- Flow Diversion- Multidevice Experience · 2016-06-03 · - Flow Diversion- One center, Two...
Transcript of - Flow Diversion- Multidevice Experience · 2016-06-03 · - Flow Diversion- One center, Two...
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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
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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
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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
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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
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“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
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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
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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
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Direct CCF
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Direct CCF
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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
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Hyperresponse
60 year old female patient
right MCA aneurysm, incidental, surgery
BA / right SCA aneurysm, incidental, FD
acute right subdural hematoma
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Hyperresponse
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Hyperresponse
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Hyperresponse
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Hyperresponse
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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
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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
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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
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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
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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
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10/2014
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10/2014
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10/2014
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10/2014
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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
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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
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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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103 1/2014 10/2014
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…