Interv Neuroradiol
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A flow-diverting stent such as the Pipeline embolization device (PED, ev3 Endovascular, Plymouth, MN, USA) and Silk flow-diverting stent (Balt Extrusion, Montmorency, France) offers an acceptable alternative for the treatment of difficult aneurysms according to their morphologies, including giant, wide-necked, fusiform, and blister types. However, complications arising from the use of these stents have frequently been reported including several cases of branch artery occlusion and delayed occlusion of the stented parent vessel shortly after antiplatelet medications were discontinued, highlighting the potential need for long-term antiplatelet therapy, and disastrous bleeding complications in unruptured aneurysm. In addition, these microcell stents are difficult to use in distal aneurysms located over the ICA bifurcation and basilar tip because of the stiffness of the device, and perforating vessel occlusion is more likely to occur due to the characteristics of the stent. ⋯ No growing aneurysm or rebleeding was found on any follow-up angiography. Thromboembolic complications were found in one patient. It is difficult to make conclusions on the long-term efficacy of this technique with such a small number of cases, however sole stenting with a large cell intracranial stent for the treatment of very small aneurysms may be used safely as an alternative treatment even during an episode of SAH.
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Post-embolization hemorrhage is the most severe, dramatic and morbidity-mortality-related complication in the treatment of endovascular arteriovenous malformations (AVMs). The objective of this study was to determine predictive factors of post-embolization hemorrhage. This is a retrospective study in 71 patients with cerebral AVMs having undergone 147 embolization sessions with n-butyl cyanoacrylate (n-BCA), carried out between 2006 and 2011. ⋯ In the multivariate analysis, hemorrhage predictors were: nidus diameter < 3 cm (OR= 45.02; CI=95%:1.17-203.79; P=0.005); devascularization > 40% (OR=32.4; CI=95%: 3.142- 518.6; P=0.009) per session; intranidal aneurysms (OR=7.5; CI=95%:1.19-341.3; P=0.041) and lack of post-procedure hypotension (OR=16.51; CI=95%:1.81-324.4; P=0.049) and the association of sessions with devascularization exceeding 40% with lack of post-procedure hypotension, showed an increase in the risk of hemorrhage (OR=36.4; CI=95%:3.67-362.4; P=0.002). Extensive devascularization and the absence of post-procedure hypotension increase the risk of hemorrhage. We suggest partial, 25-30%, devascularization per session and the induction of post-procedure hypotension, which produces a 20% decrease of the basal mean arterial pressure (MAP).
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Onyx has been widely adopted for the treatment of arteriovenous malformations (AVMs). However, its control demands operators accumulate a considerable learning curve. We describe our initial experience using a novel injection method for the embolization of AVMs. ⋯ The results remained stable on follow-up angiograms. A procedural complication occurred in one patient, with permanent mild neurologic deficit. Our preliminary series demonstrated that the coil-augmented Onyx injection technique is a valuable adjunct achieving excellent nidal penetration and improving the safety of the procedure.