
Abbott Northwestern
2 2
9
20
31
68 73
108
130
97 101
94 89 92 93 96
61
44 39
7
30
51
59 57 48
85 60
63 56
35
23
15
23
7
10
13
27
10
34
35
18
1
5
1
2
2
1
5
5 4
6
7
10
5
11
19 16
18
7 26
10
11
1
1
2
4 5 2
2
4
6
5
3
4 2 4
3
3
1
1
2
4
2
1
6
53
8
28
29
50
0
20
40
60
80
100
120
140
160
180
200
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
FD
WEB
Sacrifice
SAC
Onyx
Coiling
BAC

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

29. 29
Lancet Neurol. 2014;
13:59-66
Patient counseling

30. 30
6
(1%)
30
(5%)
86
(14%)
86
(14%)
89
(15%)
76
(12%)
49
(8%)
52
(9%)
33
(5%) 27
(4%) 21
(3%)
21
(3%)
13
(2%)
24
(4%)
0
10
20
30
40
50
60
70
80
90
<2 2 3 4 5 6 7 8 9 10 11 12 13 >13
Numberofaneurysms
Maximum aneurysm dimension (mm)
Rounded to the closest whole number
Ruptured cerebral aneurysms treated endovascularly (n=613)
373
Aneurysms
<7mm
(61%)
134
Aneurysms
7-9mm
(22%)
106
Aneurysms
≥10mm
(17%)

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