Efficacy and current limitations of intravascular stents for intracranial internal carotid, vertebral, and basilar artery aneurysms

View More View Less
  • 1 Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object. Results of previous in vitro and in vivo experimental studies have suggested that placement of a porous stent within the parent artery across the aneurysm neck may hemodynamically uncouple the aneurysm from the parent vessel, leading to thrombosis of the aneurysm. For complex wide-necked aneurysms, a stent may also aid packing of the aneurysm with Guglielmi detachable coils (GDCs) by acting as a rigid scaffold that prevents coil herniation into the parent vessel. Recently, improved stent system delivery technology has allowed access to the tortuous vascular segments of the intracranial system. The authors report here on the use of intracranial stents to treat aneurysms involving different segments of the internal carotid artery (ICA), the vertebral artery (VA), and the basilar artery (BA).

Methods. Ten patients with intracranial aneurysms located at ICA segments (one petrous, two cavernous, and three paraclinoid aneurysms), the VA proximal to the posterior inferior cerebellar artery origin (one aneurysm), or the BA trunk (three aneurysms) were treated since January 1998. In eight patients, stent placement across the aneurysm neck was followed (immediately in four patients and at a separate procedure in the remaining four) by coil placement in the aneurysm, accomplished via a microcatheter through the stent mesh. In two patients, wide-necked aneurysms (one partially thrombosed BA trunk aneurysm and one paraclinoid segment aneurysm) were treated solely by stent placement; coil placement may follow later if necessary.

No permanent periprocedural complications occurred and, at follow-up examination, no patient was found to have suffered symptoms referable to aneurysm growth or thromboembolic complications. Greater than 90% aneurysm occlusion was achieved in the eight patients treated by stent and coil placement as demonstrated on immediate postprocedural angiograms. Follow-up angiographic studies performed in six patients at least 3 months later (range 3–14 months) revealed only one incident of in-stent stenosis. In the four patients originally treated solely by stent placement, no evidence of aneurysm thrombosis was observed either immediately postprocedure or on follow-up angiographic studies performed 24 hours (two patients), 48 hours, and 3 months later, respectively.

Conclusions. A new generation of flexible stents can be used to treat complex aneurysms in difficult-to-access areas such as the proximal intracranial segments of the ICA, the VA, or the BA trunk. The stent allows tight coil packing even in the presence of a wide-necked, irregularly shaped aneurysm and may provide an endoluminal matrix for endothelial growth. Although convincing experimental evidence suggests that stent placement across the aneurysm neck may by itself promote intraluminal thrombosis, the role of this phenomenon in clinical practice may be limited at present by the high porosity of currently available stents.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1.

    Bai H, , Masuda J, & Sawa Y, et al: Neointima formation after vascular stent implantation. Spatial and chronological distribution of smooth muscle cell proliferation and phenotypic modulation. Arterioscler Thromb 14:18461853, 1994 Bai H, Masuda J, Sawa Y, et al: Neointima formation after vascular stent implantation. Spatial and chronological distribution of smooth muscle cell proliferation and phenotypic modulation. Arterioscler Thromb 14:1846–1853, 1994

    • Search Google Scholar
    • Export Citation
  • 2.

    Geremia G, , Haklin M, & Brennecke L: Embolization of experimentally created aneurysms with intravascular stent devices. AJNR 15:12231231, 1994 Geremia G, Haklin M, Brennecke L: Embolization of experimentally created aneurysms with intravascular stent devices. AJNR 15:1223–1231, 1994

    • Search Google Scholar
    • Export Citation
  • 3.

    Higashida RT, , Smith W, & Gress D, et al: Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg 87:944949, 1997 Higashida RT, Smith W, Gress D, et al: Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature. J Neurosurg 87:944–949, 1997

    • Search Google Scholar
    • Export Citation
  • 4.

    Lanzino G, , Fessler RD, & Miletich RS, et al: Angioplasty and stenting of basilar artery stenosis: technical case report. Neurosurgery (In press, 1999) Lanzino G, Fessler RD, Miletich RS, et al: Angioplasty and stenting of basilar artery stenosis: technical case report. Neurosurgery (In press, 1999)

    • Search Google Scholar
    • Export Citation
  • 5.

    Lanzino G, , Guterman LR, & Hopkins LN: Carotid artery stenosis: the case for stenting. Clin Neurosurg (In press 1999) Lanzino G, Guterman LR, Hopkins LN: Carotid artery stenosis: the case for stenting. Clin Neurosurg (In press 1999)

    • Search Google Scholar
    • Export Citation
  • 6.

    Lanzino G, , Miskolczi L, & Guterman LR, et al: Angioscopy-assisted aneurysm clipping. Neurosurgery (In press, 1999) Lanzino G, Miskolczi L, Guterman LR, et al: Angioscopy-assisted aneurysm clipping. Neurosurgery (In press, 1999)

    • Search Google Scholar
    • Export Citation
  • 7.

    Lieber BB, , Stancampiano AP, & Wakhloo AK: Alteration of hemodynamics in aneurysm models by stenting: influence of stent porosity. Ann Biomed Eng 25:460469, 1997 Lieber BB, Stancampiano AP, Wakhloo AK: Alteration of hemodynamics in aneurysm models by stenting: influence of stent porosity. Ann Biomed Eng 25:460–469, 1997

    • Search Google Scholar
    • Export Citation
  • 8.

    Lylyk P, , Ceratto R, & Hurvitz D, et al: Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report. Neurosurgery 43:385388, 1998 Lylyk P, Ceratto R, Hurvitz D, et al: Treatment of a vertebral dissecting aneurysm with stents and coils: technical case report. Neurosurgery 43:385–388, 1998

    • Search Google Scholar
    • Export Citation
  • 9.

    Massoud TF, , Turjman F, & Ji C, et al: Endovascular treatment of fusiform aneurysms with stents and coils: technical feasibility in a swine model. AJNR 16:19531963, 1995 Massoud TF, Turjman F, Ji C, et al: Endovascular treatment of fusiform aneurysms with stents and coils: technical feasibility in a swine model. AJNR 16:1953–1963, 1995

    • Search Google Scholar
    • Export Citation
  • 10.

    Mericle RA, , Lanzino G, & Wakhloo AK, et al: Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report. Neurosurgery 43:12291234, 1998 Mericle RA, Lanzino G, Wakhloo AK, et al: Stenting and secondary coiling of intracranial internal carotid artery aneurysm: technical case report. Neurosurgery 43:1229–1234, 1998

    • Search Google Scholar
    • Export Citation
  • 11.

    Moret J, , Cognard C, & Weill A, et al: The “remodeling technique” in the treatment of wide neck intracranial aneurysms: angiographic results and clinical follow-up in 565 cases. Interv Neuroradiol 3:2135, 1997 Moret J, Cognard C, Weill A, et al: The “remodeling technique” in the treatment of wide neck intracranial aneurysms: angiographic results and clinical follow-up in 565 cases. Interv Neuroradiol 3:21–35, 1997

    • Search Google Scholar
    • Export Citation
  • 12.

    Sekhon LHS, , Morgan MK, & Sorby W, et al: Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm: technical case report. Neurosurgery 43:380384, 1998 Sekhon LHS, Morgan MK, Sorby W, et al: Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm: technical case report. Neurosurgery 43:380–384, 1998

    • Search Google Scholar
    • Export Citation
  • 13.

    Sigwart U, , Puel J, & Mirkovitch V, et al: Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N Engl J Med 316:701706, 1987 Sigwart U, Puel J, Mirkovitch V, et al: Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N Engl J Med 316:701–706, 1987

    • Search Google Scholar
    • Export Citation
  • 14.

    Standard SC, , Ahuja A, & Guterman LR, et al: Balloon test occlusion of the internal carotid artery with hypotensive challenge. AJNR 16:14531458, 1998 Standard SC, Ahuja A, Guterman LR, et al: Balloon test occlusion of the internal carotid artery with hypotensive challenge. AJNR 16:1453–1458, 1998

    • Search Google Scholar
    • Export Citation
  • 15.

    Szikora I, , Guterman LR, & Wells KM, et al: Combined use of stents and coils to treat experimental wide-necked carotid aneurysms: preliminary results. AJNR 15:10911102, 1994 Szikora I, Guterman LR, Wells KM, et al: Combined use of stents and coils to treat experimental wide-necked carotid aneurysms: preliminary results. AJNR 15:1091–1102, 1994

    • Search Google Scholar
    • Export Citation
  • 16.

    Turjman F, , Massoud TF, & Ji C, et al: Combined stent implantation and endosaccular coil placement for treatment of experimental wide-necked aneurysms: a feasibility study in swine. AJNR 12:10871090, 1994 Turjman F, Massoud TF, Ji C, et al: Combined stent implantation and endosaccular coil placement for treatment of experimental wide-necked aneurysms: a feasibility study in swine. AJNR 12:1087–1090, 1994

    • Search Google Scholar
    • Export Citation
  • 17.

    Wakhloo AK, , Lanzino G, & Lieber BB, et al: Stents for intracranial aneurysms: the beginning of a new endovascular era? Neurosurgery 43:377379, 1998 Wakhloo AK, Lanzino G, Lieber BB, et al: Stents for intracranial aneurysms: the beginning of a new endovascular era? Neurosurgery 43:377–379, 1998

    • Search Google Scholar
    • Export Citation
  • 18.

    Wakhloo AK, , Schellhammer F, & de Vries J, et al: Self-expanding and balloon-expandable stents in the treatment of carotid aneurysms: an experimental study in a canine model. AJNR 15:493502, 1994 Wakhloo AK, Schellhammer F, de Vries J, et al: Self-expanding and balloon-expandable stents in the treatment of carotid aneurysms: an experimental study in a canine model. AJNR 15:493–502, 1994

    • Search Google Scholar
    • Export Citation
  • 19.

    Wakhloo AK, , Tio FO, & Lieber BB, et al: Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR 16:10431051, 1995 Wakhloo AK, Tio FO, Lieber BB, et al: Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR 16:1043–1051, 1995

    • Search Google Scholar
    • Export Citation
  • 20.

    Yadav JS, , Roubin GS, & Iyer S, et al: Elective stenting of the extracranial carotid arteries. Circulation 95:376381, 1997 Yadav JS, Roubin GS, Iyer S, et al: Elective stenting of the extracranial carotid arteries. Circulation 95:376–381, 1997

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 840 206 14
Full Text Views 251 34 2
PDF Downloads 114 17 1
EPUB Downloads 0 0 0