J Korean Neurosurg Soc.  2022 Nov;65(6):801-815. 10.3340/jkns.2022.0021.

Evaluation of Stent Apposition in the LVIS Blue Stent-Assisted Coiling of Distal Internal Carotid Artery Aneurysms : Correlation with Clinical and Angiographic Outcomes

Affiliations
  • 1Department of Neurosurgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea

Abstract


Objective
: To evaluate the stent apposition of a low-profile visualized intraluminal support (LVIS) device in distal internal carotid artery (ICA) aneurysms, examine its correlation with clinical and angiographic outcomes, and determine the predictive factors of ischemic adverse events (IAEs) related to stent-assisted coiling.
Methods
: We retrospectively analyzed a prospectively maintained database of 183 patients between January 2017 and February 2020. The carotid siphon from the cavernous ICA to the ICA terminus was divided into posterior, anterior, and superior bends. The anterior bends were categorized into angled (V) and non-angled (C, U, and S) types depending on the morphology and measured angles. Complete stent apposition (CSA) and incomplete stent apposition (ISA) were evaluated using unsubtracted angiography and flat-panel detector computed tomography. Dual antiplatelet therapy with aspirin 200 mg and clopidogrel 75 mg was administered. Clopidogrel resistance was defined as fewer responders (≥10%, <40%) and non-responders (<10%) based on the percent inhibition (%INH) of the VerifyNow system. These were counteracted by a dose escalation to 150 mg for fewer responders or substitution with cilostazol 200 mg for non-responders. IAEs included intraoperative in-stent thrombosis, transient ischemic attack, cerebral infarction, and delayed in-stent stenosis. A multivariate logistic regression analysis was used to determine the predictive factors for ISA and IAEs.
Results
: There were 33 ISAs (18.0%) and 27 IAEs (14.8%). The anterior bend angle was narrower in ISA (-4.16°±25.18°) than in CSA (23.52°±23.13°) (p<0.001). The V- and S-types were independently correlated with the ISA (p<0.001). However, treatment outcomes, including IAEs (15.3% vs. 12.1%), aneurysmal complete occlusion (91.3% vs. 88.6%), and recanalization (none of them), did not differ between CSA and ISA (p>0.05). The %INH of 27 IAEs (13.78%±14.78%) was significantly lower than that of 156 non-IAEs (26.82%±20.23%) (p<0.001). Non-responders to clopidogrel were the only significant predictive factor for IAEs (p=0.001).
Conclusion
: The angled and tortuous anatomical peculiarity of the carotid siphon caused ISA of the LVIS device; however, it did not affect clinical and angiographic outcomes, while the non-responders to clopidogrel affected the IAEs related to stent-assisted coiling.

Keyword

Carotid siphon; Clopidogrel resistance; Low-profile visualized intraluminal support; Stent apposition; Stent-assisted coiling

Figure

  • Fig. 1. A : The carotid siphon was divided into posterior (red), anterior (green), and superior bends (blue). B-E : The anterior bends were categorized into angled (V) and non-angled (C, U, and S) types depending on morphology and measured angles. The angle of each bend was measured at the intersection between two lines traced through the midpoints of the diameters of each straight segment (white dotted lines). B : V-type. C : C-type (≥20°). D : U-type (≥-20°, <20°). E : S-type (<-20°).

  • Fig. 2. A-C : The push–pull technique was utilized when the two radiopaque strands within the stent body insufficiently contacted the vessel wall. A : Incomplete coverage at the anterior bend of the S-type (-25.5°) was identified during stent deployment (white arrow). B : The malpositioned stent was retrieved and redeployed while tension was provided by the push-back of the entire stent system. C : A fully expanded stent is shown on unsubtracted angiography (white arrow). D-F : Balloon angioplasty was only applied in cases of an intraoperative rupture of the aneurysm. D : Contrast leakage outside the lumen was observed due to the superior hypophyseal artery aneurysm rupture (white arrow). E : Balloon angioplasty was applied at the position of the aneurysm neck to stop the bleeding. F : There was no more hemorrhage, and the lesion was completely obliterated.

  • Fig. 3. A : The status of stent apposition was evaluated by unsubtracted angiography, and the stent struts were in relatively good contact with the arterial wall. B : Trunk malposition was observed in the outer curvature of the anterior bend of the S-type (-45.8°) (white arrow). C : Flat-panel detector computed tomography (FDCT) with a contrast medium visualized the stent apposition through a multiplanar reconstruction in the maximal intensity projection mode. D : Trunk malposition was observed in the inner curvature of the anterior bend of the U-type (1.9°) (white arrow). E-G : FDCT without a contrast medium represented the metal components of the stent structure and coil mass as 3-dimensional reconstructed images and was taken to identify the degree of stent kinking and coil loop protrusion across the stent strut. H : The stent visualization was relatively well maintained, contrary to the concerns of metal artifacts arising from coil materials.

  • Fig. 4. Pearson's correlation analysis showed a positive correlation between the anterior bend angle and the minimum-to-maximum ratio of stent diameter in both (A) angled (correlation coefficient, 0.69; p<0.001) and (B) non-angled types (correlation coefficient, 0.36; p<0.001). CSA : complete stent apposition, ISA : incomplete stent apposition.


Reference

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