BACKGROUND: Reconstructive strategies for unruptured vertebral artery dissecting aneurysms (VADAs) have increasingly relied on newly developed endovascular devices. However, their clinical performance metrics are seldom reported. OBJECTIVE: To compare stent-assisted coil embolization (SACE) and flow-diverting stent (FDS) deployment as treatments for unruptured VADAs, focusing on efficacy and safety. METHODS: A total of 72 VADAs were submitted to SACE (n = 48) or FDS (n = 24) between April 2009 and September 2021. We reviewed medical records and radiological data to assess efficacy and safety outcomes by method, building an inverse probability of treatment-weighted (IPTW) logistic regression model and conducting survival analyses. RESULTS: Ultimately, 24 aneurysms (33.3%) showed signs of recanalization (major, 14; minor, 10) at 6-month follow-up. Initially determined 6-month rates of overall (SACE, 31.2%; FDS, 41.7%) and major (SACE, 20.8%; FDS, 16.7%) recanalization did not differ significantly by modality; but in the IPTW logistic regression model, adjusted for aneurysm morphology, major recanalization at 6 months was lower for the FDS (vs SACE) subset (odds ratio = 0.196; P = .027). Likewise, the cumulative rate of major recanalization was more favorable for the FDS (vs SACE) subset (hazard ratio = 0.291; P = .048) in IPTW Cox proportional hazards model adjusted for aneurysm morphology. Modality-based assessments of procedural and delayed complications were similar. CONCLUSION: Both reconstructive VADA interventions are safe and effective by adjusting treatment modality depending on the angioanatomic configuration. However, follow-up data after treatment proved more favorable for FDS deployment than for SACE in limiting major recanalization. Case-controlled studies of more sizeable cohorts are needed for corroboration.

Stent-Assisted Coil Embolization Versus Flow-Diverting Stent in Unruptured Vertebral Artery Dissecting Aneurysms: Efficacy and Safety Comparison

Background It is necessary to explore the safety and efficacy of various endovascular treatment techniques in the treatment of patients with intracranial vertebrobasilar trunk dissecting aneurysms (VBTDAs). This study sought to compare the clinical and angiographic outcomes of patients with intracranial VBTDAs following low-profile visualized intraluminal support (LVIS)-within-Enterprise overlapping-stent technique with those of flow diversion (FD). Methods This was a retrospective, observational, cohort study. Between January 2014 and March 2022, 9,147 patients with intracranial aneurysms were screened, and 91 patients with 95 VBTDAs who underwent LVIS-within-Enterprise overlapping-stent assisted–coiling technique or FD were included in the analysis. The primary outcome was the complete occlusion rate at the last angiographic follow-up. The secondary outcomes included adequate aneurysm occlusion, in-stent stenosis/thrombosis, general neurological complications, neurological complications within 30 days after the procedure, the mortality rate, and unfavorable outcomes. Results Among the 91 included patients, 55 were treated with LVIS-within-Enterprise overlapping-stent technique (the LE group) and 36 were treated with FD (the FD group). The angiography results at the median follow-up time of 8 months showed complete occlusion rates of 90.0% and 60.9% for the LE and FD groups, respectively, with an adjusted odds ratio of 5.79 (95% CI: 1.35–24.85; P=0.01). Adequate aneurysm occlusion (P=0.98), in-stent stenosis/thrombosis (P=0.46), general neurological complications (P=0.22), neurological complications within 30 days after the procedure (P=0.63), mortality rate (P=0.31), and unfavorable outcomes (P=0.07) at the last clinical follow-up did not differ significantly between the 2 groups. Conclusions A significantly higher complete occlusion rate for VBTDAs was found following LVIS-within-Enterprise overlapping-stent technique as compared with FD. The 2 treatment modalities have comparable adequate occlusion rates and safety profiles.

/pdf/low-profile-visualized-intraluminal-support-within-13nw0ff0.pdf

Low-profile visualized intraluminal support-within-Enterprise overlapping-stent technique versus flow diversion in the treatment of intracranial vertebrobasilar trunk dissecting aneurysms

The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications.To describe our experience with the Enterprise stent being used for SAC and other off-label indications.This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study.Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05).Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices. 

The Enterprise stent…still useful after all these years

Flow-Diverting Devices in the Treatment of Vertebral Artery Aneurysms: Insights into Efficacy and Safety from a Systematic Review and Meta-analysis.

7年の経過で拡大し，治療に苦慮した椎骨動脈解離症例を経験したので，治療方針の考察とともに報告する．症例は40代女性（発症時），頭痛精査で椎骨動脈（VA）解離（17×5mm）と診断され，脳梗塞や出血なく経過したが，7年後に病変が拡大を認め（24×9mm）紹介された．紹介時，無症候で，血圧は適切に管理されていた．画像上はPICA involved VA解離で患側VAは対側への蛇行し，壁在血栓が確認され，開頭手術ではVA-PICA分岐部および病変末梢側の確保が困難と予測された．一方，脳血管内治療では壁在血栓による塞栓性合併症とPICA閉塞が危惧された．虚血性合併症を回避するためVA-PICA分岐部の閉鎖は行わず，OA-PICA吻合術とVAの近位閉塞のみで動脈瘤の血栓化を図ることとした．術後，脳動脈瘤の血栓化が得られ，虚血性障害をきたさず退院し，1年11カ月の経過で再発は認めない．PICA involved VA解離では，OA-PICA吻合術とVA近位部閉塞により，VA-PICA分岐部を閉鎖せずとも動脈瘤が血栓化する可能性がある． 

pdf/enlarging-asymptomatic-pica-involved-vertebral-artery-p1999w07n4.pdf

Enlarging Asymptomatic PICA Involved Vertebral Artery Dissection: A Case with Challenging Treatment Strategy

OBJECTIVE To evaluate predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs) based on 608 reconstructed lesions in 30 medical centres. METHODS A total of 608 patients (male:female=479:129; mean age, 53.26±10.26 years) with 608 symptomatic uis-VADAs underwent reconstructive treatments using stent(s) with coils between January 2009 and December 2015. Treatments and predictors of unfavorable outcomes were retrospectively analyzed. RESULTS Mainly, three methods were used to treat patients with uis-VADAs, including routine single-stent in 208 patients (such as Enterprise and others), new low-profile LVIS single stent in 107 patients, and multiple stents in 293 patients. During the median 66 months of clinical follow-up, 14 patients died, and 16 of the remaining 594 survivors had unfavorable outcomes (modified Rankin Scale score 3-5). The overall mortality rate was 2.3% (14/608), and the unfavorable outcome (mRS score 3-6) rate was 4.9% (30/608). Multivariate logistic regression analysis indicated that preprocedural ischemic infarctions (OR=3.78; 95% CI 1.52 to 9.40; p<0.01), diabetes mellitus (OR=3.74; 95% CI 1.31 to 10.68; p=0.01), and procedural complications (OR=14.18; 95% CI 5.47 to 36.80; p<0.01) were predictors of unfavorable outcome in the reconstructed VADAs. CONCLUSIONS This multicenter study indicated that preprocedural ischemic infarctions, diabetes mellitus, and procedural complications were related to unfavorable clinical outcomes in the reconstructed uis-VADAs.

https://jnis.bmj.com/content/neurintsurg/early/2021/11/09/neurintsurg-2021-017619.full.pdf

Predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs): results from a multicenter study

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Predictors of unfavorable outcome in stent-assisted coiling for symptomatic unruptured intracranial spontaneous vertebral artery dissecting aneurysms (uis-VADAs): results from a multicenter study