Jorge A Roa1, Santiago Ortega-Gutierrez2, Mario Martinez-Galdamez3, Alberto Maud4, Guilherme Dabus5, Avery Pazour6, Sudeepta Dandapat6, Miguel Schüller Arteaga3, Jorge Galvan Fernandez3, Diego Paez-Granda7, Vladimir Kalousek8, Roger Barranco Pons9, Ashkan Mowla10, Gary Duckwiler10, Viktor Szeder10, Pascal Jabbour11, David M Hasan12, Edgar A Samaniego13. 1. Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. 2. Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. 3. Department of Interventional Neuroradiology and Endovascular Neurosurgery, Hospital Clínico Universitario, Valladolid, Spain. 4. Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA. 5. Miami Cardiac and Vascular Institute, Miami, Florida, USA. 6. Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. 7. Department of Neurology, Virgen de la Arrixaca University Hospital, Murcia, Spain. 8. University Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia. 9. Department of Neurointerventional Radiology, L'Hospitalet de Llobregat, Barcelona, Spain. 10. Division of Interventional Neuroradiology, Department of Radiology, University of California Los Angeles, Los Angeles, California, USA. 11. Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA. 12. Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. 13. Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA. Electronic address: edgarsama@gmail.com.
Abstract
BACKGROUND: Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. METHODS: Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. RESULTS: Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. CONCLUSIONS: Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.
BACKGROUND: Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. METHODS: Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. RESULTS: Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I-II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I-II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. CONCLUSIONS: Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery.
Authors: Jorge A Roa; Alberto Maud; Pascal Jabbour; Guilherme Dabus; Avery Pazour; Sudeepta Dandapat; Santiago Ortega-Gutierrez; Diego Paez-Granda; Vladimir Kalousek; David M Hasan; Edgar A Samaniego Journal: Front Neurol Date: 2020-05-07 Impact factor: 4.003
Authors: Mario Martínez-Galdámez; Miguel Schüller-Arteaga; Jorge Galván-Fernández; Vladimir Kalousek; Ezequiel Petra; Boris Pabón; Santiago Ortega-Gutiérrez; Paloma Jiménez-Arribas; Carlos Rodríguez-Arias Journal: Interv Neuroradiol Date: 2020-09-23 Impact factor: 1.610