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Intracranial/ brain aneurysms are if
ruptured can be fatal or can cause signiﬁcant morbidity that can limit the quality of life. With the advent of newer endovascular
techniques, these aneurysms now can be treated safely with durable eﬃcacy. One of the latest in this armamentarium is ﬂow diverter stent mostly used to treat even the most complicated brain aneurysms.
Flow diverters are biocompatible, specially designed stents meant to be placed in brain blood vessels, to divert blood away from weak points/aneurysms in the blood vessels. They allow normal blood supply through the side branches while restraining the blood ﬂow into the redundant and weak structures like brain aneurysms. After placement of the stents across the brain aneurysm, the aneurysm will slowly shrink in size, completely disappear/ obliterate in 3 months to 1 year.
They are highly ﬂexible, high mesh work, hollow metallic tubes composed of tightly woven braided wires ( varying between 48-64 wires) , which eﬀectively increase the metal density of the stent surface
Flow diverters are used to treat brain aneurysms with following morphological parameters
• Unruptured brain saccular aneurysms having wide neck ( neck > 4mm, Neck/ Dome ratio < 0.5)
• Fusiform, dissecting, blister aneurysms (Irrespective of size)
• Ruptured aneurysms which are not amenable for coiling/ clipping
Currently around 6 diﬀerent types of ﬂow diverter stents are available in India. Pipeline (Medtronic, USA), Surpass ( Stryker, USA), Silk vista ( BALT, Germany), FRED ( Microvention, USA), Derivo (Acandis, Germany), p64/p48 ( Phenox, Germany) are the currently available ﬂow diverter stents in India. Out of these Pipline and Surpass are FDA approved devices.
Each of the stent oﬀers speciﬁc technology including DFT technology ( for better ﬂuoroscopic visibility), HPC technology ( For less thrombogenecity: available in Pipline Shield, p64 HPC), usability in very small vessels ( Silk Vista baby, p48 HPC, FRED Jr). The eﬃcacy of ﬂow diversion depends upon extent of metal coverage ( usually 30-45%) which is highest in Surpass ﬂow diverter. Other technical factors which increase the operator comfort and patient safety include proﬁle of the device delivery microcatheter, stent opening, resheathibility, detachment methods.
The procedure requires hospital admission ( usually for 2-3 days). The patient needs to be fasting at least 6 hrs prior to the procedure. The procedure is a minimally invasive one, done either through the femoral route ( groin) or through the radial route ( Hand). It is usually done under
general anaesthesia and procedure lasts roughly for 2-3 hrs. A small nick is placed in the artery in the groin or hand , and small tubes called catheters are navigated into the neck through the sheath placed in the artery. Further through these catheters/ tubes the ﬂow diverter devices are delivered and placed within the desired segment of brain blood vessel. The procedure does not require any suture or long cuts, so the patient can ambulate on the next day. Generally after an uncomplicated procedure, patient needs to stay in hospital for a day or two for observation.
The ﬂow diverter stent placement requires prior administration of blood thinners called anti platelets. It requires them to be administered at least 6 hrs before the procedure. The patient needs to be on these blood thinner medication for at least 1 year after the procedure.
The aneurysms treated with ﬂow diverter usually gradually obliterated in 3 - 12 months follow up period. So it requires an angiography by either CT angiography or DSA at 3 months/ 6 months/ 12 months time to demonstrate the aneurysm complete occlusion and modify the anti platelet therapy accordingly
With the evolution of technology, in experienced hands, the complication rate is less than 5%. Complications include hematoma ( blood clot collection at groin), hemorrhagic or ischemic stroke which can be minor or major. However, these can be avoided in most cases by proper procedure planning, optimal device selection, attentive post procedure care.
DR.SURESH GIRAGANI CONSULTANT INTERVENTIONAL RADIOLOGIST at Yashoda group of hospitals, has more than
years of clinical experience in vascular interventions with a special interest in neurovascular and peripheral vascular disease interventional procedures.
+91 99121 82862
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