Fernanda Rodriguez-Erazú

Background: Concerns have arisen regarding flow diverter braid deformation (FDBD), particularly with last-generation platinum drawn-filled tube (DFT) wire devices. Braid deformation is likely multifactorial, influenced by patient characteristics, device selection, and procedural factors, yet no clinical analysis has systematically identified predictive factors. We conducted a study to determine the incidence, patterns, and predictors of braid deformation with these devices. Methods: Consecutive intracranial aneurysms treated with various flow diverters (FDs) constructed with DFT wires between June 2018 and June 2024 were included. High-resolution cone-beam CT with diluted contrast (vasoCT) and angiograms were reviewed to identify and classify FDBD following international consensus definitions. Patient, aneurysm, anatomy, procedural, and FD characteristics were retrieved and analyzed using univariate and multivariable analyses. Results: A total of 102 patients were included. FDBD was observed in 28 patients (27%), comprising 41 deformations. Three independent predictors of FDBD were identified: short distal landing zone (aOR 0.80, 95% CI 0.63 to 0.98; P=0.04), FD proximal oversizing (aOR 40.05, 95% CI 5.14 to 405.23; P<0.01), and younger age (aOR 0.93, 95% CI 0.88 to 0.98; P<0.01). Internal carotid artery aneurysms were also associated with FDBD in the univariate analysis (P<0.05). Conclusion: FDBD with DFT FDs is a frequent phenomenon observed in about 1/4 cases, associated with symptomatic complications but without affecting permanent morbidity. Patient age and technical factors such as short landing zone and FD oversizing were independent predictors of FDBD. This analysis may help to guide operator decisions when using DFT FDs and support future research in this field.

Background: Delayed aneurysm rupture (DAR) is a potentially devastating complication after flow-diverters (FD) deployment and their exact mechanisms are still unclear. The purpose of this meta-analysis is to synthesize the latest evidence on DAR after FD treatment and identify predictive factors. Methods: A systematic review and meta-analysis were conducted according to established protocols. Searches were conducted in PubMed, Scopus, Web of Science, and Embase databases up to June 2024 using variations of “aneurysm “and “delayed aneurysm rupture” terms. Original studies reporting DAR and including more than five patients were included. All analyses were conducted in R software (version 4.4.2), employing the “meta” and “tableone” packages. Results: 64 studies with 9820 patients were included, large aneurysm size (OR=1.08, 95% CI (1.02, 1.14), P value=0.008), intra-aneurysmal thrombus (OR=1.05, 95% CI (1.01, 1.09), P value=0.010) and posterior circulation location (OR=1.02, 95% CI (1.00, 1.04), P value=0.014) were significant risk factors for DAR. The pooled prevalence of DAR was 1.40%, with a rate of 1.18% after removing outliers. DAR occurred within 30 days in 66.7% of cases, with a mortality rate of 73.3% at discharge. Conclusion: DAR following flow diversion treatment is an uncommon but devastating complication and remains a limitation of the technique. It is influenced by factors such as large aneurysm size, intra-aneurysmal thrombosis, and posterior circulation involvement. The first 30 days post-procedure represent a particularly high-risk period. Despite advancements in FD technology, significant gaps remain, highlighting the need for further research to improve risk assessment and treatment strategies.

BACKGROUND AND OBJECTIVES: Embolization is part of multidisciplinary brain arteriovenous malformations (AVMs) treatment, yet safety data for novel liquid embolization agents (LEAs) such as Squid and PHIL remain limited. This study reports complications and outcomes from curative embolization using Onyx, Squid, PHIL, and Glue. METHODS: Adult patients with brain AVMs treated with LEAs from July 2015 to December 2022 were reviewed for intraprocedural technical issues, postoperative hemorrhagic, and ischemic complications. Minor (modified Rankin Scale ≤2) and major complication rate (morbidity/modified Rankin Scale >2), mortality, and 6-month angiographic cure rate were evaluated. RESULTS: In total, 135 patients (62.2% male, mean age 41.7 ± 15.1 years) with 206 embolizations (34% Onyx, 18.9% Squid, 17.5% PHIL, 28.2% Glue) were included. Overall, 87.4% procedures were in ruptured AVMs and 84% treated by the transarterial technique (84%). The 6-month angiographic cure rate was 53.3%, higher when nonadhesive LEAs were used than Glue (65.3% vs 17.6%, P < .001). In adjusted analysis, only eloquent location (odds ratio [OR] = 4.4; P = .007) and Glue (OR = 9.1; 95% CI 2.9-28.9, P < .001) were predictors of lower angiographic occlusion rate, whereas size had an inverse correlation (OR = 0.67; P = .019). Technical procedural complications, hemorrhagic, and ischemic rates were 10.2% (2.2% morbidity), 13.1% (3.7% morbidity and 2.2% mortality), and 9.2% (2.2% morbidity, 0% mortality), respectively, regardless of the preferred LEA. Minor, major complications, and mortality rates were 3.7%, 4.4%, and 2.2%, respectively. Hemorrhage was the major contributor to morbidity and mortality, whereas deep venous drainage was an independent predictor of hemorrhage and mortality. CONCLUSION: PHIL and Squid demonstrated complication and angiographic cure rates comparable with Onyx. However, curative embolization of brain AVMs resulted in only moderate angiographic occlusion. Larger multicenter studies with standardized operator protocols, cost-effectiveness assessments, and extended follow-up are warranted to validate these findings.

Background and objectives: Large-bore aspiration catheters have demonstrated better recanalization times and higher first-pass effects in large vessel occlusions. However, vessel tortuosity and branching vessels can hinder navigability, potentially increasing the ‘ledge effect’, procedural times, and the risk of vessel injury. Recently, a newly designed delivery catheter (Carrier Delivery Catheter (CDC), Balt, France) has been introduced to the US market. This paper aims to report our combined experience with this catheter in a real-life clinical setting. Methods: This is a retrospective, multicenter study based on a prospectively maintained database of patients with ischemic stroke who underwent mechanical thrombectomy between February 2024 and January 2025. All consecutive patients who underwent mechanical thrombectomy in which a CDC was used were included. Results: A total of 43 patients from three centers in the USA were included. The mean age was 69.74 years, and most of the patients were male (60.5%). The CDC delivered the aspiration catheter to the clot in all cases. The mean National Institutes of Health Stroke Scale (NIHSS) score was 18, and the mean time between puncture to clot access was 18.14 min. No vessel dissection or perforation was reported, and 4.6% of symptomatic hemorrhagic complications were reported. None of the complications were adjudicated to be directly related to the use of the Carrier. Conclusion: Our case series shows that the CDC is a useful and reliable tool as a delivery catheter for treating vessel occlusions in both the anterior and posterior circulation. This study serves as proof of concept and may provide a foundation for future prospective analyses of this innovative delivery system.

The Artisse intrasaccular device (Medtronic) offers a novel treatment option for unruptured and ruptured wide-neck bifurcating intracranial aneurysms.1 2The Artisse device features enhancements including a distal tip for dome protection, platinum band markers for improved visibility, and a bilayer high-density platinum core nitinol mesh basket for enhanced flexibility and visibility when compared with previous devices.2–7 Data from case series demonstrate the procedural safety and efficacy of the Artisse device.1 2 This versatile flared-shape intrasaccular device can be used alongside products such as the Rebar microcatheter 18 and Navien.2 In Europe, an adequate occlusion rate of 78% at 12 months and 79.2% at 36 months follow-up has been shown.3 8 This video documents the embolization of a wide-neck unruptured anterior communicating artery aneurysm using the Artisse device, where Sim&Size was used for proper sizing (video 1).4 9 The procedure was uneventful, achieving successful device deployment with no parent vessel compromise. Video 1 Artisse intrasaccular device for intracranial aneurysm treatment—first in the USA:

Background The pipeline embolization device (PED) has been increasingly used to treat brain aneurysms; however, concerns have been raised about braid stability with newer drawn filled tubing technology devices. Objective To evaluate braid stability of PED early generations using data from the PREMIER trial. Methods All consecutive intracranial aneurysms treated with PED (Classic and Flex) within the PREMIER trial were reviewed for braid stability (fish mouthing, foreshortening, braid bump, braid collapsing). Immediate postprocedure cone-beam CT and angiography were compared with 1- and 2- years' follow-up. Analyses included safety, measured with the modified Rankin Scale (mRS) score, including +1 mRS point and a good clinical outcome (mRS score 0–2), vessel stenosis ≥50%, effectiveness measured with Raymond-Roy Scale, and re-treatment rates. Results 133/141 aneurysms had a complete dataset. 8/133 (6%) aneurysms showed braid deformations. Inter-reader agreement was excellent (κ=0.83). Braid deformations were statistically significantly associated with in-stent vessel stenosis >50% (P=0.029), without impact on effectiveness or safety. Fish mouthing was found in 1/133 (0.75%) at 1 year, causing >50% vessel stenosis. Foreshortening occurred in 6/133 (4.5%), and braid bump in 1/133 (0.75%) associated with severe in-stent stenosis. Four other cases (3.0%) of asymptomatic in-stent stenosis due to neointimal hyperplasia were seen without braid changes. No new braid stability deformations were found at the 2-year follow-up. Conclusion Our study demonstrates excellent braid stability among patients treated with the PED Classic and Flex in the PREMIER trial. Within the uncommon braid changes observed, none affected the PED safety or efficacy. Trial registration number NCT02186561.

BACKGROUND and OBJECTIVES: The Woven EndoBridge (WEB) device has been increasingly used to treat wide-neck aneurysms showing a safe and effective profile, but a relatively high number of thromboembolic events (TEEs) have been reported with such treatment. We aimed to evaluate the incidence and management of TEEs and possible predictive factors related to WEB embolization of ruptured and unruptured intracranial aneurysms. METHODS: A single-center database with consecutive aneurysms treated with a WEB device between July 2012 and May 2022 was reviewed for intraoperative and delayed TEEs. Univariate and multivariable analyses were used to determine factors associated with TEEs. RESULTS: A total of 266 independent aneurysms were treated with WEB devices in 245 patients (mean age 55.78 ± 11.64 years, 169 (63.5%) females, 80 (30%) ruptured). The overall rate of TEEs is 13% (35/266), including 8.7% intraoperative. Symptomatic TEEs with clinical sequelae at a 3-month follow-up are reported to be 2.6% (7/266) with no TEE-related mortality. Both the replacement of a WEB device during the procedure (adjusted odds ratio = 2.61, 95% CI 1.24-5.49; P = .01) and ruptured aneurysms (adjusted odds ratio = 2.74, 95% CI 1.31-5.7; P = .007) were independent predictors of TEEs. A case-by-case management of intraprocedural TEE is also presented; tirofiban was successfully used in most cases of this cohort. CONCLUSION: In this study, we demonstrated that ruptured aneurysms and WEB device replacement during the procedure were independent predictive factors for TEEs. As a result, making the correct choice of WEB is crucial for improving treatment outcomes. Moreover, with proper medical management of TEEs, minimal morbidity and no mortality could be achieved, which reinforces the safety of the technique.