We prospectively collected procedure times, endovascular devices used, number of device passes, and periprocedural complications. Primary CA was the preferred first-line treatment modality in our center for patients with BAO. We used different aspiration catheters (ACE 60, 64 or 68, Penumbra Inc., Alameda, CA, USA) that were combined with stent retrievers (SR) (EMBOTRAP II, Cerenovus, Johnson and Johnson, Raynham, MA, USA; pREset, phenox GmbH, Bochum, Germany; Separator 3D, Penumbra Inc., Alameda, CA, USA) if a rescue strategy was necessary. In case an underlying high-grade stenosis of the vertebral or basilar artery had to be treated, we used balloon-mounted or self-expanding stents (Coroflex Blue, B. Braun Melsungen AG, Berlin, Germany; PRO-Kinetic Energy Explorer, Biotronik AG, Bülach, Switzerland; Neuroform Atlas, Stryker Neurovascular, Fremont, CA, USA; Enterprise, Codman Neuro, Johnson and Johnson, Raynham, MA, USA) combined with balloon angioplasty, if needed. We selected the type of anesthesia (procedural sedation or general anesthesia) in cooperation with the anesthetist and stroke neurologist based on stroke severity, cardiopulmonary stability, and patient cooperation. The patients were treated on a biplane angiography system (AlluraXper FD20/15, Philips Medical Systems, Hamburg, Germany) and then transferred to the neurological intensive care unit or stroke unit.
Neuroform atlas
Manufactured by Stryker
Sourced in United States
The Neuroform Atlas is a self-expanding, microcatheter-delivered stent used for the treatment of wide-necked, intracranial aneurysms. It is designed to provide a scaffold to assist in the coiling of the aneurysm.
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9 protocols using neuroform atlas
1
Endovascular Approach for Basilar Artery Occlusion
2
Stent-Assisted Coiling for Unsecured Aneurysms
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If the coiling was not secured by the balloon itself, we switched from a balloon- to stent-assisted coiling method (n=7). For that purpose, we used a stent (NeuroForm Atlas™; Stryker Neurovascular, Fremont, CA, USA) that could be deployed via the same balloon catheter without any difficulty (Fig. 4A –D ).
3
Intracranial Aneurysm Stent-Assisted Coiling
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This study was approved by the university hospital’s ethics commission (reference # 27–236 (8121) and 29–228 (8844)). Specific informed consent for this study was waived because the data were obtained from routine examinations and treatments and analyzed retrospectively. As also requested by the IRB, we posted a notice of the conduct of the study and gave the patients the opportunity to refuse participation. All patients with intracranial aneurysms were considered who received stent-assisted coiling with the closed cell stent Enterprise2 (Johnson & Johnson, Cerenovas, USA) or one of the open cell stents Neuroform EZ or Neuroform Atlas (Stryker, Fremont, California, USA) at our institution between June 2015 and November 2017 and who underwent angiographic imaging for confirmation of the stent deployment.
4
Comprehensive Stroke Care Cost Analysis
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The perspective of the U.S. healthcare system was adopted to calculate cumulative discounted costs in U.S.$. All costs were adjusted to 2022 values using a discount rate of 3%/year.
Hospital costs for acute stroke care as well as post-hospitalization costs within the first 365 days were included from a nation-wide cost analysis of acute stroke care costs by Mu et al. (16 (link)) Costs for EVT as well as long-term healthcare costs of stroke survivors were estimated according to a previous long-term projection of a patient cohort of n = 428 (12 (link)). Acute care costs of recurrent strokes were estimated based on Chambers et al. (17 (link)) Costs of additional stent placement was estimated, based on costs of the Neuroform Atlas® Stent (Stryker, United States). For sensitivity analysis, all costs were modulated using γ-distributions.
Hospital costs for acute stroke care as well as post-hospitalization costs within the first 365 days were included from a nation-wide cost analysis of acute stroke care costs by Mu et al. (16 (link)) Costs for EVT as well as long-term healthcare costs of stroke survivors were estimated according to a previous long-term projection of a patient cohort of n = 428 (12 (link)). Acute care costs of recurrent strokes were estimated based on Chambers et al. (17 (link)) Costs of additional stent placement was estimated, based on costs of the Neuroform Atlas® Stent (Stryker, United States). For sensitivity analysis, all costs were modulated using γ-distributions.
5
Cell-through Single-Catheter Stent-Assisted Coiling
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This retrospective study was approved by our Institutional Review Board, and the requirement for informed consent was waived. From March 2018, the Neuroform Atlas (Stryker Neurovascular, Fremont, USA) has been approved and used in our country. Since then, we treated 394 aneurysms (336 unruptured and 58 ruptured) in 359 patients with endovascular treatment. Among 197 aneurysms treated with SAC, there were 16 cases (all wide-necked unruptured aneurysms) treated with cell-through SAC using a single microcatheter, Excelsior SL-10 (Stryker Neurovascular). Among the 58 ruptured aneurysms during the same period, we tried to perform endovascular treatment other than using stents due to our results of stent-assisted coiling in ruptured aneurysms [2 (link)].
All the 16 cases underwent digital subtraction angiography (DSA) and rotational angiography (Philips Allura FD20 Clarity System, Philips Medical Systems, Best, The Netherlands) with three-dimensional reconstructions to characterize aneurysm and parent artery anatomy (Allura 3D-RA workstation, Philips Medical Systems). From these DSA results, proximal parent arteries, including the extracranial ICA or VA, were determined to use a smaller (< 6-Fr) guiding catheter due to its small-caliber, stenosis, or tortuous course. Wide-necked aneurysms were defined as having a neck width ≥ 4 mm or a dome-to-neck ratio of < 2 [2 (link), 3 (link)].
All the 16 cases underwent digital subtraction angiography (DSA) and rotational angiography (Philips Allura FD20 Clarity System, Philips Medical Systems, Best, The Netherlands) with three-dimensional reconstructions to characterize aneurysm and parent artery anatomy (Allura 3D-RA workstation, Philips Medical Systems). From these DSA results, proximal parent arteries, including the extracranial ICA or VA, were determined to use a smaller (< 6-Fr) guiding catheter due to its small-caliber, stenosis, or tortuous course. Wide-necked aneurysms were defined as having a neck width ≥ 4 mm or a dome-to-neck ratio of < 2 [2 (link), 3 (link)].
6
Retrospective Analysis of SACE Outcomes
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Prior to this study, its protocol was approved by the ethical committee of our institution. Of patients who had undergone SACE at our institution between January 2014 and December 2018, we retrospectively analyzed 57 patients who were able to be followed up (Table 1
7
Evaluating Cerebral Aneurysm Treatment Outcomes
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Our study group comprised 11 consecutive patients, including three men and eight
women. Patient age ranged from 56–77 years with a mean of 68.8 years. All the
patients underwent 3D-TOF MRA and VWI in one magnetic resonance (MR) examination
session after undergoing stent-assisted treatment between January 2018–May 2019.
The interval between DSA and MR imaging was a minimum of 1 day, a maximum of 10
days, and an average of 2.8 days. Ten patients underwent stent-assisted coil
embolization for a cerebral aneurysm. The locations of the cerebral aneurysms
were as follows: intracranial artery (ICA), 5; middle cerebral artery (MCA), 1;
anterior communicating artery (A-com), 1; vertebral artery (VA), 2; and basilar
artery (BA), 1. The remaining patient underwent PTA and stenting for symptomatic
MCA stenosis. The stents used for the treatments were as follows: Neuroform
Atlas (Stryker Neurovascular Fremont, California, USA), 4; LVIS (MicroVention,
California, USA), 5; LVIS Jr (MicroVention, California, USA), 1; and Enterprise
(Codman and Shurtleff, Miami, USA), 1. This study is a retrospective study using
MR images that were obtained in routine examinations, and there is no
information included in the submitted material that allows identification of the
patients. So, informed consent was not obtained. All research activities were
performed in accordance with the Declaration of Helsinki.
women. Patient age ranged from 56–77 years with a mean of 68.8 years. All the
patients underwent 3D-TOF MRA and VWI in one magnetic resonance (MR) examination
session after undergoing stent-assisted treatment between January 2018–May 2019.
The interval between DSA and MR imaging was a minimum of 1 day, a maximum of 10
days, and an average of 2.8 days. Ten patients underwent stent-assisted coil
embolization for a cerebral aneurysm. The locations of the cerebral aneurysms
were as follows: intracranial artery (ICA), 5; middle cerebral artery (MCA), 1;
anterior communicating artery (A-com), 1; vertebral artery (VA), 2; and basilar
artery (BA), 1. The remaining patient underwent PTA and stenting for symptomatic
MCA stenosis. The stents used for the treatments were as follows: Neuroform
Atlas (Stryker Neurovascular Fremont, California, USA), 4; LVIS (MicroVention,
California, USA), 5; LVIS Jr (MicroVention, California, USA), 1; and Enterprise
(Codman and Shurtleff, Miami, USA), 1. This study is a retrospective study using
MR images that were obtained in routine examinations, and there is no
information included in the submitted material that allows identification of the
patients. So, informed consent was not obtained. All research activities were
performed in accordance with the Declaration of Helsinki.
8
Microcatheter Tip Modification for Stent-Assisted Coiling
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In this study, we used the SL-10 straight microcatheter (Stryker Neurovascular, Kalamazoo, MI, USA) and Neuroform Atlas stent (Stryker Neurovascular). The microcatheter tip had a very small bend of approximately 45°. The microcatheter tip was manually bent using an inner mandrel, and it was heated with a hot air gun (BOSCH, Gerlingen, Germany) [Figure 1 ]. The microcatheter tip was set at 3 cm from the nozzle of the hot air gun, which had a temperature of 130°C for 30 s. We noted that the front view showed a round curve while the lateral view showed a right angle in the catheter's advancing direction [Figure 2 ]. In a terminal-type aneurysm, we thought that a straight-tip catheter would not easily pass the stent strut even using a guidewire because the straight tip has a flat plain surface [Figure 3 ], whereas a 45° catheter would easily pass the stent strut because the tip has a column edge and not a plain surface. We evaluated the difference between the straight tip and 45° microcatheter using a silicon vascular model (in vitro experiments) and then applied the WTA to a case of an unruptured basilar apex aneurysm.
9
Retrospective Analysis of NeuroForm Atlas Stent-Assisted Coil Embolization
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We retrospectively analyzed electronic medical records and picture archiving and communication system data from 31 consecutive patients with intracranial aneurysms treated at our institution using the NeuroForm Atlas (Stryker Neurovascular) stent-assisted coil embolizaiton (SAC) between February 2018 and July 2018. Patients with both ruptured and unruptured aneurysms were included. This study was approved by Institutional Review Board of Pusan National University Yangsan Hospital (IRB No. 05-2019-090).
In addition to aneurysm-related information (location, size, prior treatment, and dome-neck ratio), we collected detailed procedural information regarding the techniques used (i.e., jailing or trans-strut technique), angiographic outcomes (Raymond-Roy occlusion classification, RROC), and periprocedural complications. Follow-up clinical and angiographic data were also obtained. In-stent stenosis was defined as narrowing of the vessel by more than 10%. Angiographic results were independently adjudicated by two neurovascular specialists.
In addition to aneurysm-related information (location, size, prior treatment, and dome-neck ratio), we collected detailed procedural information regarding the techniques used (i.e., jailing or trans-strut technique), angiographic outcomes (Raymond-Roy occlusion classification, RROC), and periprocedural complications. Follow-up clinical and angiographic data were also obtained. In-stent stenosis was defined as narrowing of the vessel by more than 10%. Angiographic results were independently adjudicated by two neurovascular specialists.
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