Post on 24-Jul-2020
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- Flow Diversion- Multidevice Experience
Hans Henkes
Clinic for Neuroradiology Neurocenter, Klinikum Stuttgart, Germany
Polenov’s Readings, Sankt Petersburg, April 14th 2016
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- Flow Diversion- One center, Two devices
Hans Henkes
Clinic for Neuroradiology Neurocenter, Klinikum Stuttgart, Germany
25 minutes presentation
10 statements
5 minutes discussion
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Sample period: 9/2009 – 3/2016
920 FD procedures in 695 patients with 789 aneurysms or other targets 546 p64(+) procedures 310 PED(+) procedures 49 p64 + PED procedures 15 failed attempts
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472 saccular aneurysms 334p64 123PED 7p64+PED 8f.a. 248 fusiform aneurysms 131p64 89PED 24p64+PED 4f.a. 107 dissections 46p64 55PED 6p64+PED 0f.a. (+19 CCF, +63 acute artery occlusions, 10 thrombus fixation)
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Procedures
Retrospective analysis (per procedure) Total number of procedures
546 310 49 no complication* 486(89%) 261(84%) 37(75%)
any complication* 60(11%) 49(16%) 12(25%)
*of potential clinical relevance
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Safety
3 1 2 mo y y % Complete 56 76 84 Minor remnant 19 11 12 Failure 25 14 5
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Follow-up: saccular @
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PTA for ISS: 26 patients
Retreatment: performed or planned 97
mRS worsening: 21 / 695 patients (3.0%)
FD thrombosis: 25 / 695 patients (3.6%)
25 / 920 procedures (2.7%):
13 asymptomatic, 10 symptomatic (3 mRS), 2 fatal
12/298 (2.3%) PED; 10/ 433(0.9%) p64
Mortality: 32/695 patients (4.6%)
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Cessation of antiaggregation...
Issues
5.5.2010 9.3.2012
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Issues
Patient stopped ASA and Clopidogrel without reason
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Cessation of antiaggregation...
Issues
20.3.2014 9.10.2014
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Issues
Cessation of antiaggregation...
5.12.2014 pre LIF 5.12.2014 post LIF
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Cessation of antiaggregation...
Issues
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Issues
Vascular surgeon stopped
ASA and Clopidogrel
for minor reasons
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Unorthodox measures
“Flow Diversion” is not a generic term, it is a
concept which can be executed with different
tools, including a variety of flow diverters
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#1 FD Concept
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#1 FD Concept
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#1 FD Concept
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#1 FD Concept
The usual suspects are Pipeline (Flex, Shield) (Medtronic)
SILK (+) (Balt Extrusion) Surpass (Stryker)
p64 (phenox)
FRED (Microvention)
and others to come; understand the differences
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#2
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#2 Most popular
Only FDA Approved FD
Most widely published
Largest clinical experience
73% complete occlusion at 6 months in PUFS
Solid theory behind it
Seeking FDA approval
Usage requires effort
75% complete occlusion at 6 months
Double layer concept
Seeking FDA approval
Easy to use
73% complete occlusion at 6 months
Controlled detachment
CE mark
Easy to use
79% complete occlusion at 9 months
Oldest FD on the market
CE mark
Easy to use
83% complete occlusion at last F/U – Canadian Registry
48 strand NiTi FD
CE mark
“Poor visibility”
No published data
PED
Surpass
FRED
p64
Derivo
SILK
Select the right target for FD - side-wall aneurysms are most suitable
- repair of arterial dissections
- blister aneurysms
- collateralls, filling an aneurysm
- a few bifurcation aneurysms
- direct CCFs (became rare)
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#3
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Premium indication for FD are
sidewall aneurysm
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sidewall aneurysm
8/2014
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sidewall aneurysm
11/2014 5/2015
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Another indication for FD
bifurcation aneurysm with blister
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bifurcation aneurysm
2/2014
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bifurcation aneurysm
4/2014
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bifurcation aneurysm
4/2014 coil occlusion of the superior sac
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bifurcation aneurysm
5/2014 pre p64
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bifurcation aneurysm
5/2014 post p64 3/12
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bifurcation aneurysm
5/2014 pre p64
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bifurcation aneurysm
8/2014 F/U#1
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bifurcation aneurysm
2/2015 F/U#2
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Another indications for FD
dissections and collaterals
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Collateral
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Dissection
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Dissection
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Collateral
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Another indication for FD
direct CCF
Direct CCF
Direct CCF
Direct CCF
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Another indication for FD
bifurcation aneurysm with slip stream FD effect
(the aneurysm is under the effect of but not covered by the FD)
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Slipstream
4/2014
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Slipstream
4/2014
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Slipstream
4/2015
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With the available devices all patients need dual platelet
function inhibition prior to and after FD
Efficacy of the medication has to be tested and corrected if
necessary
#4 Response testing
Hyperresponse
60 year old female patient
right MCA aneurysm, incidental, surgery
BA / right SCA aneurysm, incidental, FD
acute right subdural hematoma
Hyperresponse
Hyperresponse
Hyperresponse
Hyperresponse
02.06.2016 Prof. Dr. Vorname Nachname Themennennung
Seite 55
7.2.2015 excessive platelet inhibition with 50 mg ASA PO and ½ 75 mg Plavix PO daily, now ½ 75 mg Plavix every other day
Hyperresponse
02.06.2016 Prof. Dr. Vorname Nachname Themennennung
Seite 56
6.5.2015 adequate platelet inhibition with 50 mg ASA PO and ½ 75 mg Plavix PO daily
Hyperresponse
53 year old male patient
MRI 16.10.2014: large aneurysm of the proximal basilar artery, partially thrombosed, mass effect
15.04.2015: VP shunt prior to the endovascular treatment
MRI 17.04.2015: aneurysm enlarged
Hyporesponse
Treatment on 17.04.2015
Anesthesia, medication: premedication with 1x 500 mg ASA IV und 1x 180 mg Brilique PO on the day of treatment; general anesthesia; medication: 3000 U Heparin IV, 500 mg ASA IV, 0.5 g Trapanal IV, 7.9 ml Integrilin IV (2 mg/ml); 2 ml Integrilin IA (2 mg/m); 40 mg Fortecortin IV
Hyporesponse
Treatment on 17.04.2015
Coils: 1x Morpheus 3D 10/30; 4x HydroCoil 10/20
Stent: 1x Enterprise2 4/39 mm (basilar artery / rt VA V4)
Flow diverter: 2x p64 4/24 mm (basilar artery / rt VA V4)
Hyporesponse
10/2014
10/2014
10/2014
10/2014
04/2015
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Treatment
pre, 17.4.2015
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Treatment
post, 17.4.2015
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Follow-up
ceMRA, 20.4.2015
Case Report
Post-medication
Medication since 18.04.2014: 1) 100 mg ASA PO daily forever (1-0-0) 2) 2x 90 mg Brilique (1-0-1) PO daily for 1 year 3) 2x 3000 U MonoEmbolex s.c. daily for 3weeks
4) 3x 4 mg Fortecortin daily for 3 days, tapering 5) 1x 400 mg Ibuprofen PO daily for 3 weeks (0-0-1) 6) gastric protection (e.g., Ranitidin, Pantozol) during steroid therapy 7) all other medication as before
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Multiplate
17.4.15 post loading 18.4.15 post Tx 24.4.15 post Ibuprofen
ADP
ASPI
TRAP
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pre aTE
pre aTE, 24.4.2015
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post aTE
post aTE, 24.4.2015
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MRI post aTE
Eur J Clin Pharmacol. 2013 Mar;69(3):365-71 Interference of NSAIDs with the thrombocyte inhibitory effect of aspirin: a placebo-controlled, ex vivo, serial placebo-controlled serial crossover study.
Meek IL, Vonkeman HE, Kasemier J, Movig KL, van de Laar, MA
RESULTS: Ibuprofen and naproxen inhibit ASA's antithrombocyte effect below the nonresponse threshold..
CONCLUSIONS: COX-1 affinity determines the interaction between NSAIDs and ASA on thrombocyte adhesion and aggregation. Ibuprofen and naproxen, … taken 2 h before ASA, significantly inhibit ASA's antithrombocyte effect.
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Hyporesponse on antiplatelet medication may result in thrombosis of the FD.
Hyperresponse is the cause of severe hemorrhagic
complications (e.g., SDH, ICH) and can prevent aneurysm
obliteration
#4 Response testing
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FD are iStents expect the preservation of side
branches, even after the aneurysm is obliterated
#5 Side branches
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Side branches
12/2014
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Side branches
4/2015
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Adding coils (just 1 or 2) enhances the efficacy of flow diversion in saccular aneurysms
#6 Additional coils
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Additional coils
pre 5/2014
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Additional coils
post 5/2014
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Additional coils
F/U 8/2014
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FD can be a viable option for aneurysms recurrent after (repeated) coil occlusion
#7 FD for recurrent @
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FD for recurrent @
pre recoiling 12/2011
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FD for recurrent @
post recoiling 12/2011
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FD for recurrent @
pre recoiling 6/2012
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FD for recurrent @
post recoiling 6/2012
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FD for recurrent @
pre recoiling 10/2012
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FD for recurrent @
post recoiling 10/2012
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FD for recurrent @
pre recoiling & FD 11/2012
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FD for recurrent @
post recoiling & FD 11/2012
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FD for recurrent @
post recoiling & FD 11/2012
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FD for recurrent @
F/U 1/2013
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FD for recurrent @
F/U & pre FD #2 1/2013
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FD for recurrent @
F/U & post FD #2 1/2013
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FD for recurrent @
F/U 3/2014
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FD for recurrent @
F/U 10/2014
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FD for recurrent @
F/U 10/2014
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Telescoping two identical FD may enhance the hemodynamic effect, combining two different
FD does it more reliably
#8 combine different FD
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Combine different FD
2 FD, matching braids, braids of same braiding angle
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Combine different FD
2 FD, non-matching braids, braids of same braiding angle
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Combine different FD
2 FD, non-matching braids, braids of different braiding angle
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1x 4 mm FRED, 1x 4 mm p64 24.9.2013
Combine different FD
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Combine different FD
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In-stent stenosis is mostly benign and transient
#9 In-stent stenosis
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In-stent stenosis
blister @ seen intra OP 4/13
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In-stent stenosis
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In-stent stenosis
post p64 4/13
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In-stent stenosis
F/U 7/13
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In-stent stenosis
F/U 6/15
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Beware of FD
you might become addicted
#10 Warning
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Conclusion
While treating aneurysms, flexibility is the key…