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Endovascular Treatment of Cerebral Aneurysms Current Devices, Emerging Therapies, and Future Technology for the Management of Cerebral Aneurysms

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Endovascular Treatment of Cerebral Aneurysms Current Devices, Emerging Therapies, and Future Technology for the Management of Cerebral Aneurysms COVER STORY Endovascular Treatment of Cerebral Aneurysms Current devices, emerging therapies, and future technology for the management of cerebral aneurysms. BY DAVID FIORELLA, MD, PHD; MICHAEL E. KELLY, MD; RAYMOND D. TURNER IV, MD; AND PEDRO LYLYK, MD uring the past 2 decades, the endovascular Ruptured Aneurysms treatment of cerebral aneurysms has quickly These lesions are almost always treated provided that evolved from a nascent technology to a front- the patient is neurologically and physiologically well line therapy using sophisticated disease and enough to undergo therapy, either surgical clipping or Danatomy-specific devices that allow the minimally inva- endovascular coiling. Subarachnoid hemorrhage from sive treatment of even the most complex cerebrovascular aneurysm rupture is a devastating event with a case-fatali- lesions. The available devices have transitioned from ty rate of 51% and a 50% rate of significant disability implantable balloons to embolization coils, to bioactive among survivors.1,2 embolization coils, to adjunctive intracranial stents for Treatment is typically carried out urgently rather than use with embolization coils, and ultimately to “stand- emergently, usually within 24 hours after the arrival of the alone” stent-like devices. The fundamental basis for treat- patient to the hospital. Initially, there was considerable ment is rapidly shifting from techniques that are targeted controversy with respect to the treatment modality that at occluding the aneurysm sac (endosaccular occlusion) was best suited for the right of first refusal for therapy, to those designed to achieve a durable physiological however, much of this controversy was settled by the reconstruction of the parent vessel that gives rise to the International Subarachnoid Aneurysm Trial (ISAT), which aneurysm (parent vessel reconstruction). In this article, demonstrated that for aneurysms amenable to either ther- we review the predicate devices, currently available treat- apy, patients undergoing coil embolization had better ments, and finally the status of new and emerging tech- long-term outcomes than those who underwent open sur- nologies. gical clipping.3,4 Although there were some concerns regarding the durability of coil embolization as a treat- INDICATIONS FOR CEREBRAL ment modality, an analysis of the ISAT data demonstrated ANEURYSM TREATMENT that the superiority of endovascular coiling was preserved In general, there are two broad categories of intracra- for at least 7 years after treatment.3 For this reason, at nial aneurysms: (1) those that have already ruptured, cre- most institutions, endovascular coiling is granted the right ating subarachnoid hemorrhage, and (2) those that are of first refusal for ruptured aneurysms amenable to either unruptured. Typically, unruptured aneurysms are asymp- treatment modality. tomatic; however, rarely they may become sympto- matic—usually due to their size and subsequent mass Unruptured Aneurysms effect. The management of these two types of lesions dif- The vast majority of aneurysms discovered incidentally fers dramatically. are completely asymptomatic. During the past decade, JUNE 2008 I ENDOVASCULAR TODAY I 53 COVER STORY with the proliferation of noninvasive cerebrovascular imag- Occasionally, an unruptured aneurysm may become ing studies ordered by referring physicians, we have begun suddenly symptomatic, typically related to either an to diagnose small, unruptured aneurysms with increasing abrupt increase in size or less frequently acute thrombosis. frequency. The diagnosis typically is the cause of great anx- The most common example is a posterior communicating iety on the part of the patient and referring physician, artery aneurysm that classically produces the acute onset resulting in immediate referral to a cerebrovascular inter- of third nerve palsy. This clinical scenario typically is a har- ventionist for evaluation. At this point, the decision of binger of impending aneurysm rupture and should whether to treat must be based on the best available evi- prompt treatment on an accelerated basis. dence regarding the risk of rupture of an incidentally diag- nosed cerebral aneurysm. Unfortunately, the available evi- ANEURYSM TREATMENT dence and its interpretation are still actively debated, and The Past these decisions are rarely straightforward. Ultimately, three A number of strategies for endovascular aneurysm treat- options are typically provided—conservative management ment have been employed during the past 3 decades. In (with or without imaging surveillance), open surgical clip- 1970, Serbinenko first described the use of implantable ping, and endovascular coil embolization—with the latex balloons in the management of cerebral aneurysms.15 patient making a final decision based on a fair and unbi- Whereas the technique described by Serbinenko usually ased presentation of the available data regarding all treat- involved occlusion or deconstruction of the parent vessel ment modalities. and aneurysm, further development of balloon and The largest study of the natural history of incidentally catheter technology allowed for the placement of detach- discovered unruptured intracranial aneurysms (The able silicone or latex balloons directly into cerebral International Study of Unruptured Intracranial Aneurysms aneurysms, allowing, in some cases, a constructive occlu- [ISUIA]) is highly controversial and indicated much lower sion of the aneurysm with preservation of the parent ves- rates of annual rupture than the majority of previous stud- sel.16-18 Given the developmental nature of this technology, ies on this topic.5-13 It is accepted that the risk of rupture of the lesions treated were generally limited to those that an incidental aneurysm is most closely related to its size. were believed to be of unacceptably high rates of surgical Kotomar et al,14 in their recent summary of this available lit- morbidity (ie, giant aneurysms), particularly involving the erature, estimated a yearly risk of rupture of approximately posterior circulation and aneurysms in patients too ill to 1% for lesions between 7 mm and 10 mm, with the risk undergo surgery. Predictably, these treatments were associ- being much lower in lesions <5 mm and significantly higher ated with very high rates (at least 30%) of serious peripro- in lesions >10 mm. Whereas small aneurysms (<5 mm) are cedural morbidity and mortality.19 generally left untreated, larger lesions, particularly in patients younger than 60 years, are considered for treatment with The Present the preference toward treatment increasing with aneurysm Detachable coils. The modern era of neuroendovascu- size. For lesions >10 mm, treatment is generally recom- lar aneurysm treatment was heralded by the develop- mended in most patients who are without significant other ment of detachable platinum coils in the early 1990s and comorbidities and are younger than 70 years of age.14 their subsequent FDA approval in 1995.20,21 These flexible, When left untreated, patients are sometimes offered soft, detachable coils could be delivered through a micro- serial imaging for surveillance of the aneurysm, with the catheter that could be safely navigated into the targeted idea that any increase in size or change in morphology aneurysm. Intra-aneurysmal coil placement was also far could represent an indication for treatment. However, as a more atraumatic, controllable, and safer than the manip- practical matter, for a small aneurysm (eg, 4 mm), whereas ulation, insufflation, and detachment of the predicate sili- a 1-mm change in the size of the aneurysm might be diffi- cone balloons. Once coils were introduced and commer- cult to detect even with the most advanced noninvasive cially available, there was a proliferation of reports imaging systems (CTA or MRA), this small change in diam- describing their application in the embolization of eter translates to a doubling of the aneurysm volume. intracranial aneurysms. Complex-shaped, three-dimen- Also, there is no guarantee that an aneurysm will sional coils were developed to facilitate the embolization detectably change in size or morphology prior to ruptur- of wide-necked aneurysms. Coils with faster detachment ing. As such, this recommendation of serial imaging fol- times were developed to speed the process of emboliza- low-up is somewhat controversial, but often provides tion and shorten procedure times. As aneurysm some piece of mind to the patients (and their physicians), embolization with the Guglielmi Detachable Coil (GDC, and occasionally might demonstrate significant interval Boston Scientific Corporation, Natick, MA) became growth of a lesion. increasingly accepted and more widely performed, com- 54 I ENDOVASCULAR TODAY I JUNE 2008 COVER STORY AB aneurysm fundus, through the wide neck and into the par- ent vessel, giving rise to possible thromboembolic compli- cations or unintentional parent vessel occlusion. Initially, these wide-necked lesions were labeled as inappropriate for endovascular therapy and were largely referred for open surgical treatment. Balloon Remodeling In the late 1990s, the technique of balloon remodeling CD was developed for the treatment of wide-necked aneurysms.22,23 With the balloon remodeling technique, a temporary occlusion balloon is inflated across the neck of the aneurysm while embolization coils are introduced. The balloon functions to prevent the prolapse of coils into the parent vessel. After the introduction of a coil under bal- loon protection, the occlusion balloon is
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