Flow diverters for cerberal aneurysms

1. FLOW DIVERTERS FOR
CERBERAL ANEURYSMS
Vipul Gupta
Artemis Hospitals
Gurgaon
India

2. Endovascular mgt of aneurysms….
Issues..
 Large and giant aneurysms
 Fusiform/dissecting aneurysms
 Blister aneurysms
 Small dysplastic aneurysms

3. 1917
pts.
451
patients
ISUIA Trial

4. Large, giant aneurysms
 Classically - Surgery treatment of choice -
Better occlusion, more permanent, mass
effect
 Endovascular – safer, issue of
residual/recurrences; mass effect of coils
Stents
 Flow modification
 Intimal growth and healing
 Change of angles

5. Flow modification/diversion-
Flow diversion with stents- single, overlapping
Further evolution – flow diverters (stents)

6. 0
1
2
3
4
5
6
7
8
9
10
0 10 20 30 40 50 60 70 80 90 100
Flow
index
Ineffective
(clotting)
Ineffective
(free flow)
Effective flow
diversion and side
branch patencyOptimizing
flow diversion

13. A B
Cavernous aneurysms
26 year old,
Cranial nerve palsy
B
G

15. Large ICA aneurysms …
• Complete occlusion – 90 %, no recurrences
• Complication rate – 2-8 %
• Careful placement , avoid overlapping
devices, anti-platelet regime

16. Small Blister/dissecting…
 Blister aneurysms (BA) are rare lesions
characterized by a hemispherical shape and
fragile walls
 Surgical Options - Direct clipping, clipping plus
wrapping, wrapping alone, clipping with Sundt
encircling graft clips, encircling silicone clip
application, primary suturing of ICA, vascular
staple clip closure of ICA and trapping with or
without extracranial-intracranial bypass
 High risk of premature rupture during surgery,
large lacerations
 Endovascular- difficult to coil, friable,
continued growth, stent needed (issues in
SAH), single/overlapping

17. Classical blister aneurysm
34-year M, SAH

18. D E F
B CA B

19. B
C D
A

21. Blister Aneurysm
Our experience with FD vs non FD
FD – 11 cases
Complete occlusion – 89% vs 71% i.f.o FD
Repeat treatment – none vs 11.7% i.f.o FD
Rebleed resulting in death – none vs 5.8% i.f.o FD
Submitted for publication

22. Small ICA aneurysms …

24. Dissections with blister
2-overlapping Enterprise stents
Posterior circulation aneurysms …

28. Distal bifurcation aneurysms

29. Intermediate Flow diverters (FRED junior)

30. Is it all easy ….

33. Progressive intraaneurysmal
partial thrombosis starts
8th DAY POST COILING PRESENTED WITH VERTIGO AND HEADACHE

34. 56 yr old,
ischaemic
stroke

35. Flow diverters …
 Major evolution of EVT of aneurysms
 TOC for large/giant ICA aneurysms
 Blister/small dysplastic aneurysms
 Posterior circulation – more careful use
 Evolving – distal aneurysms
 Issues – cost, expertise, posterior ciruclation
giant aneurysms …

36. For more information on:
STROKE & NEUROVASCULAR INTERVENTIONS:
URL:
www.sanif.co.in
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Dr Vipul Gupta

37. Thank you ….