際際滷

際際滷Share a Scribd company logo

Lima 2013 final

Download as PPTX, PDF
Boris Pab坦n
Boris Pab坦n

This document discusses endovascular treatment of intracranial aneurysms using flow diverter devices like the Pipeline Embolization Device (PED). It provides an overview of the limitations of traditional coiling techniques and how flow diverters work by excluding aneurysms from circulation rather than filling them. The document then reviews tips for pre-procedure preparation, deployment of the PED during the procedure, and post-procedure considerations.

1 of 91
Download to read offline
Rionegro / 2013
Disclosures Boris Pabon MD, has received research support through Boston Scientific, Cordis and Microvention, and has served as a consultant to Chestnut Medical. Currently, perform proctoring activities to COVIDIEN.
Intracranial Endovascular Reconstruction of Cerebral Aneurysms with Pipeline Boris Pabon MD,
Introduction Endovascular treatment of intracranial aneurysms has evolved substantially over the past two decades, transitioning from an investigational therapy into routine clinical practice and ultimately emerging as the treatment of choice for many lesions. Despite this tremendous evolution in endovascular therapy, some important limitations remain, particularly in the treatment of wide- necked, large and giant, or nonsaccular fusiform aneurysms.
Aneurysm Treatment Subject Clinical series display aneurysm recurrence due to long-term coil effectiveness
Coiling 1994
DSA 2 yr Follow-Up
DSA 2 yr Follow-Up 3DA 15 yr Follow-Up
DSA -3D 15 year Follow-Up
Why are Flow-Diverter so exciting? This device does not function as previous self expanding stents (i.e. Neuroform ,Enterprise) in that it is not designed to provide support to keep material within an aneurysm dome; instead it appear to function by excluding the aneurysm from the circulation.
Goal of Stents Treatment Circulatory Exclusion
PED Like a Flow-Diverter Lieber BB, Seong J, Wakhloo AK,.J Biomech Eng. 2007 . Canton G, Levy DI, Lasheras JC, Nelson PK. J Neurosurg. 2005
Flow Diversion Features PED
Endovascular Treatment Evolution Intracranial Flow Diverter Endovascular Aneurysms Devices Reconstruction
What is the PED ? The PED is a flexible, microcatheter- delivered, self- expanding, endovascular stent- like construct engineered specifically for the treatment of cerebral aneurysms . The device consists of a braided mesh cylinder composed of 48 individual platinum and cobalt chromium microfilaments.
Pipeline Embolizaiton Device Structure: Metal Surface Area Coverage Neuroform/Enterprise: 6.5 9.5% PED: 30-35%
Pipeline Approach Tips Pre procedure Procedure After procedure
Pre procedure Accurate Images ( DSA 3DRA CT angio/ MRI ) Gastric protection Ranitidine better than Omeprazol Check the individual response to antiplatelets (Verify now) Check your PEDs Stock If you have any concern, then ASK ! Confirm the presence of a 2nd Operator Corticoids load , to Giant or partially thrombosed lesions
Pre procedure Antiplatelets (Electively) : ASA 100mg qd PO and, Clopidrogrel 75mg qd PO , Five days before the procedure. Antiplatelets (Urgency) : ASA 300mg PO and, if NGT available, Load dosis of Clopidrogrel 600mg fractioned with almost 1h of interval. Antiplatelets (Emergency): We recommend to use IIb-IIIa GP Inhibitors.
Procedure Check again all Images (Last time Findings ) Check again your PEDs Stock (avoid a heart attack !...) Confirm if the antiplatelet protocol is OK Always be ready for surprises.
Procedure Remember the Antiagregation, be careful during femoral puncture Systemic Heparinazation (ACT >250 seg) Femoral Introducer sheath 6/8Fr. Coaxial Systems: 6/8 Fr (Neuron / Chaperon) + Micro catheter Marksman 0.27in
Procedure Accepting a suboptimal material (guide, catheter, Micro wire) can turn a 20 minutes case into a 4 hour nightmare. Put the Microcatheter more distally than you think would be right ! Avoid to leave the Microcatheter tip near to the sharp curved vessel : during PED implantation you will have a system backward and the microwire would advance suddenly. (Perforation risk) Maintain constantly the forward tension of the PED, using the torque device and, avoiding the kinking of the PED pusher.
Procedure keep in mind the PED foreshortening, again, its better to be distally to avoid misplacement. For telescoping technique, never undersize the next device, you will affect the construct. Try it not oversized ! If the distal end of the stent remain close, you can rotate the wire gently (no more than 3 cycles) or, you can try to advance the microcatehter ; this simple maneuver would be enough to open it. Once you sure about the distal position , delivery the stent slowly and gradually , specially at sharp angles.
Procedure Value the Hemodynamic effect , using a 25Fr/sec acquisition. Verify PED conformability. ( X-per CT / Dyna CT) Safeguard the distal access with the stent-wire at the end of the procedure. Only, if you are satisfied with the result, so, pullback the wire. Determine your strategy (1 or >1 PED)
Pipeline Deployment Slowly retract the Marksman microcatheter, mai ntaining delivery wire position Microcatheter Distal Marker (applying slight fwd tension) Protective Coil Distal market (bumper) Tip Coil 息2009 ev3 Inc. All rights reserved. Contents are 25 confidential.
Pipeline Deployment Continue catheter retraction until 10 to 15mm have been exposed and PED begins to belly Maintain delivery PED bellying wire position 息2009 ev3 Inc. All rights reserved. Contents are 26 confidential.
Pipeline Deployment Rotate delivery wire clockwise to facilitate PED expansion Distal Proximal 息2009 ev3 Inc. All rights reserved. Contents are 27 confidential.
Pipeline Deployment To reposition the implant backwards, pull deliverywire so that bumper corks implant against Bumper butted against microcatheter microcatheter Pullback microcatheter and deliverywire together as a system 息2009 ev3 Inc. All rights reserved. Contents are 28 confidential.
Pipeline Deployment Continue deployment of PED by slowly pushing out delivery wire To avoid unexpected movements, load catheter while pushing delivery wire by applying slight forward tension
Pipeline Deployment Monitor the angle of the PED exiting the Marksman If the angle is too shallow, the Good deployment angle Marksman is being pulled too much; push out delivery wire If the angle is to broad, the delivery wire is being pushed too much; retract Marksman 息2009 ev3 Inc. All rights reserved. Contents are 30 confidential.
Pipeline Deployment After deployment, advance Marksman over deliverywire to maintain access If catheter tip gets caught on PED edge, advance the deliverywire to algin the proximal bumper at the tip Use bumper as a catheter tip guide to negotiate PED edge 息2009 ev3 Inc. All rights reserved. Contents are 31 confidential.
Pipeline Deployment Slowly withdraw deliverywire If distal bumper snags on Marksman tip, gently rotate clockwise 息2009 ev3 Inc. All rights reserved. Contents are 32 confidential.
Pipeline Deployment When telescoping 2 PEDs ensure there is enough overlap to secure position Start conservative, you can always pull back if you are too distal Consider the jump back as the PED opens 息2009 ev3 Inc. All rights reserved. Contents are 33 confidential.
Pipeline Deployment Some times, pushing out delivery wire can cause the PED to not expand, specially if the catheter was not loaded Continue to very slowly toggle between pulling back catheter and pushing out delivery wire 息2009 ev3 Inc. All rights reserved. Contents are 34 confidential.
Pipeline Deployment Even when all seems lost, as long as you maintain access, a complete flow diverter can be constructed (most of the times) 息2009 ev3 Inc. All rights reserved. Contents are 35 confidential.
Pipeline Deployment 息2009 ev3 Inc. All rights reserved. Contents are 36 confidential.
After procedure Be cautious with femoral access (Risk of retroperitoneal hematoma and pseudoaneurysms) Clinical and radiological follow up 3, 6, 12 Continue the gastric protection Dual antiplatelet regime (i.e. ASA + Clopidrogrel) for 6 m ASA lifetime Corticoids scheme in cases selected (Large/Giant lesions)
Clinical Cases
PED to Treat Very-Small Aneurysms
PED to Treat Blister-like Aneurysms
22mo FU
PED Small Wide-neck Aneurysms BA 65 y.o, Female. History: Headache Small L-Parophthalmic unruptured aneurysm Treatment: Stent Pipeline
6 mo FU
PED Small /multiple Aneurysms
PED Small /multiple Aneurysms DSA Pre treatment Stenting Post Post treatment 3 Month F.U.
PED Dysplasic Aneurysms DSA Pre Treatment
Lima 2013 final
Lima 2013 final
9 Months Follow Up
PED Giant aneurysms
57 YOF Visual Loss Headache
Lima 2013 final
Lima 2013 final
CT PRE CT POST
55 YOF 6th CN Palsy
Lima 2013 final
Lima 2013 final
3 Month FU
63 YOF Cavernous Syndrome
Lima 2013 final
Lima 2013 final
Lima 2013 final
Lima 2013 final
MRI Pre MRI Post MRI 6 m F. Up
52 YOM Trigeminal Neuralgia Headache
Lima 2013 final
DSA immediately DSA 6 month PComA Jailed Fully Open
PComA Jailed Fully Open
PED Controlling Recanalization C.A. - 1- 09- 59 y.o. female Large R-Ophthalmic unruptured aneurysm. 16-12-2005 Coils. 14-12-2009PED
DSA 1 moFU DSA 1 yr FU
PED 24 month Follow-up
PED / Branching
PED : Vessel Reconstruction
Immediate post PED
3 months FU
TISS Transient In-Stent Stenosis
PED Transient In-Stent Stenosis Different than ISR (Atherosclerosis) Inflammatory Reaction No Clinical Significance Parent Vessel Remodeling Etiology Uncertain
12 mo FU
PED - Results World-wide Experience
Occlusion Occlusion Occlusion F.U. n:68 F.U. 3 m F.U. 6 m > 12 m R ASD E FU 42/63 S 56% U L 83% T S 92.1%
PED / Major Concern
PRE ROTATIONAL SCAN
Lima 2013 final
Lima 2013 final
POST STENTING
Stent delivery
Lima 2013 final
Lima 2013 final
Conclusions The PED constituted easier strategy for treatment of selected aneurysms than coiling. Essentially, eliminating the risk of procedural rupture and complications related to the introduction and manipulation of microcatheters or coils. There are limitations related to existence of SAH and treatment of bifurcation aneurysms. Specific trials are required to evaluate this topic. PED Experience is early. However, the existing clinical data have been very encouraging. Based on our clinical experience, PED may significantly improve the endovascular treatment of complex aneurysms.
Take Home Messages Know the patient. Treat the patient; not only the artery. Learn from other peoples mistakes, better than learning from your own. Learn techniques from different people and then come up with your own. Keep it simple. Risk free Intracranial Stenting is not doing it. Recognize your limits; dont push your luck
Thank you ! Gracias

More Related Content

Lima 2013 final

  • 2. Disclosures Boris Pabon MD, has received research support through Boston Scientific, Cordis and Microvention, and has served as a consultant to Chestnut Medical. Currently, perform proctoring activities to COVIDIEN.
  • 3. Intracranial Endovascular Reconstruction of Cerebral Aneurysms with Pipeline Boris Pabon MD,
  • 4. Introduction Endovascular treatment of intracranial aneurysms has evolved substantially over the past two decades, transitioning from an investigational therapy into routine clinical practice and ultimately emerging as the treatment of choice for many lesions. Despite this tremendous evolution in endovascular therapy, some important limitations remain, particularly in the treatment of wide- necked, large and giant, or nonsaccular fusiform aneurysms.
  • 5. Aneurysm Treatment Subject Clinical series display aneurysm recurrence due to long-term coil effectiveness
  • 7. DSA 2 yr Follow-Up
  • 8. DSA 2 yr Follow-Up 3DA 15 yr Follow-Up
  • 9. DSA -3D 15 year Follow-Up
  • 10. Why are Flow-Diverter so exciting? This device does not function as previous self expanding stents (i.e. Neuroform ,Enterprise) in that it is not designed to provide support to keep material within an aneurysm dome; instead it appear to function by excluding the aneurysm from the circulation.
  • 11. Goal of Stents Treatment Circulatory Exclusion
  • 12. PED Like a Flow-Diverter Lieber BB, Seong J, Wakhloo AK,.J Biomech Eng. 2007 . Canton G, Levy DI, Lasheras JC, Nelson PK. J Neurosurg. 2005
  • 14. Endovascular Treatment Evolution Intracranial Flow Diverter Endovascular Aneurysms Devices Reconstruction
  • 15. What is the PED ? The PED is a flexible, microcatheter- delivered, self- expanding, endovascular stent- like construct engineered specifically for the treatment of cerebral aneurysms . The device consists of a braided mesh cylinder composed of 48 individual platinum and cobalt chromium microfilaments.
  • 16. Pipeline Embolizaiton Device Structure: Metal Surface Area Coverage Neuroform/Enterprise: 6.5 9.5% PED: 30-35%
  • 17. Pipeline Approach Tips Pre procedure Procedure After procedure
  • 18. Pre procedure Accurate Images ( DSA 3DRA CT angio/ MRI ) Gastric protection Ranitidine better than Omeprazol Check the individual response to antiplatelets (Verify now) Check your PEDs Stock If you have any concern, then ASK ! Confirm the presence of a 2nd Operator Corticoids load , to Giant or partially thrombosed lesions
  • 19. Pre procedure Antiplatelets (Electively) : ASA 100mg qd PO and, Clopidrogrel 75mg qd PO , Five days before the procedure. Antiplatelets (Urgency) : ASA 300mg PO and, if NGT available, Load dosis of Clopidrogrel 600mg fractioned with almost 1h of interval. Antiplatelets (Emergency): We recommend to use IIb-IIIa GP Inhibitors.
  • 20. Procedure Check again all Images (Last time Findings ) Check again your PEDs Stock (avoid a heart attack !...) Confirm if the antiplatelet protocol is OK Always be ready for surprises.
  • 21. Procedure Remember the Antiagregation, be careful during femoral puncture Systemic Heparinazation (ACT >250 seg) Femoral Introducer sheath 6/8Fr. Coaxial Systems: 6/8 Fr (Neuron / Chaperon) + Micro catheter Marksman 0.27in
  • 22. Procedure Accepting a suboptimal material (guide, catheter, Micro wire) can turn a 20 minutes case into a 4 hour nightmare. Put the Microcatheter more distally than you think would be right ! Avoid to leave the Microcatheter tip near to the sharp curved vessel : during PED implantation you will have a system backward and the microwire would advance suddenly. (Perforation risk) Maintain constantly the forward tension of the PED, using the torque device and, avoiding the kinking of the PED pusher.
  • 23. Procedure keep in mind the PED foreshortening, again, its better to be distally to avoid misplacement. For telescoping technique, never undersize the next device, you will affect the construct. Try it not oversized ! If the distal end of the stent remain close, you can rotate the wire gently (no more than 3 cycles) or, you can try to advance the microcatehter ; this simple maneuver would be enough to open it. Once you sure about the distal position , delivery the stent slowly and gradually , specially at sharp angles.
  • 24. Procedure Value the Hemodynamic effect , using a 25Fr/sec acquisition. Verify PED conformability. ( X-per CT / Dyna CT) Safeguard the distal access with the stent-wire at the end of the procedure. Only, if you are satisfied with the result, so, pullback the wire. Determine your strategy (1 or >1 PED)
  • 25. Pipeline Deployment Slowly retract the Marksman microcatheter, mai ntaining delivery wire position Microcatheter Distal Marker (applying slight fwd tension) Protective Coil Distal market (bumper) Tip Coil 息2009 ev3 Inc. All rights reserved. Contents are 25 confidential.
  • 26. Pipeline Deployment Continue catheter retraction until 10 to 15mm have been exposed and PED begins to belly Maintain delivery PED bellying wire position 息2009 ev3 Inc. All rights reserved. Contents are 26 confidential.
  • 27. Pipeline Deployment Rotate delivery wire clockwise to facilitate PED expansion Distal Proximal 息2009 ev3 Inc. All rights reserved. Contents are 27 confidential.
  • 28. Pipeline Deployment To reposition the implant backwards, pull deliverywire so that bumper corks implant against Bumper butted against microcatheter microcatheter Pullback microcatheter and deliverywire together as a system 息2009 ev3 Inc. All rights reserved. Contents are 28 confidential.
  • 29. Pipeline Deployment Continue deployment of PED by slowly pushing out delivery wire To avoid unexpected movements, load catheter while pushing delivery wire by applying slight forward tension
  • 30. Pipeline Deployment Monitor the angle of the PED exiting the Marksman If the angle is too shallow, the Good deployment angle Marksman is being pulled too much; push out delivery wire If the angle is to broad, the delivery wire is being pushed too much; retract Marksman 息2009 ev3 Inc. All rights reserved. Contents are 30 confidential.
  • 31. Pipeline Deployment After deployment, advance Marksman over deliverywire to maintain access If catheter tip gets caught on PED edge, advance the deliverywire to algin the proximal bumper at the tip Use bumper as a catheter tip guide to negotiate PED edge 息2009 ev3 Inc. All rights reserved. Contents are 31 confidential.
  • 32. Pipeline Deployment Slowly withdraw deliverywire If distal bumper snags on Marksman tip, gently rotate clockwise 息2009 ev3 Inc. All rights reserved. Contents are 32 confidential.
  • 33. Pipeline Deployment When telescoping 2 PEDs ensure there is enough overlap to secure position Start conservative, you can always pull back if you are too distal Consider the jump back as the PED opens 息2009 ev3 Inc. All rights reserved. Contents are 33 confidential.
  • 34. Pipeline Deployment Some times, pushing out delivery wire can cause the PED to not expand, specially if the catheter was not loaded Continue to very slowly toggle between pulling back catheter and pushing out delivery wire 息2009 ev3 Inc. All rights reserved. Contents are 34 confidential.
  • 35. Pipeline Deployment Even when all seems lost, as long as you maintain access, a complete flow diverter can be constructed (most of the times) 息2009 ev3 Inc. All rights reserved. Contents are 35 confidential.
  • 36. Pipeline Deployment 息2009 ev3 Inc. All rights reserved. Contents are 36 confidential.
  • 37. After procedure Be cautious with femoral access (Risk of retroperitoneal hematoma and pseudoaneurysms) Clinical and radiological follow up 3, 6, 12 Continue the gastric protection Dual antiplatelet regime (i.e. ASA + Clopidrogrel) for 6 m ASA lifetime Corticoids scheme in cases selected (Large/Giant lesions)
  • 39. PED to Treat Very-Small Aneurysms
  • 40. PED to Treat Blister-like Aneurysms
  • 42. PED Small Wide-neck Aneurysms BA 65 y.o, Female. History: Headache Small L-Parophthalmic unruptured aneurysm Treatment: Stent Pipeline
  • 44. PED Small /multiple Aneurysms
  • 45. PED Small /multiple Aneurysms DSA Pre treatment Stenting Post Post treatment 3 Month F.U.
  • 46. PED Dysplasic Aneurysms DSA Pre Treatment
  • 50. PED Giant aneurysms
  • 55. 55 YOF 6th CN Palsy
  • 64. MRI Pre MRI Post MRI 6 m F. Up
  • 67. DSA immediately DSA 6 month PComA Jailed Fully Open
  • 69. PED Controlling Recanalization C.A. - 1- 09- 59 y.o. female Large R-Ophthalmic unruptured aneurysm. 16-12-2005 Coils. 14-12-2009PED
  • 70. DSA 1 moFU DSA 1 yr FU
  • 71. PED 24 month Follow-up
  • 73. PED : Vessel Reconstruction
  • 77. PED Transient In-Stent Stenosis Different than ISR (Atherosclerosis) Inflammatory Reaction No Clinical Significance Parent Vessel Remodeling Etiology Uncertain
  • 80. Occlusion Occlusion Occlusion F.U. n:68 F.U. 3 m F.U. 6 m > 12 m R ASD E FU 42/63 S 56% U L 83% T S 92.1%
  • 81. PED / Major Concern
  • 89. Conclusions The PED constituted easier strategy for treatment of selected aneurysms than coiling. Essentially, eliminating the risk of procedural rupture and complications related to the introduction and manipulation of microcatheters or coils. There are limitations related to existence of SAH and treatment of bifurcation aneurysms. Specific trials are required to evaluate this topic. PED Experience is early. However, the existing clinical data have been very encouraging. Based on our clinical experience, PED may significantly improve the endovascular treatment of complex aneurysms.
  • 90. Take Home Messages Know the patient. Treat the patient; not only the artery. Learn from other peoples mistakes, better than learning from your own. Learn techniques from different people and then come up with your own. Keep it simple. Risk free Intracranial Stenting is not doing it. Recognize your limits; dont push your luck
  • 91. Thank you ! Gracias