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Management of aneurysmal recurrence after Woven EndoBridge (WEB) treatment
Abstract
Background
Around 10% of Woven EndoBridge device (WEB)-treated intracranial aneurysms will need retreatment, and it is generally believed to be more challenging than retreatment after an initial coiling. We aim to report retreatment strategies and outcomes after initial WEB embolizations.
Methods
Databases from four treatment centers, containing consecutive aneurysms treated with a WEB between 2013 and 2022, were reviewed. Demographics, aneurysm characteristics, retreatment strategies and outcomes were collected and analyzed.
Results
From a 756 WEB database, 57 aneurysms were included. The global retreatment rate was 7.5% (95% CI 5.6% to 9.4%). The retreatment rate was significantly higher in the ruptured compared with the unruptured population (13% vs 3.9%, respectively, P<0.0001). Aneurysms were retreated on average 21.2 months after the initial WEB treatment (range 4.8–70 months). Surgery was performed in 11% and endovascular treatment in 89% of cases, consisting of flow diversion (48%), stent-assisted coiling (30%), coiling (12%), and second WEB placement (10%). Imaging follow-up was available in 88% of all WEB retreatments (50/57) (average 17 months, 49% digital subtraction angiography), demonstrating complete occlusion in 56% and ‘adequate’ occlusion in 88%. Morbidity was 5.3% (95% CI 0% to 12.0%) and mortality 0%. No patient experienced rebleeding during the follow-up period.
Conclusion
The retreatment rate after an initial WEB treatment seems to compare favorably with that of coiling. Endovascular treatment of recurrence following WEB implantation is feasible in most situations; it generally requires the use of a stent and leads to a high rate of satisfactory occlusion.
... In general, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. In three recent, large multicenter studies, 0.8 % (6/756) [6], 1.4% (10/691) [14], and 2% (6/342) [36] of WEB-treated aneurysms were retreated with microsurgical clipping. Previous rupture of the aneurysms retreated with microsurgical clipping has been mentioned in two of the studies and was 0.6% (4/691) [14] and 0.9% (3/342) [36], respectively. ...
... A variety of retreatment modalities after WEB including coiling, stent-assisted coiling, flow-diverter stents, a second WEB, and microsurgical clipping have been proposed [, 6,36]. Retreatment, however, depends on several factors such as location of the aneurysm, size, and feasibility of surgery. ...
... AComA MCA BA Kortman et al., 2022 [19] 78 78 (100) 5 (6) 1 (1.2) n/a n/a n/a Alpay et al., 2022 [3] 66 25 (38) 8 (12) n/a n/a n/a n/a Caroff et al., 2022 [6] 756 294 (39) 57 (8) n/a n/a n/a n/a Alpay et al., 2022 [2] 91 28 (31) 13 (14) n/a n/a n/a n/a Spelle et al., 2022 [34] 60 60 (100) 6 (10) n/a n/a n/a n/a Diestro et al., 2022 [14] 691 162 (23) 51 (7) 4 (0.6) n/a n/a n/a Pierot et al., 2022 [32] 95 7 (7) 11 (12) n/a n/a n/a n/a Goertz et al., 2022 [16] 94 54 (57) 11 (12) n/a n/a n/a n/a Cortese et al., 2022 [11] 215 59 (27) 20 (9) n/a n/a n/a n/a Kewlani et al., 2022 [17] 74 28 (37) 6(8) n/a n/a n/a n/a Srinivasan et al., 2022 [36] 342 13 (4) 30 (9) 3 (0.9) 2 (0.5) 1 (0.2) n/a Algin et al., 2022 [1] 83 49 (59) 4 (5) n/a n/a n/a n/a Mouchtouris et al., 2021 [24] 115 34 (30) 6 (5) n/a n/a n/a n/a Pagano et al., 2021 [27] 92 6 (7) 2 (2) n/a n/a n/a n/a Cherian et al., 2021 [9] 91 8 (9) 4 (4) n/a n/a n/a n/a Cortez et al., 2021 [12] 94 94 (100) 4 (4) n/a n/a n/a n/a Youssef et al., 2021 [39] 48 48 (100) 2 (4) n/a n/a n/a n/a Pierot et al., 2020 [30] 152 8 (5) 14 (9) n/a n/a n/a n/a Arthur et al., 2019 [4] 143 8 (6) 14 (10) n/a n/a n/a n/a Pierot et al., 2019 [29] 4 1 (25) 4 (100) 1 (25) 1 (25) n/a n/a Kranawetter et al., 2023* 5 5 (100) 5 (100) 5 (100) 4 (80) n/a 1 (20) did evaluate our own results after microsurgical clipping of incidental WNBAs and compared them with the outcome after WEB treatment in the 3 European landmark studies [7]. The morbidity has been low with both methods, but the complete occlusion rate has been significantly higher after microsurgical clipping (99% vs. 58%). ...
Background
Since its approval by the US Food and Drug Administration (FDA) in 2018, the flow disruptor Woven EndoBridge (WEB) device has become increasingly popular for the endovascular treatment of unruptured and ruptured cerebral aneurysms. However, the occlusion rates seem rather low and the retreatment rates rather high compared to other treatment methods. For initially ruptured aneurysms, a retreatment rate of 13 % has been reported. A variety of retreatment strategies has been proposed; however, there is a paucity of data concerning microsurgical clipping of WEB-pretreated aneurysms, especially previously ruptured ones. Thus, we present a single-center series of five ruptured aneurysms treated with the WEB device and retreated with microsurgical clipping.
Methods
A retrospective study including all patients presenting with a ruptured aneurysm undergoing WEB treatment at our institution between 2019 and 2021 was performed. Subsequently, all patients with an aneurysm remnant or recurrence of the target aneurysm retreated with microsurgical clipping were identified.
Results
Overall, five patients with a ruptured aneurysm treated with WEB and retreated with microsurgical clipping were included. Besides one basilar apex aneurysm, all aneurysms were located at the anterior communicating artery (AComA) complex. All aneurysms were wide-necked with a mean dome-to-neck ratio of 1.5. Clipping was feasible and safe in all aneurysms, and complete occlusion was achieved in 4 of 5 aneurysms.
Conclusions
Microsurgical clipping for initially ruptured WEB-treated aneurysms is a feasible, safe, and effective treatment method in well-selected patients.
... 2 The Woven Endobridge (WEB) embolization device has demonstrated high efficacy, flexibility, and safety for the treatment of wide-neck bifurcation IAs, including ruptured and recurrent IAs, as shown in multiple retrospective studies and meta-analyses. [3][4][5][6][7][8] Due to its optimal barrel shape, the WEB device is useful in the setting of previously treated aneurysms, particularly with wide-neck previously coiled aneurysms. 1 9 10 In this technical video of four cases (video 1), we describe the technical nuances of WEB embolization for recurrent IAs, which were initially either coiled or clipped and demonstrated progressive growth with a wide-neck presentation on follow-up. ...
Recurrent intracranial aneurysms (IAs) often present with more complex morphology such as irregular shape, shallow height, and wide neck, which can make for challenging endovascular treatments.1 Initial rupture and interventions are associated with fibrotic changes and considerable alteration in the aneurysm configuration, which limits retreatment options and increases the risk of complications during retreatment.2 The Woven Endobridge (WEB) embolization device has demonstrated high efficacy, flexibility, and safety for the treatment of wide-neck bifurcation IAs, including ruptured and recurrent IAs, as shown in multiple retrospective studies and meta-analyses.3–8 Due to its optimal barrel shape, the WEB device is useful in the setting of previously treated aneurysms, particularly with wide-neck previously coiled aneurysms.1 9 10 In this technical video of four cases (video 1), we describe the technical nuances of WEB embolization for recurrent IAs, which were initially either coiled or clipped and demonstrated progressive growth with a wide-neck presentation on follow-up.
Video 1 Management of recurrent intracranial aneurysms via WEB: This video describes four recurrent intracranial aneurysms, which were initially either coiled or clipped but demonstrated progressive growth with a wide-neck presentation on follow-up. All cases were successfully treated via WEB.
... It is generally believed that treating the recurrence of MCA aneurysms after WEB device deployment can be more challenging. The retreatment consisted of FD deployment, stent-assisted coiling, and second WEB placement, and open surgery was the last resort (79,80). Therefore, there is a long way to go for WEB to replace traditional EVT for MCA bifurcation aneurysms. ...
Middle cerebral artery (MCA) aneurysms are complex and widely distributed throughout the course of the MCA. Various types of aneurysms can occur in the MCA. Ruptured as well as unruptured MCA aneurysms may require treatment to avoid bleeding or rebleeding. Currently, clipping is regarded as the first-line choice for the treatment of MCA aneurysms. However, endovascular treatment (EVT) is emerging as an alternative treatment in selected cases. EVT techniques vary. Therefore, it is necessary to review EVT for MCA aneurysms. In this review, the following issues were discussed: MCA anatomy and anomalies, classifications of MCA aneurysms, the natural history of MCA aneurysms, EVT status and principle, deployments of traditional coiling techniques and flow diverters (FDs), and deployments and prospects of intrasaccular flow disruptors and stent-like devices. According to the review and our experience, traditional coiling EVT is still the preferred therapy for most MCA aneurysms. FD deployment can be used in selective MCA aneurysms. Parent artery occlusion (PAO) can be used to treat distal MCA aneurysms. In addition, new devices can be used to treat MCA aneurysms, such as intrasaccular flow disruptors and stent-like devices. In general, EVT is gaining popularity as an alternative treatment option; however, there is still a lack of evidence regarding EVT, and longer-term data are not currently available for most EVT devices.
... Finally, 11 studies with 165 retreated aneurysms were determined to satisfy our inclusion criteria with the appropriate report of outcomes of interest ( Figure S1 in the Supplement). [12][13][14][15][16][17][18][19][20][21][22] Study characteristics and risk of bias ...
Background
The Woven EndoBridge (WEB) device is used to treat wide-neck bifurcation aneurysms (WNBAs). We conducted a systematic review and meta-analysis to determine the retreatment rate strategies following aneurysmal recurrence of WEB device treated WNBAs.
Methods
This study is reported following the PRISMA 2020 guidelines. We conducted a systematic review of the literature using PubMed, Scopus, Embase, and Web of Science. Data were pooled using a random-effects model. We calculated pooled prevalence and corresponding 95% confidence intervals (CI).
Results
We included 11 studies. The overall retreatment rate was 171/1875 aneurysms (10.3%; 95% CI = 8.3–12.9). Stent-assisted coiling was used to treat 59 aneurysms (36.7%; 95% CI = 26.4–48.5), and flow diverters were used to treat 44 aneurysms (18.7%; 95% CI = 9.9–32.5). Following retreatment, the complete occlusion rate was 57/91 aneurysms (62.8%; 95% CI = 48.2–75.3) and the adequate occlusion rate was 24/91 aneurysms (26.4%; 18.4%–36.4%). The most common aneurysmal recurrence site was the anterior communicating artery (44/136 aneurysms, 32.4%; 95% CI = 25.0–40.7).
Conclusions
Roughly 10% of WNBAs initially treated with the WEB device will undergo retreatment. Retreatment is an effective strategy for WEB-treated aneurysms, with high rates of adequate and complete occlusion. Future studies should work to identify risk factors for aneurysmal recurrence.
The Woven Endobridge (WEB) intrasaccular flow diversion device (Microvention, Inc.) is commonly used to treat both unruptured and ruptured wide-necked bifurcation aneurysms. ¹ Despite its relative safety and comparable rates of aneurysm occlusion, the device may compress over time resulting in aneurysm recurrence. ² In this video, we demonstrate the microsurgical retreatment of a large anterior communicating artery (ACoA) aneurysm previously treated with WEB. A 53-year-old patient with hypertension and current tobacco use presented with a ruptured ACoA aneurysm measuring 8.4 mm × 8 mm × 7 mm. She was urgently treated with a 9 mm × 5 mm WEB SL and made a full recovery. At 6 months, cerebral angiography showed a significant recurrence secondary to WEB compression. We considered both endovascular and microsurgical approaches; however, the anatomy was unfavorable for endovascular treatment. ³ Although previous reports have documented clipping as a retreatment strategy, a minority of these aneurysms were ACoA aneurysms. ⁴⁻⁷ The patient consented to the surgical procedure. This operative video illustrates the in vivo appearance of the WEB device and the surgical technique used to treat this unusual situation. The WEB device was firm and not as compressible as previously reported, but clipping was still possible. 4,6 We highlight the use of temporary clipping, fenestrated clips, and intraoperative angiography in treatment. The aneurysm was occluded, and the patient remained without deficits. In summary, clip ligation can be an excellent option for ACoA aneurysms in the setting of WEB recurrence. The patient consented to this report; Institutional Review Board/ethics committee approval was not required.
BACKGROUND AND OBJECTIVES
This multicenter study aimed to assess the safety and efficacy of the Woven EndoBridge (WEB) device for treating unruptured wide-neck intracranial bifurcation aneurysms (WIBAs) with short-, mid-, and long-term follow-ups (FUPs).
METHODS
Consecutive patients with unruptured WIBAs treated with WEB between December 2014 and January 2018 were included. Patient, aneurysm, and device characteristics were collected and analyzed retrospectively. Morbidity and mortality rates were determined by collecting intraprocedural, periprocedural, and delayed complications. Aneurysm occlusion was assessed at 1, 3, and 5 years using a 3-grade scale: complete occlusion, neck remnant, and residual aneurysm. Complete occlusion and neck remnant were considered as adequate occlusion. Patients who received re-treatment were also evaluated.
RESULTS
The study included 104 consecutive patients (55.8% female, mean age 58.6 ± 11.8 years). Aneurysm maximum size, neck, and dome-to-neck mean were, respectively, 6.9 ± 2.1 mm, 4.5 ± 1.2 mm, and 1.4 ± 0.3 mm. One-year FUP was collected for 95 patients, and 3- and 5-year FUPs were collected for 83 patients. Adequate occlusion was observed at 1-year FUP in 90.5% (86/95), 91.6% (76/83) was observed at 3-year FUP, and 92.8% (77/83) at 5-year FUP. None of the aneurysms bled after treatment. During FUP, 6/83 patients (7.2%) were re-treated for residual aneurysm. Morbidity and mortality rates closely related to aneurysm occlusion were 0% (0/104).
CONCLUSION
The WEB device was safe and effective for treating unruptured WIBAs, both in short-term and long-term FUPs.
Background:
In recent 10 years, Woven EndoBridge(WEB) device has been used as endovascular instrumentation for treating wide neck Bifurcation aneurysms. Its safety and efficacy in the mid-term (6-24 months) and long-term (more than 24 months) follow-up period have yet to be systematically reviewed.
Purpose:
To evaluate the WEB device safety and efficacy, relevant literature and publications were extensively reviewed, and a meta-analysis was conducted.
Data resource:
All relevant literature/publications were achieved from Pubmed, Cochrane, Embase, and Web of Science databases.
Results:
767 patients that were studied in 13 literature were included. The focus of this review was placed on the clinical and anatomic outcomes. Complete occlusion was achieved in 67.3% (95% CI, 59.0-75.5%) and 69.3% (95% CI, 55.7-82.8%) of the cases at mid- and long-term follow-up. The rate of adequate occlusion was 86.6% (95% CI, 83.0-90.2%) and 90.1% (95% CI, 85.5-94.4%) for the mid and long-term, respectively. 51 patients (8.8%; 95% CI,5.6-11.9%) and 18 (8.1%; 95% CI,0.8-15.5%) received retreatments during mid- and long-term follow-up, respectively. 410 patients from 427 (94.3%; 95% CI, 89.7-98.9%) showed favorable clinical outcomes. The all-cause mortality rate was 3.5% (95% CI, 1.4-5.6%), where only a few cases were related to the WEB implantation. The WEB device deployment was associated with an overall clinical complication rate of 4.1% (95% CI, 2.7-6.6%), 3 hemorrhagic (1.2%; 95% CI, 0.2-2.6%), and 30 thromboembolic (4.0%; 95% CI, 4.0- 6.0%) complications.
Conclusions:
The findings reveal the satisfactory safety and effectiveness of the WEB device for the Treatment of wide-neck aneurysms during mid-to-long-term follow-up, indicating the high potential of the WEB device for wide application.
Background
Utilization of Woven EndoBridge (WEB) for treatment of intracranial aneurysms has increased due to increasing operator experience. We aimed to report our contemporary series of a North American center with the WEB, examining factors associated with occlusion rates.
Method
Consecutive patients (2019–2022) with intracranial aneurysms treated with WEB device were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (RR1/RR2) were examined. Procedural and clinical results were reported.
Results
A total of 104 consecutive aneurysms/patients (25 men/79 women; median age, 63 years, IQR: 55–71) were treated with single-layer WEB-SL in our institution. Seventeen patients (16%) had a ruptured aneurysm. The median aneurysm dome size was 5.5 mm (IQR = 4.5–6.5), and the most common locations were AcomA (36/104 = 34.6%), MCA bifurcation (29/104 = 27.9%), and BT (22/104 = 21.2%). The rate of technical failure was 0.9%. The median intervention time was 32 min (IQR = 25–43). Overall, 8 (7.6%) cases needed additional interventions: 4 (3.8%) additional stenting, 3 cases (3.8%) of intravenous tirofiban infusion (because of the excessive WEB protrusion), and one case (0.9%) of additional coiling (need to complete the neck occlusion). At 12-month follow-up, 67 patients were available showing 59/67 (88%) and 6/67 (9%) of complete occlusion and neck remnant, respectively on dual-energy CTA. There were no cases necessitating retreatment. Ruptured presentation (OR = 0.09, 95% CI = 0.008–0.9, p = .024), undersized WEB (OR = 15, 95% CI = 1.2–50, p = .006), WEB shape change (OR = 0.07, 95% CI = 0.001–0.6, p = .05), aneurysm neck diameter (OR = 0.4, 95% CI = 0.2–0.9, p = .05), and angle between the parent artery and the aneurysm dome (OR = 0.2, 95% CI = 0.01–0.8, p = .008) were significantly associated with occlusion status (RR1-2) at follow-up. However, in the multivariate logistic regression, these factors did not reach the statistical significance. The overall rate of morbidity was 0.9%.
Conclusions
Our contemporary North American experience on consecutive intracranial aneurysms treated with WEB confirms the medium-term efficacy of this strategy, with low procedural time and morbidity. Further research is needed to demonstrate long-term occlusion rates.
Background
Evaluating a new endovascular treatment for intracranial aneurysms must not only demonstrate short-term safety and efficacy, but also evaluate longer-term outcomes (eg, delayed complications, anatomical results, retreatment). The current analysis reports the 5-year clinical and anatomical results of Woven EndoBridge (WEB) treatment in two European combined trial populations (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2).
Methods
All adverse events occurring between the procedure and 5-year follow-up were independently evaluated by an expert. Aneurysm occlusion was evaluated by an independent core laboratory using a three-grade scale: complete occlusion, neck remnant, and aneurysm remnant. In cases where data were not available at 5-year follow-up, the last observation carry forward (LOCF) method was used.
Results
The safety and efficacy populations comprised 100 patients and 95 aneurysms, respectively. No adverse event related to the device occurred after the procedure during the 5-year follow-up period. Mortality at 5 years was 7.0% (7/100 patients) including mortality related to the WEB (0/100, 0.0%), the procedure (1/100, 1.0%), and another condition (6/100, 6.0%). At 5 years, complete aneurysm occlusion was observed in 49/95 (51.6%) aneurysms, neck remnant in 25/95 (26.3%), and aneurysm remnant in 21/95 (22.1%). Retreatment rate at 5 years was 11.6% (11/95 aneurysms).
Conclusions
This analysis conducted in a population of patients with wide-neck bifurcation aneurysms confirms WEB’s safety profile. Additional evidence demonstrates good stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) at 5 years in 77.9% of aneurysms with a low retreatment rate (11.6%).
Clinical trial registration
WEBCAST and WEBCAST-2: Unique identifier: NCT01778322 .
The prevalence of recurrent and residual aneurysms following Woven EndoBridge (WEB) treatment is not insignificant. The goal of this systematic review was to evaluate retreatment methods for such aneurysms and their outcomes. PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Original studies reporting on aneurysms that were retreated after WEB were included. Sixteen studies (n = 901 aneurysms), of which three were prospective, reported on retreated aneurysms following initial WEB treatment. Of those 901 aneurysms, on average 18.7 ± 11.5% were recurrent or residual at the last follow-up and 10.7 ± 11% required some form of retreatment. When compared to WEB-IT (WEB Intra-saccular Therapy) data, retreated aneurysms were more likely to be large in size (p < 0.0001) and more likely to have been initially treated with the WEB dual-layer configuration. The mean age of those with retreated aneurysms was 58 ± 5.7 years old, and the mean size of aneurysm dome was 11.1 ± 5.5 millimeters. Majority (34.1%) of the aneurysms were located at the basilar apex. Retreatment modalities included coiling (20%), stent-assisted coiling (38.7%), additional WEB device (13.3%), flow diversion (16%), and clipping (12%). Majority of retreated cases had favorable outcomes, with 96.4 ± 13.4% of the cases demonstrating technical success and 90.5 ± 18.2% having adequate occlusion at the last follow-up. Our systematic review suggests that retreatment of recurrent and residual aneurysms after initial WEB treatment is feasible. Future prospective studies would be helpful in validating these results.
Background
WEB treatment is an endovascular approach for wide-neck bifurcation aneurysms that has demonstrated high safety and good efficacy in mid-term follow-up. While evaluating safety in the long term is important to determine if delayed adverse events occur affecting late morbidity and mortality, the most important point to evaluate is the long-term stability of aneurysm occlusion. The current analysis reports the 3-year clinical and anatomical results of WEB treatment in the combined population of two European trials (WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm Therapy) and WEBCAST-2).
Methods
Aneurysm occlusion was evaluated using a 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.
Results
The safety population comprised 79 patients. The efficacy population comprised 61 aneurysms. Aneurysm locations were middle cerebral artery in 32/61 aneurysms (52.5%), anterior communicating artery in 13/61 (21.3%), basilar artery in 9/61 (14.8%), and internal carotid artery terminus in 7/61 (11.5%). No adverse events related to the device or procedure occurred between 2 and 3 years. At 3 years, complete occlusion was observed in 31/61 (50.8%) aneurysms, neck remnant in 20/61 (32.8%), and aneurysm remnant in 10/61 (16.4%). Between 1 year and 3 years, aneurysm occlusion was improved or stable in 53/61 (86.9%) aneurysms and worsened in 8/61 (13.1%). Worsening was mostly from complete occlusion to neck remnant in 6/61 (9.8%) aneurysms. The retreatment rate at 3 years was 11.4%.
Conclusions
This analysis confirms the high safety profile of WEB. Moreover, evidence demonstrates the great stability of aneurysm occlusion with adequate occlusion (complete occlusion or neck remnant) in 83.6% of aneurysms.
Clinical trial registration
URL: http://www.clinicaltrials.gov . WEBCAST and WEBCAST-2: Unique identifier: NCT01778322 .
Wide-necked bifurcation aneurysms (WNBAs) make up 26–36% of all brain aneurysms. Treatments for WNBAs pose unique challenges due to the need to preserve major bifurcation vessels while achieving a durable occlusion of the aneurysm. Intrasaccular flow disruption is an innovative technique for the treatment of WNBAs. The Woven EndoBridge (WEB) device is the only United States Food and Drug Administration approved intrasaccular flow disruption device. In this review article we discuss various aspects of treating WNBAs with the WEB device, including indications for use, aneurysm/device selection strategies, antiplatelet therapy requirement, procedural technique, potential complications and bailouts, and management strategies for residual/recurrent aneurysms after initial WEB treatment.
Background and purpose
Intrasaccular flow disruption using the Woven EndoBridge (WEB) is a safe and effective method to treat intracranial aneurysms, particularly wide neck bifurcation aneurysms. However mid term and long term follow-up imaging can show aneurysm remnant or recanalization, and retreatment is therefore sometimes necessary. In most cases, retreatment is performed using an endovascular approach. The present series reports and analyzes aneurysm clipping of recanalized or incompletely occluded aneurysms following WEB treatment.
Methods
All patients treated with the WEB device since the beginning of our experience in June 2011 were prospectively collected in a local database. Among them, patients who were retreated by clipping for aneurysm remnants were included in the present series.
Results
In the cumulative population of 130 patients with aneurysms treated by the WEB device from June 2011 to February 2019, 4 patients (3.1%) were retreated with surgical clipping due to incomplete occlusion (2 patients) and aneurysm recanalization (2 patients). Three of the four aneurysms retreated (75%) were located in the middle cerebral artery and one in the anterior communicating artery (25.0%). The aneurysm was ruptured in 1 of 4 patients (25%). Clipping was performed 10–54 months after initial treatment with the WEB. Surgical exposure showed that the WEB device was inside the aneurysm sac in all cases. Clipping was easily performed in all but 1 case. Control DSA showed complete occlusion in two aneurysms and a neck remnant in two.
Conclusion
Clipping is a feasible option for treating aneurysm remnants following initial treatment with intrasaccular flow disruption using the WEB.
Introduction
The Woven EndoBridge Intrasaccular Therapy (WEB-IT) Study is a pivotal, prospective, single-arm, investigational device exemption study designed to evaluate the safety and effectiveness of the WEB device for the treatment of wide-neck bifurcation aneurysms.
Methods
One-hundred and fifty patients with wide-neck bifurcation aneurysms were enrolled at 21 US and six international centers. Angiograms from the index procedure, and 6-month and 1-year follow-up visits were all reviewed by a core laboratory. All adverse events were reviewed and adjudicated by a clinical events adjudicator. A data monitoring committee provided oversight during the trial to ensure subject safety.
Results
One-hundred and forty-eight patients received the WEB implant. One (0.7%) primary safety event occurred during the study—a delayed ipsilateral parenchymal hemorrhage—on postoperative day 22. No primary safety events occurred after 30 days through 1 year. At the 12-month angiographic follow-up, 77/143 patients (53.8%) had complete aneurysm occlusion. Adequate occlusion was achieved in 121/143 (84.6%) subjects.
Conclusions
The prespecified safety and effectiveness endpoints for the aneurysms studied in the WEB-IT trial were met. The results of this trial suggest that the WEB device provides an option for patients with wide-neck bifurcation aneurysms that is as effective as currently available therapies and markedly safer.
Trial registration number
NCT02191618
Background
Flow disruption with the WEB is an innovative endovascular approach for treatment of wide-neck bifurcation aneurysms. Initial studies have shown a low complication rate with good efficacy.
Purpose
To report clinical and anatomical results of the WEB treatment in the cumulative population of three Good Clinical Practice (GCP) studies: WEBCAST (WEB Clinical Assessment of Intrasaccular Aneurysm), French Observatory, and WEBCAST-2.
Methods
WEBCAST, French Observatory, and WEBCAST-2 are single-arm, prospective, multicenter, GCP studies dedicated to the evaluation of WEB treatment. Clinical data were independently evaluated. Postoperative and 1-year aneurysm occlusion was independently evaluated using the 3-grade scale: complete occlusion, neck remnant, and aneurysm remnant.
Results
The cumulative population comprised 168 patients with 169 aneurysms, including 112 female subjects (66.7%). The patients' ages ranged between 27 and 77 years (mean 55.5±10.2 years). Aneurysm locations were middle cerebral artery in 86/169 aneurysms (50.9%), anterior communicating artery in 36/169 (21.3%), basilar artery in 30/169 (17.8%), and internal carotid artery terminus in 17/169 (10.1%). The aneurysm was ruptured in 14/169 (8.3%). There was no mortality at 1 month and procedure/device-related morbidity was 1.2% (2/168). At 1 year, complete aneurysm occlusion was observed in 81/153 aneurysms (52.9%), neck remnant in 40/153 aneurysms (26.1%), and aneurysm remnant in 32/153 aneurysms (20.9%). Re-treatment was carried out in 6.9%.
Conclusions
This series is at the moment the largest prospective, multicenter, GCP series of patients with aneurysms treated with WEB. It shows the high safety and good mid-term efficacy of this treatment.
Clinical trial registration
French Observatory: Unique identifier (NCT18069); WEBCAST and WEBCAST-2: Unique identifier (NCT01778322).
Background and purpose:
Flow diverters have been increasingly used lately in off-label, distal intracranial aneurysm treatments. Our aim was to evaluate the effectiveness of flow diverters in the treatment of middle cerebral artery bifurcation aneurysms and to analyze midterm angiographic patterns of regional flow modifications for safety and clinical outcomes.
Materials and methods:
Consecutive patients treated from January 2010 to December 2014 by the authors by using endovascular flow-diverting stents for MCA bifurcation aneurysms were evaluated retrospectively with prospectively maintained data. All patients had been followed for at least 12 months after treatment, with at least 2 control angiograms; regional flow-related angiographic modifications were registered by using a new angiographic outcome scale for flow diverters. Data were analyzed with emphasis on procedure-related events, angiographic results, and clinical outcome.
Results:
Fifty-eight patients were included in the study, with 63 MCA bifurcation aneurysms; 13 of these were large and giant. Pretreatment mRS was 0 for 12 patients (20.7%), 1 for 41 (70.7%), and 2 for 5 patients (8.6%). Six-month control revealed mRS 0-2 for 57 (98.3%) patients and 3 for 1 (1.7%) patient. Procedure-related morbidity and mortality were 8.6% (5/58) and 0%, respectively. From 95% of still circulating immediate postprocedure angiographic outcomes, 68% progressed to aneurysm occlusion at 6 months and 95%, to occlusion at 12 months, with a 0% aneurysm rupture rate.
Conclusions:
Flow diverters seem to be an effective treatment alternative for complex MCA bifurcation aneurysms, with reasonable complication rates. Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture.
Introduction
The Woven EndoBridge (WEB) system is an innovative device under evaluation for its capacity to treat wide-neck bifurcation intracranial aneurysms. The purpose of this study is to evaluate the use of the different occlusion scales available in clinical practice.
Methods
Seven WEB-experienced neurointerventionalists were provided with 30 angiographic follow-up data sets and asked to grade each evaluation point according to the Bicêtre Occlusion Scale Score (BOSS), firstly based on DSA images only then using additional C-Arm VasoCT analysis. This BOSS evaluation was then converted into the WEB Occlusion Scale (WOS) and into a dichotomized scale (complete occlusion or not). To estimate the inter-rater agreement among the seven raters, an overall kappa coefficient [1] and its standard error (SE) were computed.
Results
Using the five-grade BOSS, raters showed “moderate” agreement (kappa = 0.56). Using the three-grade WOS, agreement appeared slightly better (kappa = 0.59). Strongest inter-rater agreement was observed with a dichotomized version of the scale (complete occlusion or not), which enabled an “almost perfect” agreement (kappa = 0.88). VasoCT consistently enhanced the agreement particularly with regards depicting intra-WEB residual filling.
Conclusion
The WOS is a consistent means to angiographically evaluate the WEB device efficiency. But the five-grade BOSS scale allows to identify aneurysm subgroups with differing risks of recurrence and/or rehemorrhage, which needs to be separated especially at the initial phase of evaluation of this innovative device. The additional use of VasoCT allows better inter-rater agreement in evaluating occlusion and specially in depicting intra-WEB persistent filling.
A new classification is proposed for cerebral aneurysms treated with any endovascular technique, for example, coiling with or without adjunctive devices, flow diversion, intrasaccular flow modifiers, or any combination of the above. Raymond-Roy Occlusion Classification is expanded with novel subgroups such as class 1 represents complete occlusion and is subdivided if a branch is integrated to, or originated from, the aneurysm sac; class 2 represents neck filling; class 3 represents incomplete occlusion with aneurysm filling as in the previous classification; and class 4 describes the immediate postoperative status after extra- or intrasaccular flow modification treatment. A new concept, "stable remodeling," is included as class 5, which represents filling in the neck region that stays unchanged or reduced, as shown with at least 2 consecutive control angiographies, at least 6 months apart, for not <1 year, or the remodeled appearance of a dilated and/or tortuous vessel in continuation with the parent artery without sac filling.
© 2016 American Society of Neuroradiology.
The ability of polymer-modified coils to promote stable aneurysm occlusion after endovascular treatment is not well-documented. Angiographic aneurysm recurrence is widely used as a surrogate for treatment failure, but studies documenting the correlation of angiographic recurrence with clinical failure are limited. This trial compares the effectiveness of Matrix(2) polyglycolic/polylactic acid biopolymer-modified coils with bare metal coils and correlates the angiographic findings with clinical failure (ie, target aneurysm recurrence), a composite end point that includes any incident of posttreatment aneurysm rupture, retreatment, or unexplained death.
This was a multicenter randomized noninferiority trial with blinded end point adjudication. We enrolled 626 patients, divided between Matrix(2) and bare metal coil groups. The primary outcome was target aneurysm recurrence at 12 ± 3 months.
At 455 days, at least 1 target aneurysm recurrence event had occurred in 14.6% of patients treated with bare metal coils and 13.3% of Matrix(2) (P = .76, log-rank test) patients; 92.8% of target aneurysm recurrence events were re-interventions for aneurysms that had not bled after treatment, and 5.8% of target aneurysm recurrence events resulted from hemorrhage or rehemorrhage, with or without retreatment. Symptomatic re-intervention occurred in only 4 (0.6%) patients. At 455 days, 95.8% of patients with unruptured aneurysms and 90.4% of those with ruptured aneurysms were independent (mRS ≤ 2). Target aneurysm recurrence was associated with incomplete initial angiographic aneurysm obliteration, presentation with rupture, and a larger aneurysmal dome and neck size.
Tested Matrix(2) coils were not inferior to bare metal coils. Endovascular coiling of intracranial aneurysms was safe, and the rate of technical success was high. Target aneurysm recurrence is a promising clinical outcome measure that correlates well with established angiographic measurements.
Aneurysmal subarachnoid hemorrhage (SAH) is a rare but devastating form of stroke. Endovascular therapy has been criticized for its higher rate of recanalization and retreatment. The safety and predictors of retreatment are unknown. We report the clinical outcomes, imaging outcomes and predictors for aneurysm retreatment after initial endovascular embolization.
We identified patients who underwent endovascular retreatment from July 2005 through November 2011. Aneurysm and patient data were collected. Periprocedural complications were reported as intraoperative perforation (IOP) or thromboembolic event (TEE). Aneurysm and patient characteristics were compared between aneurysms requiring retreatment and those not requiring retreatment to evaluate aneurysm retreatment predictors.
A total of 111/871 (13%) aneurysms underwent retreatment. Two (0.2%) were retreated for recurrent acute SAH, 82 (74%) aneurysms were located in the anterior circulation, 47 (42%) required stent and 5 (5%) required balloon assist during retreatment. There were a total of 5 (5%) IOP and 6 (5%) TEE from which 2 (2%) and 1 (1%) were symptomatic, respectively. Overall symptomatic events rate were 2.7%. Patients were followed up for an average of 15±14 months. Seven (0.8%) aneurysms required a second retreatment without any recurrent SAH. Multivariable analysis revealed an OR for aneurysms requiring retreatment of 2.965 for aneurysms presenting as aneurysmal SAH, 1.791 for aneurysms in the posterior circulation and 1.053 for aneurysms with large dome size.
Aneurysm retreatment is a safe option without a significant increase in morbidity or mortality. SAH, posterior circulation aneurysms and larger aneurysm dome size are predictors of aneurysms requiring retreatment.
Background
The Woven EndoBridge (WEB) device is a novel intrasaccular flow disruptor tailored for bifurcation aneurysms. We aim to describe the degree of aneurysm occlusion at the latest follow-up, and the rate of complications of aneurysms treated with the WEB device stratified according to rupture status.
Methods
Our data were taken from the WorldWideWeb Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups: ruptured and unruptured. We compared clinical and radiologic outcomes of both groups. Propensity score matching (PSM) was done to match according to age, gender, bifurcation, location, prior treatment, neck, height, dome width, daughter sac, incorporated branch, pretreatment antiplatelets, and last imaging follow-up.
Results
The study included 676 patients with 691 intracranial aneurysms (529 unruptured and 162 ruptured) treated with the WEB device. The PSM analysis had 55 pairs. In both the unmatched (85.8% vs 84.3%, p=0.692) and matched (94.4% vs 83.3%, p=0.066) cohorts there was no significant difference in the adequate occlusion rate at the last follow-up. Likewise, there were no significant differences in both ischemic and hemorrhagic complications between the two groups. There was no documented aneurysm rebleeding after WEB device implantation.
Conclusion
There was no significant difference in both the radiologic outcomes and complications between unruptured and ruptured aneurysms. Our findings support the feasibility of treatment of ruptured aneurysms with the WEB device.
Background
Woven EndoBridge (WEB) devices are becoming a reliable option for the treatment of wide-neck bifurcation aneurysms, but clear predictive factors are still missing to understand the one in five aneurysm remnant rate.
Objective
To evaluate occlusion outcomes after WEB treatment to identify potential determinants of aneurysm occlusion.
Methods
A single-center database with consecutive aneurysms treated with WEB between July 2012 and October 2021 was reviewed for potential determinants of aneurysm adequate occlusion (defined as a Bicêtre Occlusion Scale Score (BOSS) of 0, 0’, 1 or 2), through univariate and multivariable analysis. Patients without angiographic follow-up were excluded.
Results
215 of 247 individual aneurysms were included in the final analysis, of which 59 (27%) were ruptured. Mean age of patients was 56 years (range 23–90 years) and 65% were female. Mean angiographic follow-up was at 18 months (range 3–97 months). Adequate and complete occlusion were achieved in 171/215 (79.5%) and 135/215 (62.8%) of cases, respectively. Aneurysm irregular shape (aOR=0.42, 95% CI 0.20 to 0.88; p=0.02), aneurysm height (aOR=0.79, 95% CI 0.66 to 0.94; p<0.01), and WEB shape modification (aOR=0.98, 95% CI 0.97 to 1.00; p=0.02) were all independent predictors of aneurysm recurrence, whereas the WEB oversizing ratio (WEB width/aneurysm mean width) (aOR=16.4, 95% CI 1.4 to 266.7; p=0.04) was an independent predictor of adequate occlusion.
Conclusion
In this study we demonstrated that a width oversizing strategy of the WEB device was an independent predictor of aneurysm angiographic occlusion. Conversely, aneurysm height, irregular aneurysm, and WEB shape modification were all independent determinants of angiographic aneurysm remnant. These results may help to select aneurysms suitable for the WEB device and WEB sizing.
Background:
We aim to compare the safety and efficacy of WEB with coiling for acutely ruptured aneurysms.METHODS: All consecutive ruptured aneurysms with width suitable for WEB (2-10 mm) treated over 5 years (1/1/2015 to 31/12/2019) were included. We recorded WFNS, Fisher grade, patient demographics and aneurysm characteristics (size, location, D/W and aspect ratio, lobulation). Primary endpoints were mRS status at 3 months, aneurysm occlusion on latest available imaging follow-up, retreatment rate and procedural complications. We applied propensity score matching using aneurysm morphology (size, D/N ratio, ASPECT ratio and lobulation) to optimise matching for WEB versus coil comparison and minimise the effects of confounding.
Result:
A total of 493 patients were identified, 97 treated with the WEB device. 1:1 propensity score matching was used to establish a matched group of 97 patients treated with coiling. The WEB arm showed 3% procedural complication rate, with no haemorrhagic complications and use of adjunctive device in 4%. Satisfactory occlusion on follow-up (mean 14 months) was 79%, with 19% retreatment rate. The coil arm had 8% complication rate, with use of an adjunctive device in 52% of cases (balloon 44%, stent 8%). Satisfactory occlusion on follow-up (mean 22 months) was 90%, with 8% retreatment rate.
Conclusion:
Treatment of ruptured wide-necked bifurcation aneurysms with WEB has a lower complication rate than coiling with high rate of satisfactory occlusion. However, there was a higher retreatment rate when compared with patients treated with coiling. An adjunct device (balloon or stent), was used in over 50% of aneurysms in the coiling group.
Background:
The Woven EndoBridge (WEB) device (Terumno Corp. [parent company of Microvention]) was approved by the U.S. Food and Drug Administration as the first intrasaccular device for intracranial aneurysm treatment in December 2018. Its use has become more common since then, but both trial results and postmarket experiences have raised questions about the efficacy in achieving complete aneurysm obliteration. Retreatment after WEB embolization has not been extensively discussed.
Objective:
To discuss the incidence and retreatment of aneurysms after initial WEB embolization.
Methods:
Retrospective review across 13 institutions identified all occurrences of WEB retreatment within neurovascular databases. Details regarding demographics, aneurysm characteristics, treatment considerations, clinical outcomes, and aneurysm occlusion were obtained and analyzed.
Results:
Thirty aneurysms were retreated in 30 patients in a cohort of 342 WEB-treated aneurysms. The retreatment rate was 8.8%. Endovascular methods were used for 23 cases, and 7 were treated surgically. Two aneurysms presented with rehemorrhage after initial WEB embolization. Endovascular treatments included stent-assisted coiling (12), flow diversion (7), coiling (2), PulseRider (Johnson & Johnson)-assisted coiling (1), and additional WEB placement (1). Surgical treatments included primary clipping (6) and Hunterian ligation (1). There were no major complications within the study group.
Conclusion:
WEB retreatments were successfully performed by a variety of techniques, including stent-assisted coiling, clipping, and flow diversion as the most common. These procedures were performed safely with subsequent obliteration of most aneurysms. The potential need for retreatment of aneurysms should be considered during primary WEB treatments.
Background:
The treatment of wide-necked and bifurcation aneurysms has become a common indication for the Woven Endobridge (WEB) device. In many instances, WEB embolization fails and retreatment strategies for the recanalized aneurysms have not been established and may be challenging.
Objective:
To report an experience with retreatment strategies after WEB failure in 7 cases involving various aneurysm shapes, sizes, and location using multiple strategies including endovascular modalities and microsurgical clip ligation.
Methods:
Data were retrospectively collected from 1 high-volume cerebrovascular center for 7 patients treated with a WEB device for an aneurysm who subsequently required retreatment for that same aneurysm from 2015 through January 2021.
Results:
We identified 7 patients with WEB recurrences over a period of 6 years. Four patients initially presented with incidental findings, whereas 3 patients presented with subarachnoid hemorrhage. One patient was lost to follow-up and presented with a rerupture, whereas the 6 other patients were diagnosed with routine follow-up. Two patients received clip ligation, 2 had simple coil embolization, 1 had stent-assisted coil embolization, 1 had a flow-diverting stent, and 1 patient required 2 retreatments; he received stent-assisted coil embolization for the first retreatment and a simple coil embolization for the second retreatment. All patients had excellent angiographic outcomes and no complications.
Conclusion:
The authors conclude that aneurysm recurrence after WEB is very diverse, and no single modality can properly address all recurrences. Rather, an individualized approach based on aneurysm features, neurointerventionalist expertise, and patient preference should be implemented.
BACKGROUND: The Woven EndoBridge device has been increasingly used to treat wide-neck aneurysms, particularly ruptured ones.
PURPOSE: Our aim was to investigate the safety and efficacy of the Woven EndoBridge device in the treatment of ruptured intracranial aneurysms.
DATA SOURCES: All studies evaluating the outcomes of Woven EndoBridge device use in the treatment of ruptured intracranial aneurysms from inception through 2020 were searched on Ovid Evidence-Based Medicine Reviews, EMBASE, MEDLINE, Scopus, and the Web of Science Core Collection.
STUDY SELECTION: Eighteen studies encompassing 487 patients with 496 ruptured aneurysms treated with the Woven EndoBridge device were included.
DATA ANALYSIS: We studied rates of rerupture and retreatment, angiographic outcomes at the last follow-up point, complications, and mortality rates. Data were collected on anticoagulation and antiplatelet use. Meta-analysis was performed using the random effects model.
DATA SYNTHESIS: The rate of late rebleeding was 1.1% (95% CI, 0.1%–2.1%). The treatment-related perioperative complication rate and the overall clinical complication rate were 13.2% (95% CI, 9.2%–17.2%) and 3.2% (95% CI, 1.6%–4.7%), respectively. Thirteen hemorrhagic (2%; 95% CI, 0.8%–3.3%) and 41 thromboembolic (6.8%; 95% CI, 4.6%–9%) complications occurred. Favorable clinical outcomes were achieved in 85% of patients. Procedure-related mortality and overall mortality rates were 2.1% (95% CI, 0.8%–3.3%) and 11.5% (95% CI, 7%–16%), respectively. At last follow-up, an adequate occlusion rate was 87.3% (95% CI, 82.1%–92.4%) and the retreatment rate was 5.1% (95% CI, 3%–7.3%).
LIMITATIONS: Our meta-analysis is limited by selection bias and high heterogeneity.
CONCLUSIONS: This meta-analysis demonstrated the safety and efficacy of the Woven EndoBridge device in the management of ruptured aneurysms, but further studies are needed.
Background
The Woven EndoBridge (WEB) shape modification (WShM) during follow-up may be a potential cause of poor angiographic outcomes. WShM predisposing factors have not yet been determined. Our systematic use of rotational cone beam computed tomography (VasoCT) imaging during follow-up allowed us to perform the first quantitative analysis of the shape of WEBs over time. Our goal was to identify possible strategies to reduce the occurrence of this phenomenon.
Methods
All patients treated in our hospital with a WEB device between October 2015 and January 2019 were included. Using VasoCT acquisitions, systematically performed after implantation and during follow-up, we analyzed WEB morphology. WShM was defined as the percentage reduction in the distance between the two WEB markers.
Results
Sixty-three aneurysms treated with a WEB device were finally included in this analysis. At the last follow-up (mean 15.5 months), mean WShM was 48%±24. The mean WShM was significantly higher in the aneurysm recurrence group than in the adequate occlusion group (51±6.5% vs 36±3.4%, difference 15% points (95% CI 0.7 to 30); p<0.05). Conversely, the extent of WShM did not directly correlate with occlusion rates. Indeed, 32% of completely occluded aneurysms presented severe WShM (≥50%). Importantly, the absence of WShM guaranteed complete occlusion in our study (n=12). We demonstrated that oversizing the width of the WEB significantly correlated with WShM reduction during follow-up (r=−0.38, p=0.002).
Conclusion
WShM can be partly overcome by use of an appropriate width oversizing strategy that could lead to improved angiographic results.
Background:
Tissue growth over covered branches is a leading cause of delayed thrombotic complications after flow-diverter stenting (FDS). Due to insufficient resolution, no imaging modality is clinically available to monitor this phenomenon.
Objective:
To evaluate high-frequency optical coherence tomography (HF-OCT), a novel intravascular imaging modality designed for the cerebrovascular anatomy with a resolution approaching 10 microns, to monitor tissue growth over FDS in an arterial bifurcation model.
Methods:
FDS were deployed in a rabbit model (n = 6), covering the aortic bifurcation. The animals were divided in different groups, receiving dual antiplatelet therapy (DAPT) (n = 4), aspirin only (n = 1), and no treatment (n = 1). HF-OCT data were obtained in vivo at 3 different time points in each animal. For each cross-sectional image, metal and tissue coverage of the jailed ostium was quantified. Scanning electron microscopy images of harvested arteries were subsequently obtained.
Results:
Good quality HF-OCT data sets were successfully acquired at implant and follow-up. A median value of 41 (range 21-55) cross-sectional images were analyzed per ostium for each time point. Between 0 and 30 d after implant, HF-OCT analysis showed a significantly higher ostium coverage when DAPT was not given. After 30 d, similar growth rates were found in the DAPT and in the aspirin group. At 60 d, a coverage of 90% was reached in all groups.
Conclusion:
HF-OCT enables an accurate visualization of tissue growth over time on FDS struts. The use of FDS in bifurcation locations may induce a drastic reduction of the jailed-branch ostium area.
Objective
To investigate factors affecting recurrence and effects and safety of endovascular retreatment for aneurysms recurrent after embolization.
Methods
Among 815 aneurysms treated with embolization, recurrence was in 114 aneurysms (14.0%). Forty-three recurrent aneurysms were managed with re-embolization. Procedural complications, angiographic, and clinical results of retreatment were analyzed.
Results
Patients with recurrent aneurysms were significantly ( P < 0.01) younger than without recurrence (51.09 ± 10.46 vs. 53.88 ± 9.61 years). Recurrent aneurysms ( n = 114) were significantly ( P = 0.00) greater (11.12 ± 8.35 vs. 5.81 ± 3.44 mm) with a significantly ( P = 0.00) greater neck (4.34 ± 2.26 vs. 2.90 ± 1.44 mm) than without recurrence. The rupture status of aneurysms significantly ( P = 0.00) affected recurrence at follow-up. Significantly ( P = 0.00) more aneurysms without recurrence were treated with advanced embolization techniques (81.0% vs. 62.3%) and got complete occlusion at the first embolization than those with recurrence (93.7% vs. 36.8%). In treating 43 recurrent aneurysms, stent-assisted recoiling was used in 48.8% in the first retreatment and 50% in the second and third retreatment procedures. Angiographic follow-up in 38 (88.4%) cases showed complete or near complete occlusion in 30 aneurysms, with the rest eight aneurysms experiencing a second recurrence (21.1%). Of the eight aneurysms with the second recurrence, five underwent the second endovascular retreatment, with complete aneurysm occlusion achieved in three cases (60%), near-complete occlusion in one (20%), and incomplete occlusion in one case at immediate angiography and six-month follow-up. Procedure-related complications occurred in three patients.
Conclusions
Endovascular retreatment of recurrent previously coiled aneurysms is safe and effective even though advanced embolization techniques are frequently involved especially for large and giant aneurysms.
Background and purpose:
Flow disruption with the Woven EndoBridge is increasingly used for the treatment of intracranial aneurysms. We examined factors leading to aneurysm occlusion and Woven EndoBridge shape change during a midterm follow-up.
Materials and methods:
Patients with a minimum 12-month angiographic follow-up were included. Through a univariate and multivariate analysis, independent predictors of adequate occlusion (Raymond-Roy 1/Raymond-Roy 2) and Woven EndoBridge shape change (decrease of the height of the device) were assessed.
Results:
Eighty-six patients/aneurysms were included. The aneurysm mean size was 5.5 mm (range, 3-11.5 mm). The most common locations were the MCA (43/86 = 50%), basilar tip (13/86 = 15.1%), and anterior communicating artery (12/86 = 14%). Twenty-one patients (21/86 = 24%) had acute SAH. Immediate and long-term Raymond-Roy 1/Raymond-Roy 2 occlusion rates were 49% (42/86) and 80% (68/86), respectively. Woven EndoBridge shape change was detected among 22% (19/86) of cases. At binary logistic regression, wide ostium (≥4 mm) (OR = 0.2; 95% CI, 0.01-1; P = .04) and regular aneurysm morphology (OR = 5.9; 95% CI, 1.4-24; P = .01) were independent factors of incomplete and adequate aneurysm occlusion, respectively. In addition, irregular morphology (OR = 5.4; 95%CI , 1.4-19; P = .01) and a wide ostium (OR = 9.8; 95% CI, 1.6-60; P = .03) significantly increased the probability of the Woven EndoBridge shape change. Decrease of the Woven EndoBridge height was more common among incompletely occluded aneurysms (6/12 = 50% versus 13/74 = 17.5%), but it was not an independent prognosticator of occlusion at the multivariate model.
Conclusions:
The likelihood of good occlusion was 5 times lower in the presence of a wide ostium, whereas aneurysms with regular morphology were 6 times more likely to be occluded. Woven EndoBridge shape modification was strongly influenced by the aneurysm shape and ostium size, and it was not independently associated with the angiographic occlusion.
Objective
Incomplete aneurysm occlusions and re-treatment rates of 52 and 10–30%, respectively, have been reported following endovascular treatment of intracranial aneurysms, raising clinical concerns regarding procedural efficacy. We compare residual, recurrence and re-treatment rates subject to different endovascular techniques in both ruptured and unruptured intracranial aneurysms at a comprehensive state-wide tertiary neurovascular centre in Australia.
Methods
Medical records, procedural and follow-up imaging studies of all patients who underwent endovascular treatment for intracranial aneurysms between July 2010 and July 2017 were reviewed retrospectively. Residuals, recurrences and re-treatment rates were assessed regarding initial aneurysm rupture status and applied endovascular technique: primary coiling, balloon- and stent-assisted coiling and flow diversion.
Results
Among 233 aneurysms, residual, recurrence and re-treatment rates were 27, 11.2 and 9.4%, respectively. Compared with unruptured aneurysms, similar residual and recurrence (p > .05), but higher re-treatment rates (4.5% vs. 19%; p < .001) were found for ruptured aneurysms. Residual, recurrence and re-treatment rates were: 13.3, 16 and 12% for primary coiling; 12, 12 and 10.7% for balloon-assisted coiling; 14.9, 7.5 and 4.5% for stent-assisted coiling; 91.9, 0 and 5.4% for flow diversion. Stent-assistance and flow-diversion were associated with lower recurrence and re-treatment rates, when compared with primary- and balloon-assisted coiling (p < .05).
Conclusions
Residuals and recurrences after endovascular treatment of intracranial aneurysms are less common than previously reported. Stent assistance and flow diversion seem associated with reduced recurrence- and re-treatment rates, when compared with primary- and balloon-assisted coiling. Restrained use of stents in ruptured aneurysms may be a contributing factor for higher recurrence/retreatment rates compared to unruptured aneurysms.
Endosaccular flow disruption is an innovative method of treating wide-necked complex aneurysms. Currently four types of devices have obtained the CE mark for use within Europe. These are the Woven EndoBridge device (WEB), the Luna Aneurysm Embolization System, the Medina Embolic Device (Medtronic), and the Contour Neurovascular System. The aim of this article is to provide an overview of these devices and to summarize the evidence in the literature pertaining to the treatment of intracranial aneurysms with them.
Background
The Woven EndoBridge (WEB) device is a novel endovascular tool for the treatment of wide-necked intracranial aneurysms.
Objective
To evaluate factors influencing aneurysm occlusion and aneurysm recurrence after WEB embolization.
Methods
A total of 113 patients (mean age 58.9±11.9 years) with 114 aneurysms (mean size 8.6±4.6 mm) were successfully treated with the WEB device at three German tertiary care centers between May 2011 and February 2018. Aneurysm occlusion was evaluated using the Raymond-Roy occlusion classification. We retrospectively collected patient characteristics, anatomical details, and procedural aspects and evaluated their impact on aneurysm occlusion and recurrence.
Results
Of 98 patients available for a 6-month angiographic follow-up, complete occlusion was achieved in 62.2%, neck remnants in 21.4%, and aneurysm remnants in 16.3%. Aneurysm recurrence occurred in 15.3%. Initial partial aneurysm thrombosis, recurrent aneurysms, aneurysm size, and simultaneous treatment by WEB and coil were associated with aneurysm remnants (p<0.05). Initial partial aneurysm thrombosis, increasing aneurysm size, and treatment by WEB and coil also predicted aneurysm recurrence (p<0.05).
In the subgroup analysis of 71 aneurysms treated with WEB only, initial incomplete occlusion and male sex were associated with aneurysm remnants (p<0.05), while aneurysm height correlated with aneurysm recurrence (p=0.008).
Conclusions
The WEB provides a high rate of adequate occlusion even in a subset of complex wide-necked intracranial aneurysms. Anatomic results tend to be less favourable in large and partially thrombosed aneurysms and after treatment with WEB and coil.
Background
Woven Endobridge (WEB) embolization is a safe and efficient technique for endovascular treatment of intracranial aneurysms. However, the management of aneurysm recurrence after WEB placement has not been well described to date. We present our multicenter experience of endovascular retreatment of aneurysm recurrence after WEB implantation.
Methods
This is a multicenter study of patients who underwent endovascular retreatment after WEB implantation in three German tertiary care centers. Treatment strategies, complications, and angiographic outcome were retrospectively assessed.
Results
Among 122 aneurysms treated with the WEB device, 15 were retreated. Of these, six were initially treated with the WEB only, two were pretreated by coiling, and seven large aneurysms were treated in a multimodality approach. Ten were true aneurysm remnants and five were neck remnants. The reasons for retreatment were WEB migration (n=6), initial incomplete occlusion (n=5), and WEB compression (n=4). Retreatment strategies included coiling (n=4), stent-assisted coiling (n=7
)
, flow diversion (n=3), and placement of an additional WEB (n=1). All procedures were technically successful and there were no procedure-related complications. Among 11 patients available for follow-up after retreatment, three were retreated again. At last angiographic follow-up, available in 11/15 cases at a median of 23 months, complete occlusion was obtained in eight cases and neck remnants in three.
Conclusions
This pilot study shows that endovascular retreatment of recurrent or residual aneurysms after WEB implantation can be done safely and can achieve adequate occlusion rates.
Background and purpose:
Intrasaccular flow diverters are increasingly being used in the treatment of wide-neck and bifurcation aneurysms. We performed a systematic review and meta-analysis of existing literature on the Woven EndoBridge device in the treatment of intracranial aneurysms.
Materials and methods:
A comprehensive literature search was performed through October 1, 2015. We extracted information on baseline aneurysm and patient characteristics. Outcomes studied included immediate and midterm (>3 month) angiographic outcomes (complete occlusion as well as adequate occlusion, defined as complete occlusion or neck remnant), aneurysm retreatment, intraoperative rupture, perioperative morbidity and mortality, thromboembolic complications, and treatment failure. Meta-analysis was performed by using the random-effects model.
Results:
Fifteen uncontrolled series were included in this analysis, including 565 patients with 588 aneurysms, of which 127 were ruptured. Initial complete and adequate occlusion rates were 27% (95% CI, 15%-39%) and 59% (95% CI, 39%-78%), respectively. Midterm complete and adequate occlusion rates after a median of 7 months were 39% (95% CI, 26%-52%) and 85% (95% CI, 78%-91%), respectively. Perioperative morbidity and mortality rates were 4% (95% CI, 1%-8%) and 1% (95% CI, 0%-2%), respectively. Midterm adequate occlusion rates for ruptured aneurysms were 85% (95% CI, 67%-98%), compared with 84% (95% CI, 72%-94%) for unruptured aneurysms (P = .89). Patients with ruptured aneurysm had similar rates of perioperative morbidity to patients with unruptured aneurysm (2%; 95% CI, 0%-26% versus 2%; 95% CI, 0%-6%, respectively; P = .35).
Conclusions:
Early evidence derived from uncontrolled studies suggests that Woven EndoBridge treatment has a good safety profile and promising rates of adequate occlusion, especially given the complexity of aneurysms treated. Further prospective clinical trials are needed to confirm these results and better define the risks and benefits of use of the Woven EndoBridge device in treating wide-neck and wide-neck bifurcation aneurysms.
Endovascular treatment of intracranial aneurysms is less invasive than surgical repair but poses a higher risk for aneurysm recurrence, which may necessitate retreatment, thus adding to the long-term risk. Cerebrovascular neurosurgeons from 8 institutions in the United States and Puerto Rico collaborated to assess the risk of retreatment for residual or recurrent aneurysms after the initial endovascular coiling.
Data were prospectively recorded for 311 patients with coiled intracranial aneurysms who underwent 352 retreatment procedures after angiographic or clinical recurrence (hemorrhage after initial coiling). Results analyzed included procedural complications and procedure-related morbidity. Morbidity was classified as major (modified Rankin scale score > 3) or minor, and temporary (<30 days) or permanent (>30 days).
Retreatment mortality was 0.85% per procedure and 0.96% per patient. Treatment-related rates were 0.32% per patient (0.28% per procedure) for permanent or temporary major disability; 1.29% for permanent minor disability (1.14% per procedure); and 1.61% for temporary minor disability (1.42% per procedure). Total risk for death or permanent major disability was 1.28% per patient and 1.13% per procedure.
Retreatment poses a low risk for patients with recurrences of intracranial aneurysms after initial coiling; this risk is smaller than that posed by the initial endovascular therapy. The risk of disability associated with retreatment for aneurysm recurrence after coiling must be considered prospectively in the choice of treatment but with the recognition that its effects are low in the overall management risk.
The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups.
We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment.
Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used.
At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.
Your Nâme: Manuscript Title: Manuscript Number (if known): Management of aneury smal recurrences after Woven EndoBridge {WEB)treatments Click or tap here to enter text
- Laurent Pierot Dâte
Laurent Pierot
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Management of aneury smal recurrences after Woven EndoBridge {WEB)treatments
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Predicting factors of angiographic aneurysm occlusion after treatment with the Woven EndoBridge device: a single-center experience with midterm follow-up
- Cagnazzo