血流导向装置治疗复杂颅内动脉瘤单中心经验
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摘要
目的评价应用Tubridge和Pipeline血流导向装置治疗复杂颅内动脉瘤的安全性和有效性。方法回顾性连续纳入我科2010年8月至2017年12月应用血流导向装置治疗的99例患者共101个复杂颅内动脉瘤的临床资料,其中91个为首次治疗,10个为复发动脉瘤。动脉瘤平均最大径为(19.6±6.6)mm,94个位于前循环,7个位于后循环。61例患者的61个动脉瘤应用Tubridge血流导向装置治疗,38例患者的40个动脉瘤应用Pipeline血流导向装置治疗。术后予以临床随访与影像学随访。结果 99例患者的101个动脉瘤共置入血流导向装置116枚(Tubridge74枚、Pipeline 42枚),均成功输送并释放。术后1例患者发生迟发性出血并死亡,2例发生缺血性并发症。88个动脉瘤获得了影像学随访,其中短期随访(0～6个月)完全闭塞率为66.7%(42/63)、中长期随访(7～18个月)完全闭塞率为73.5%(36/49)、长期随访(>18个月)完全闭塞率为89.3%(25/28)。全部动脉瘤末次影像学随访完全闭塞率为72.7%(64/88),Tubridge组和Pipeline组分别为73.6%(39/53)和71.4%(25/35),差异无统计学意义(P>0.05)。结论应用Tubridge血流导向装置与Pipeline血流导向装置治疗复杂颅内动脉瘤均安全有效,但也存在一定的并发症风险。
Objective To evaluate the safety and efficacy of Tubridge and Pipeline embolization devices in the treatment of complex intracranial aneurysms. Methods The clinical data of 99 patients harboring 101 complex intracranial aneurysms, who underwent embolization device treatment between Aug. 2010 and Dec. 2017 in our department, were retrospectively collected and analyzed. Among them, 91 aneurysms were treated for the ?rst time and 10 were recurrent lesions.The mean maximum diameter of the aneurysms was(19.6±6.6) mm. Ninety-four lesions were located in anterior circulation and 7 in posterior circulation. Sixty-one aneurysms of 61 patients were treated with Tubridge embolization device, and 40 of 38 patients were treated with Pipeline embolization device. Clinical and angiographic follow-up were preformed conventionally.Results A total of 116 embolization devices(74 Tubridge and 42 Pipeline) were delivered and implanted successfully. One patient died of delayed hemorrhage, and 2 patients suffered from ischemic events after operation. Angiographic follow-up data was available in 88 aneurysms. The complete occlusion rates of short-term(0-6 months), mid-term(7-18 months) and longterm(>18 months) were 66.7%(42/63), 73.5%(36/49) and 89.3%(25/28), respectively. The complete occlusion rate of all aneurysms was 72.7%(64/88) at the last imaging follow-up, and there was no signi?cant difference between the Tubridge and Pipeline groups(73.6% [39/53] vs 71.4% [25/35], P>0.05). Conclusion Both Tubridge and Pipeline embolization devices are safe and effective in treatment of complex intracranial aneurysms. However, the complications shall not be ignored after implantation of embolization device.
Objective To evaluate the safety and efficacy of Tubridge and Pipeline embolization devices in the treatment of complex intracranial aneurysms. Methods The clinical data of 99 patients harboring 101 complex intracranial aneurysms, who underwent embolization device treatment between Aug. 2010 and Dec. 2017 in our department, were retrospectively collected and analyzed. Among them, 91 aneurysms were treated for the ?rst time and 10 were recurrent lesions.The mean maximum diameter of the aneurysms was(19.6±6.6) mm. Ninety-four lesions were located in anterior circulation and 7 in posterior circulation. Sixty-one aneurysms of 61 patients were treated with Tubridge embolization device, and 40 of 38 patients were treated with Pipeline embolization device. Clinical and angiographic follow-up were preformed conventionally.Results A total of 116 embolization devices(74 Tubridge and 42 Pipeline) were delivered and implanted successfully. One patient died of delayed hemorrhage, and 2 patients suffered from ischemic events after operation. Angiographic follow-up data was available in 88 aneurysms. The complete occlusion rates of short-term(0-6 months), mid-term(7-18 months) and longterm(>18 months) were 66.7%(42/63), 73.5%(36/49) and 89.3%(25/28), respectively. The complete occlusion rate of all aneurysms was 72.7%(64/88) at the last imaging follow-up, and there was no signi?cant difference between the Tubridge and Pipeline groups(73.6% [39/53] vs 71.4% [25/35], P>0.05). Conclusion Both Tubridge and Pipeline embolization devices are safe and effective in treatment of complex intracranial aneurysms. However, the complications shall not be ignored after implantation of embolization device.
引文
[1]K A L L M E S D F,B R I N J I K J I W,C E K I R G E S,FIORELLA D,HANEL R A,JABBOUR P,et al.Safety and efficacy of the Pipeline embolization device for treatment of intracranial aneurysms:a pooled analysis of3 large studies[J].J Neurosurg,2017,127:775-780.
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[3]RAYMOND J,GUILBERT F,WEILL A,GEORGANOSS A,JURAVSKY L,LAMBERT A,et al.Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils[J].Stroke,2003,34:1398-1403.
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[6]BRINJIKJI W,MURAD M H,LANZINO G,CLOFT HJ,KALLMES D F.Endovascular treatment of intracranial aneurysms with flow diverters:a meta-analysis[J].Stroke,2013,44:442-447.
[7]LI Z F,FANG X G,YANG P F,HUANG Q H,ZHAO WY,LIANG C,et al.Endothelial progenitor cells contribute to neointima formation in rabbit elastase-induced aneurysm after flow diverter treatment[J].CNS Neurosci Ther,2013,19:352-357.
[8]ZHANG Y,ZHOU Y,YANG P,LIU J,XU Y,HONG B,et al.Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms:safety and efficacy based on a propensity score-matched analysis[J].Eur Radiol,2016,26:2369-2377.
[9]ZANATY M,CHALOUHI N,STARKE R M,BARROSG,SAIGH M P,SCHWARTZ E W,et al.Flow diversion versus conventional treatment for carotid cavernous aneurysms[J].Stroke,2014,45:2656-2661.
[10]PUFFER R C,PIANO M,LANZINO G,VALVASSORIL,KALLMES D F,QUILICI L,et al.Treatment of cavernous sinus aneurysms with flow diversion:results in 44patients[J].AJNR Am J Neuroradiol,2014,35:948-951.
[11]BRASILIENSE L B C,AGUILAR-SALINAS P,MILLER D A,TAWK R G,SAUVAGEAU E A,HANELR A.Analysis of predictors and probability of aneurysm occlusion in the internal carotid artery after treatment with Pipeline embolization device[J].World Neurosurg,2017,107:641-648.
[12]ROUCHAUD A,RAMANA C,BRINJIKJI W,DING YH,DAI D,GUNDERSON T,et al.Wall apposition is a key factor for aneurysm occlusion after flow diversion:a histologic evaluation in 41 rabbits[J].AJNR Am JNeuroradiol,2016,37:2087-2091.
[13]AQUARIUS R,DE KORTE A,SMITS D,GOUNIS M,VERRIJP K,DRIESSEN L,et al.The importance of wall apposition in flow diverters[J].Neurosurgery,2019,84:804-810.
[14]BENDER M T,JIANG B,CAMPOS J K,LIN L M,BEATY N,VO C D,et al.Single-stage flow diversion with adjunctive coiling for cerebral aneurysm:outcomes and technical considerations in 72 cases[J].J Neurointerv Surg,2018,10:843-850.
[15]PARK M S,KILBURG C,TAUSSKY P,ALBUQUERQUEF C,KALLMES D F,LEVY E I,et al.Pipeline embolization device with or without adjunctive coil embolization:analysis of complications from the IntrePED Registry[J].AJNR Am J Neuroradiol,2016,37:1127-1131.
[16]ZHOU G,SU M,YIN Y L,LI M H.Complications associated with the use of flow-diverting devices for cerebral aneurysms:a systematic review and metaanalysis[J/OL].Neurosurg Focus,2017,42:E17.doi:10.3171/2017.3.FOCUS16450.
[17]ROUCHAUD A,BRINJIKJI W,LANZINO G,CLOFT HJ,KADIRVEL R,KALLMES D F.Delayed hemorrhagic complications after flow diversion for intracranial aneurysms:a literature overview[J].Neuroradiology,2016,58:171-177.
[18]CEBRAL J R,MUT F,RASCHI M,SCRIVANO E,CERATTO R,LYLYK P,et al.Aneurysm rupture following treatment with flow-diverting stents:computational hemodynamics analysis of treatment[J].AJNR Am J Neuroradiol,2011,32:27-33.
[19]IKEDA H,ISHII A,KIKUCHI T,ANDO M,CHIHARAH,ARAI D,et al.Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device:histopathological investigation[J].Interv Neuroradiol,2015,21:674-683.
[20]WHITE A C,KUMPE D A,ROARK C D,CASE DE,SEINFELD J.Patterns,predictors,and outcomes of postprocedure delayed hemorrhage following flow diversion for intracranial aneurysm treatment[J/OL].World Neurosurg,2018,115:e97-e104.doi:10.1016/j.wneu.2018.03.190.
[21]CRUZ J P,CHOW M,O’KELLY C,MAROTTA B,SPEARS J,MONTANERA W,et al.Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms[J].AJNR Am J Neuroradiol,2012,33:603-608.
[22]RANGEL-CASTILLA L,MUNICH S A,JALEEL N,CRESS M C,KRISHNA C,SONIG A,et al.Patency of anterior circulation branch vessels after Pipeline embolization:longer-term results from 82 aneurysm cases[J].J Neurosurg,2017,126:1064-1069.
[23]BHOGAL P,GANSLANDT O,B?ZNER H,HENKES H,PéREZ M A.The fate of side branches covered by flow diverters―results from 140 patients[J].World Neurosurg,2017,103:789-798.
[2]LIU J M,ZHOU Y,LI Y,LI T,LENG B,ZHANG P,et al.Parent artery reconstruction for large or giant cerebral aneurysms using the Tubridge flow diverter:a multicenter,randomized,controlled clinical trial(PARAT)[J].AJNR Am J Neuroradiol,2018,39:807-816.
[3]RAYMOND J,GUILBERT F,WEILL A,GEORGANOSS A,JURAVSKY L,LAMBERT A,et al.Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils[J].Stroke,2003,34:1398-1403.
[4]QUINN T J,DAWSON J,WALTERS M R,LEES K R.Reliability of the modified Rankin scale:a systematic review[J].Stroke,2009,40:3393-3395.
[5]WALCOTT B P,STAPLETON C J,CHOUDHRI O,PATEL A B.Flow diversion for the treatment of intracranial aneurysms[J].JAMA Neurol,2016,73:1002-1008.
[6]BRINJIKJI W,MURAD M H,LANZINO G,CLOFT HJ,KALLMES D F.Endovascular treatment of intracranial aneurysms with flow diverters:a meta-analysis[J].Stroke,2013,44:442-447.
[7]LI Z F,FANG X G,YANG P F,HUANG Q H,ZHAO WY,LIANG C,et al.Endothelial progenitor cells contribute to neointima formation in rabbit elastase-induced aneurysm after flow diverter treatment[J].CNS Neurosci Ther,2013,19:352-357.
[8]ZHANG Y,ZHOU Y,YANG P,LIU J,XU Y,HONG B,et al.Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms:safety and efficacy based on a propensity score-matched analysis[J].Eur Radiol,2016,26:2369-2377.
[9]ZANATY M,CHALOUHI N,STARKE R M,BARROSG,SAIGH M P,SCHWARTZ E W,et al.Flow diversion versus conventional treatment for carotid cavernous aneurysms[J].Stroke,2014,45:2656-2661.
[10]PUFFER R C,PIANO M,LANZINO G,VALVASSORIL,KALLMES D F,QUILICI L,et al.Treatment of cavernous sinus aneurysms with flow diversion:results in 44patients[J].AJNR Am J Neuroradiol,2014,35:948-951.
[11]BRASILIENSE L B C,AGUILAR-SALINAS P,MILLER D A,TAWK R G,SAUVAGEAU E A,HANELR A.Analysis of predictors and probability of aneurysm occlusion in the internal carotid artery after treatment with Pipeline embolization device[J].World Neurosurg,2017,107:641-648.
[12]ROUCHAUD A,RAMANA C,BRINJIKJI W,DING YH,DAI D,GUNDERSON T,et al.Wall apposition is a key factor for aneurysm occlusion after flow diversion:a histologic evaluation in 41 rabbits[J].AJNR Am JNeuroradiol,2016,37:2087-2091.
[13]AQUARIUS R,DE KORTE A,SMITS D,GOUNIS M,VERRIJP K,DRIESSEN L,et al.The importance of wall apposition in flow diverters[J].Neurosurgery,2019,84:804-810.
[14]BENDER M T,JIANG B,CAMPOS J K,LIN L M,BEATY N,VO C D,et al.Single-stage flow diversion with adjunctive coiling for cerebral aneurysm:outcomes and technical considerations in 72 cases[J].J Neurointerv Surg,2018,10:843-850.
[15]PARK M S,KILBURG C,TAUSSKY P,ALBUQUERQUEF C,KALLMES D F,LEVY E I,et al.Pipeline embolization device with or without adjunctive coil embolization:analysis of complications from the IntrePED Registry[J].AJNR Am J Neuroradiol,2016,37:1127-1131.
[16]ZHOU G,SU M,YIN Y L,LI M H.Complications associated with the use of flow-diverting devices for cerebral aneurysms:a systematic review and metaanalysis[J/OL].Neurosurg Focus,2017,42:E17.doi:10.3171/2017.3.FOCUS16450.
[17]ROUCHAUD A,BRINJIKJI W,LANZINO G,CLOFT HJ,KADIRVEL R,KALLMES D F.Delayed hemorrhagic complications after flow diversion for intracranial aneurysms:a literature overview[J].Neuroradiology,2016,58:171-177.
[18]CEBRAL J R,MUT F,RASCHI M,SCRIVANO E,CERATTO R,LYLYK P,et al.Aneurysm rupture following treatment with flow-diverting stents:computational hemodynamics analysis of treatment[J].AJNR Am J Neuroradiol,2011,32:27-33.
[19]IKEDA H,ISHII A,KIKUCHI T,ANDO M,CHIHARAH,ARAI D,et al.Delayed aneurysm rupture due to residual blood flow at the inflow zone of the intracranial paraclinoid internal carotid aneurysm treated with the Pipeline embolization device:histopathological investigation[J].Interv Neuroradiol,2015,21:674-683.
[20]WHITE A C,KUMPE D A,ROARK C D,CASE DE,SEINFELD J.Patterns,predictors,and outcomes of postprocedure delayed hemorrhage following flow diversion for intracranial aneurysm treatment[J/OL].World Neurosurg,2018,115:e97-e104.doi:10.1016/j.wneu.2018.03.190.
[21]CRUZ J P,CHOW M,O’KELLY C,MAROTTA B,SPEARS J,MONTANERA W,et al.Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms[J].AJNR Am J Neuroradiol,2012,33:603-608.
[22]RANGEL-CASTILLA L,MUNICH S A,JALEEL N,CRESS M C,KRISHNA C,SONIG A,et al.Patency of anterior circulation branch vessels after Pipeline embolization:longer-term results from 82 aneurysm cases[J].J Neurosurg,2017,126:1064-1069.
[23]BHOGAL P,GANSLANDT O,B?ZNER H,HENKES H,PéREZ M A.The fate of side branches covered by flow diverters―results from 140 patients[J].World Neurosurg,2017,103:789-798.