Korean J Radiol.  2016 Oct;17(5):801-810. 10.3348/kjr.2016.17.5.801.

Stent-Assisted Coil Embolization of Vertebrobasilar Dissecting Aneurysms: Procedural Outcomes and Factors for Recanalization

• Jeon JP
• Cho YD
• Rhim JK
• Park JJ
• Cho WS
• Kang HS
• Kim JE
• Hwang G
• Kwon OK
• Han MH

• KMID: 2458074
• DOI: http://doi.org/10.3348/kjr.2016.17.5.801

Abstract

OBJECTIVE
Outcomes of stent-assisted coil embolization (SACE) have not been well established in the setting of vertebrobasilar dissecting aneurysms (VBDAs) due to the low percentage of cases that need treatment and the array of available therapeutic options. Herein, we presented clinical and radiographic results of SACE in patients with VBDAs.
MATERIALS AND METHODS
A total of 47 patients (M:F, 30:17; mean age ± SD, 53.7 ± 12.6 years), with a VBDA who underwent SACE between 2008 and 2014 at two institutions were evaluated retrospectively. Medical records and radiologic data were analyzed to assess the outcome of SACE procedures. Cox proportional hazards regression analysis was conducted to determine the factors that were associated with aneurysmal recanalization after SACE.
RESULTS
Stent-assisted coil embolization technically succeeded in all patients. Three cerebellar infarctions occurred on postembolization day 1, week 2, and month 2, but no other procedure-related complications developed. Immediately following SACE, 25 aneurysms (53.2%) showed no contrast filling into the aneurysmal sac. During a mean follow-up of 20.2 months, 37 lesions (78.7%) appeared completely occluded, whereas 10 lesions showed recanalization, 5 of which required additional embolization. Overall recanalization rate was 12.64% per lesion-year, and mean postoperative time to recanalization was 18 months (range, 3-36 months). In multivariable analysis, major branch involvement (hazard ratio [HR]: 7.28; p = 0.013) and the presence of residual sac filling (HR: 8.49, p = 0.044) were identified as statistically significant independent predictors of recanalization. No bleeding was encountered in follow-up monitoring.
CONCLUSION
Stent-assisted coil embolization appears feasible and safe for treatment of VBDAs. Long-term results were acceptable in a majority of patients studied, despite a relatively high rate of incomplete occlusion immediately after SACE. Major branch involvement and coiled aneurysms with residual sac filling may predispose to recanalization.

Keyword

Posterior circulation; Aneurysm; Dissecting aneurysm; Stents

MeSH Terms

Adult
Aged
Aneurysm, Dissecting/*therapy
Brain Infarction/etiology
Embolization, Therapeutic/adverse effects/*methods
Female
Follow-Up Studies
Humans
Intracranial Aneurysm/*therapy
Male
Middle Aged
Recurrence
Retreatment/methods
Retrospective Studies
Risk Factors
*Stents
Treatment Outcome
Vertebral Artery

Figure

• 

  Fig. 1 Flow diagram of subjects recruited for study. AICA = anterior inferior cerebellar artery, PICA = posterior inferior cerebellar artery, SACE = stent-assisted coil embolization, VA = vertebral artery

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  Fig. 2 Angiographic types of vertebrobasilar dissecting aneurysms. A. Circumferential type: sac encompasses parent artery by > 180° in three-dimensional image. B. Eccentric type: lateral dilatation.

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  Fig. 3 Illustrative case of ruptured VBDA incorporating major branch of PICA. A. 76-year-old female presenting with SAH. B. Angiography of right vertebral artery (VA) with proximal sac of fusiform aneurysm incorporating posterior inferior cerebellar artery (PICA) (note hypoplasia of contralateral VA): 6-Fr Envoy guiding catheter placed in distal right VA under general anesthesia. C. Enterprise stent 4.5 × 37 mm deployed across dissecting segment and suspected rupture point (arrows in B and C) successfully protected by coils, without compromise of PICA. SAH = subarachnoid hemorrhage

• 

  Fig. 4 Illustrative case of VBDA using down-the-barrel view. A. 41-year-old female presenting with SAH on CT. B. Angiography of left vertebral artery (VA) showing fusiform aneurysm with medullary branch arising from artery proximal to aneurysm; 6-Fr Envoy guiding catheter placed in distal left VA under general anesthesia and Enterprise stent 4.5 × 28 mm deployed across aneurysm for coil embolization. C. Down-the-barrel view (inner box) used during procedure to confirm patency of parent artery for successful embolization. D, E. Follow-up angiography (postoperative month 12) showing sustained occlusion of aneurysm, without recanalization. SAH = subarachnoid hemorrhage

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  Fig. 5 44-year-old female presenting with severe occipital headache. A, B. Angiography of right vertebral artery (VA) showing lateral protrusion of aneurysm and mild stenosis proximal to sac; 6-Fr Envoy guiding catheter placed in distal right VA under general anesthesia, two Enterprise stents 4.5 × 22 mm deployed across dissecting segment, and coiling done. C, D. Angiography post-procedure shows residual filling of aneurysm, but follow-up view (postoperative month 12) confirms complete occlusion of sac, without in-stent restenosis.

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