Safety and efficacy of the remodelling technique in the treatment of ruptured and unruptured intracranial aneurysms: Analysis in two prospective series.

Safety and efficacy of the remodelling technique in the treatment of ruptured and

unruptured intracranial aneurysms:Analysis in two prospective series

(ATENA, CLARITY)

L. Pierot, C. Cognard, L. Spelle, J. MoretReims, Toulouse, Paris - France

Symposium Neuroradiologicum, October 4 – 9 2010, Bologna

Remodelling?

• Technique initially designed for the treatment of wide neck aneurysms

• What is a wide neck?– > 4mm (Zubillaga, 1994)– Sac / collet < 2? 1.5?

Remodelling: technique

• Balloon placed in front of the aneurysm in the parent vessel

• Inflated during deposition of each coil

• Deflated between each coil• Removed at the end of the

procedure

Remodelling: technique variants

• How to place the balloon?– In the parent vessel, in front of the neck– In the neck– Angle of attack

• Remodelling 2 balloons

Important issues

• Is the remodelling technique associated with a higher risk of complications and morbi-mortality compared to standard coiling?

• Are anatomical results improved by the remodelling technique?

Remodelling

Clinical results

Remodelling: Complications

• Sluzewski et al, 2006:– 1995 / 2005 - 757 patients - 827 aneurysms– Remodelling: 71 / 827 aneurysms (8.6%)– Complications:

Coiling Remodelling

TE 2.2% 9.8%

Rupture 0.8% 4%

Total 3.0% 14.1%*

* P < 0.0001

Remodelling: Complications

• Shapiro et al, 2008: literature review

Coiling Remodelling

TE Complications

8.0% (69/867) 8.1% (2/273)

Rupture

Ruptured A.

3.4% (17/507) 1.7% (1/59)

Rupture

Unruptured A.

1.4% (7/486) 1.8% (2/111)

Ruptured aneurysms (CLARITY)

782 patients

Coiling608 patients77.7%

Remodelling160 patients20.5%

Stenting14 patients1.8%

Ruptured aneurysms (CLARITY)

Aneurysm location

Ruptured aneurysms (CLARITY)

Aneurysm size Neck size

Ruptured aneurysms (CLARITY)

TE complications Intraoperative rupture

Ruptured aneurysms (CLARITY)

Early rebleeding Global complications

Ruptured aneurysms (CLARITY)

Delayed ischemia Hydrocephalus

Ruptured aneurysms (CLARITY)

Treatment morbidity Treatment mortality

Ruptured aneurysms (CLARITY)

Treatment and SAH morbidity Treatment and SAH mortality

Unruptured aneurysms (ATENA)

Traitement sélectif727 anévrismes

Coiling396 anévrismes74.5%

Remodelling271 anévrismes37,3%

Stenting57 anévrismes7,8%

Trispan: 3 anévrismes (0.4%)

Unruptured aneurysms (ATENA)

Aneurysm location

Unruptured aneurysms (ATENA)

Aneurysm size D-to-N ratio

Unruptured aneurysms (ATENA)

Unruptured aneurysms (ATENA)

Remodelling

Anatomical results

Literature review (Schapiro)

Initial occlusion Occlusion at FU

Ruptured aneurysms (CLARITY)

Initial occlusion Packing

P=0.017

AO= Adequate Occlusion. AR=Aneurysm Remnant.

Unruptured aneurysms (ATENA)

Conclusions

• Safety of the remodelling technique is similar to standart coiling in both ruptured and unruptured aneurysms (ATENA, CLARITY, Literature review).

• The remodelling technique seems to be more efficacious than the standart coiling on anatomical point-of-view.

• The remodelling technique can be widely used in the treatment of ruptured and unruptured aneurysms.

Publications

• Endovascular treatment of Unruptured Intracranial Aneurysms : Comparison of Safety of remodeling technique and standard treatment with coils.L. Pierot, L. Spelle, X. Leclerc, C. Cognard, A. Bonafé, J. Moret Radiology, 2009, 251: 846-855.

• The remodelling technique for endovascular treatment of ruptured intracranial aneurysms is anatomically more efficacious than standard coiling with comparable safety.L. Pierot, C. Cognard, R. Anxionnat, F. Ricolfi, and CLARITY investigatorsRadiology (in press)

Principales séries

• Moret J, Cognard C, Weill A, Castaings L, Rey A. The “remodelling technique” in the treatment of wide neck intracranial aneurysms. Intervent Neuroradiol 1997; 3: 21-35.

• Aletich VA, Debrun GM, Misra M, Charbel F, Ausman JL. The remodelling technique of balloon assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago. J Neurosurg 2000; 93: 388-396.

Principales séries

• Cottier JP, Pasco A, Gallas S, Gabrillargues J, Cognard C, Drouineau J, Brunereau L, Herbreteau L. Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study. AJNR Am J Neuroradiol 2001; 22: 345-351.

• Lefkowitz MA, Gobin YP, Akiba Y, Duckwiler GR, Murayam Y, Guglielmi G, Martin NA, Vinuela F. Balloon-assisted Guglielmi detachable coiling of wide necked aneurysms, II : clinical results. Neurosurgery 1999; 45: 531-537.

Principales séries

• Malek AM, Halbach VV, Phatouros CC, Lempert TE, Meyers PM, Dowd CF, Higashida RT. Balloon-assisted technique for endovascular coil embolization of geometrically difficult intracranial aneurysms. Neurosurgery 2000; 22: 19-26.

• Nelson PK, Levy DI. Ballon-assisted coil embolization of wide-necked aneurysms of the internal carotid artery: medium term angiographic and clinical follow-up in 22 patients. AJNR Am J Neuroradiol 2001; 22: 19-26.

Principales séries

• Layton KF, Cloft HJ, Gray LA, Lewis DA, Kallmes DF. Balloon-assisted coiling of intracranial aneurysms: evaluation of local thrombus formation and symptomatic thromboembolic complications. AJNR Am J Neuroradiol 2007; 28: 1172-1175.

• Sluzewski M, Von Rooij WJ, Beute GN, Nijssen PC. Balloon-assisted coil embolization of intracranial aneurysms: incidence, complications, and angiography results. J Neurosurg 2006; 105: 396-399.