Should indications for WEB aneurysm treatment be enlarged? Report of a series of 20 patients with aneurysms in “atypical” locations for WEB treatment

doi:10.1016/j.neurad.2016.12.011

Journal of Neuroradiology

Volume 44, Issue 3, June 2017, Pages 203-209

https://doi.org/10.1016/j.neurad.2016.12.011 Get rights and content

Abstract

Background and purpose

Flow disruption with the WEB device is an innovative technique for the endovascular treatment of wide neck bifurcation aneurysms. Good clinical practice trials have shown high safety of this treatment with good efficacy. Technical developments (single layer devices and smaller microcatheters) facilitate the treatment, potentially leading to enlargement of indications. This series is collecting aneurysms in “atypical” locations for WEB treatment and analyzing safety and efficacy of this treatment.

Materials and methods

In each participating center, patients with aneurysms treated with WEB were prospectively included in a local database. Patients treated for aneurysms in “atypical” locations were extracted. Patient and aneurysm characteristics, intraoperative complications, and anatomical results at the end of the procedure and at last follow-up were collected and analyzed.

Results

Five French neurointerventional centers included 20 patients with 20 aneurysms in “atypical” locations for WEB treatment treated with WEB. Aneurysm locations were ICA carotid-ophthalmic in 9 aneurysms (45.0%), ICA posterior communicating in 4 (20.0%), Pericallosal artery in 5 (25.0%), and basilar artery between P1 and superior cerebellar artery in 2 (10.0%). There were no complications (thromboembolic or intraoperative rupture) in this series. At follow-up (mean: 7.4 months), adequate occlusion was obtained in 100.0% of aneurysms.

Conclusions

This series confirms that it is possible to enlarge indications of WEB treatment to “atypical” locations with good safety and efficacy. These data have to be confirmed in large prospective series.

Introduction

Endovascular treatment (EVT) is now the first line treatment for ruptured and unruptured aneurysms, but aneurysms with a complex anatomy (singularly wide-neck aneurysms) are in some cases untreatable or difficult to treat with standard coiling and that prompted the development of new endovascular techniques, such as balloon-assisted coiling, stent-assisted coiling, and flow diversion [1], [2], [3], [4], [5], [6], [7], [8], [9].

Flow disruption is a new endovascular approach, which involves placement of an intrasaccular device, which modifies the blood flow at the level of the neck and induces aneurysmal thrombosis. The WEB (Sequent Medical, Aliso Viejo, CA) was designed to treat wide necked bifurcation aneurysms [10], [11], [12], [13]. The device has been progressively developed from a dual-layer version (WEB DL) to single-layer versions (WEB SL and WEB SLS, single layer spherical). Good clinical practice (GCP) series showed good safety and efficacy of the treatment with no mortality and 2.7% morbidity at 1 month [14], [15], [16], [17]. In a recent meta-analysis, perioperative morbidity and mortality rates were 4% and 1%, respectively [18]. In addition, mid-term and long-term anatomical results were evaluated in retrospective series showing good stability of the treatment [19], [20].

Due to technical developments (single layer devices, enhanced visualization devices, smaller microcatheters), WEB treatment is becoming an option for aneurysms not located in usual locations: internal carotid artery (ICA), middle cerebral artery (MCA), anterior communicating artery (Acom), basilar tip (BT) and also for small aneurysms or aneurysms with small neck. To evaluate the feasibility and results of WEB treatment in these “atypical” locations, a retrospective analysis of patients prospectively included in local databases of neurointerventional centers were collected and analyzed.

Section snippets

Materials and methods

The study received Reims institutional review board approval. Written informed consent was waived due to the retrospective nature of the trial.

Patient and aneurysm population

Between August 2011 and June 2016, 5 French centers included 20 patients (14 females, 70.0%) aged 32 to 73 years with 20 aneurysms in “atypical” locations (Table 1).

Five (25.0%) aneurysms were ruptured (World federation of neurosurgery grade 1 in 3 patients and 2 in 2 patients) and 15 (75.0%) unruptured. Aneurysm locations were ICA carotid-ophthalmic (ICA-oph) in 9 aneurysms (45.0%), ICA posterior communicating (ICA-Pcom) in 4 (20.0%), pericallosal artery in 5 (25.0%), and basilar artery

Discussion

Flow disruption is an innovative endovascular treatment that was initially designed for the treatment of wide-neck bifurcation aneurysms (WNBA). Initial indications were aneurysms located at MCA bifurcation, Acom, ICA terminus, and top of the BA [10], [11], [12], [13]. Feasibility, safety, and efficacy were evaluated for these locations in several GCP trials including WEBCAST, French observatory, and WEBCAST-2 [14], [15], [16], [17], [18]. The WEB implant has rapidly evolved from larger profile

Conclusion

This series illustrates the progressive enlargement of indications for WEB aneurysm treatment. Initially dedicated to wide neck bifurcation aneurysms, WEB can now be used in other locations, including ICA (carotidophthalmic and posterior communicating), pericallosal, and BA-SCA.

Disclosure of interest

L. Pierot is consultant for Microvention/Sequent.

References (23)

L. Pierot
Flow diverter stents in the treatment of intracranial aneurysms: where are we?
J Neuroradiol.
(2011)
C. Cognard et al.
Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: clinical results of the Clarity GDC study
Neurosurgery.
(2011)
L. Pierot et al.
Clinical outcome of patients harbouring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA trial
Stroke.
(2008)
L. Pierot et al.
Safety and efficacy of balloon remodeling technique during endovascular treatment of intracranial aneurysms: critical review of the literature
AJNR Am J Neuroradiol.
(2012)
L. Pierot et al.
Endovascular treatment of unruptured intracranial aneurysms: Comparison of Safety of remodeling technique and standard treatment with coils
Radiology.
(2009)
L. Pierot et al.
The remodelling technique for endovascular treatment of ruptured intracranial aneurysms is more efficacious than standard coiling with a similar safety
Radiology.
(2011)
M. Shapiro et al.
Stent-supported aneurysm coiling: a literature survey of treatment and follow-up
AJNR Am J Neuroradiol
(2012)
J. Berge et al.
Flow-diverter silk stent for the treatment of intracranial aneurysms: 1-year follow-up in a multicenter study
AJNR Am J Neuroradiol.
(2012)
L. Pierot et al.
Endovascular treatment of intracranial aneurysms: current status
Stroke
(2013)
L. Pierot et al.
Intrasaccular flow disruption: a new endovascular approach for the treatment of intracranial aneurysms. Results of a preliminary clinical evaluation in a multicenter series
AJNR Am J Neuroradiol.
(2012)

L. Pierot et al.

Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study

Neurosurgery.

(2013)

Cited by (44)

Oversizing of the Woven EndoBridge for Treatment of Intracranial Aneurysms Improves Angiographic Results (WEBINAR)
2024, World Neurosurgery
Several studies have demonstrated a high safety and efficacy profile of the Woven EndoBridge (WEB) for endovascular aneurysm treatment. However, contemporary large-scale studies of the WEB are rare. This multicenter study attempts to set a benchmark for state-of-the-art WEB treatment with consistent application of the WEB oversizing technique.
This is a retrospective, multicenter study of aneurysms (dome width 2–10 mm) treated with the WEB between 2015 and 2023. Patient and aneurysm characteristics, complications, and clinical and angiographic outcomes were analyzed.
The study consisted of 247 patients treated for 251 aneurysms (25.5% ruptured, 5.6% recurrent). WEB implantation was feasible in 98.8%, achieving a mean WEB/dome ratio of 1.2 ± 0.1. The thromboembolic complication rate was 7.2%, which was higher in ruptured versus unruptured aneurysms (hazard ratio: 2.8, 95%CI: 1.0–7.6, P = 0.04), but lower in cases where WEB 17 was used (hazard ratio: 4.0, 95%CI: 1.4–11.2, P = 0.01). Neurological complications occurred in 8 procedures (3.2%), including 3 (1.2%) major, and 5 (2.0%) minor events. Procedural morbidity and mortality were 0.8% and 0%, respectively. Mid-term complete and adequate occlusion rates were 66.3% and 88.4%, respectively. The retreatment rate was 5.2%. Feasibility, complication, and occlusion rates were comparable between typical and atypical aneurysm locations.
Oversizing the WEB and using currently available WEB types in this series resulted in slightly better treatment outcomes compared to early WEB studies, confirming the high safety, feasibility, and efficacy of this technique.
Endovascular Treatment and Microsurgical Clipping for the Management of Paraclinoid Intracranial Aneurysms: A Systematic Review and Meta-Analysis
2023, World Neurosurgery
We aimed to compare the efficacy and safety of microsurgical clipping versus endovascular treatment (EVT) for paraclinoid aneurysms.
A systematic search for studies including patients with paraclinoid aneurysms treated with a microsurgical or endovascular technique was conducted in 6 databases from inception to February 2022. Efficacy outcomes included complete angiographic occlusion at last follow-up, favorable functional outcome, and recurrence of the aneurysm. For safety, we assessed a composite of intraoperative and postoperative complications. Data were pooled using a random-effects model.
A total of 95 studies including 6711 patients, 3029 in the surgical group and 3682 in the EVT group were found. Pooled rates of complete occlusion were 94% (95% CI 91%–96%; I² = 0%) in the surgical group and 69% (95% CI 63%–74%; I² = 79%) in the EVT group, respectively. The favorable functional outcome rate was 86% (95% CI 76%–92%; I² = 72%) with surgical treatment and 95% (95% CI 92%–97%; I² = 61%) with EVT. The rate of aneurysm recurrence with surgical treatment was 1% (95% CI 0%–4%; I² = 0%) and 12% (95% CI 9%–16%; I² = 57%) with EVT. The composite safety outcome rate in the surgical group was 24% (95% CI 18%–30%; I² = 90%) and 10% (95% CI 8%–13%; I² = 71%) in the EVT group.
Our findings suggest that microsurgical clipping seems to have a higher efficacy than EVT in terms of angiographic occlusion and aneurysm recurrence; however, EVT seems to be safer in terms of intraoperative and postoperative complications. Considering the heterogeneity and low-level evidence of the data available, further prospective randomized studies are warranted to confirm our findings.
How a decade of aneurysms embolization with the Woven EndoBridge has changed our understanding and practices?
2023, Journal of Neuroradiology
Safety and efficacy of the WEB (Woven EndoBridge) device have been extensively evaluated in several good clinical practice studies. Nonetheless, the WEB had several structural evolutions overtime up to the fifth generation WEB device (WEB17). Here, we tried to understand how this may have modified our practices and enlarged our indications for its use.
We retrospectively analyzed data from all patients with aneurysms treated (or intended to be treated) with a WEB at our institution between July 2012 and February 2022. The time frame was split in two periods: before and after the arrival of the WEB17 in our center (February 2017).
252 patients with 276 wide-necked aneurysms were included; 78 aneurysms (28.2%) were ruptured. Successful embolization with a WEB device was achieved in 263/276 aneurysms (95.3%). With the availability of WEB17, treated aneurysms were significantly smaller (8.2 mm versus 5.9 mm, p<0.001) and off-label location significantly increased (4.4% versus 17.3%, p = 0.02) with an increase of sidewall aneurysm (4.4% versus 11.6%, p = 0.06). Also, WEB were more significantly oversized (1.05 versus 1.11, p<0.01). Adequate and complete occlusion rates increased constantly during the two periods (54.8% versus 67.5%, p = 0.08 and 74.2% versus 83.7%, p = 0.10, respectively). The proportion of ruptured aneurysms slightly increased between the two periods (24.6% versus 29.5%, p = 0.44).
Over the first decade of its availability, the WEB device usage shifted towards smaller aneurysms and broader indications, including ruptured aneurysms. The oversizing strategy also became the standard of practice for WEB deployment in our institution.
Intrasaccular Flow Disruption with the Woven EndoBridge for Narrow-Necked Aneurysms: A Safety and Feasibility Study
2021, World Neurosurgery
Citation Excerpt :
In 2018, the WEB received approval of the U.S. Food and Drug Administration for treatment of wide-necked aneurysms with diameters of 3–10 mm located at the anterior communicating artery, internal carotid artery (ICA) terminus, middle cerebral artery bifurcation, and basilar tip.5 Encouraged by the positive clinical and angiographic results of the WEB studies, the device has become increasingly popular, and the indications for its use are continuously expanding.6,7 However, in the available literature, the WEB has been predominantly used and evaluated for wide-necked aneurysms.
The Woven EndoBridge (WEB) received U.S. Food and Drug Administration approval for endovascular treatment of wide-necked bifurcation aneurysms. We evaluated the feasibility, safety, and efficacy of the WEB for treatment of narrow-necked aneurysms.
This multicenter study included 17 narrow-necked aneurysms, defined by a neck width <4 mm and a dome-to-neck ratio >2. Aneurysm characteristics, treatment strategies, technical success, complications, and angiographic outcomes were retrospectively assessed.
Aneurysm locations included the internal carotid artery (7 cases), anterior communicating artery (4 cases), middle cerebral artery (4 cases), and basilar artery (2 cases). The median aneurysm size was 7.4 mm with a median neck width of 2.3 mm. The technical success rate was 100%. There were no neurological complications. Angiographic control revealed complete and adequate occlusion in 13 of 15 (86.7%) and 14 of 15 (93.3%) cases, respectively, after 6 months and in 6 of 7 (85.6%) and 7 of 7 (100%) cases, respectively, after a median of 13 months. Two aneurysms were retreated with flow diverters.
WEB embolization of narrow-necked aneurysms was technically feasible and safe and might be considered as an alternative treatment option to conventional coiling in selected cases.
Endovascular Treatment of Intracranial Aneurysms
2021, Stroke: Pathophysiology, Diagnosis, and Management
In the past three decades, endovascular therapy (EVT) has replaced microsurgical clipping as the main treatment modality for both unruptured and ruptured intracranial aneurysms (IA). EVT techniques and devices have quickly evolved and now allow a safe and effective minimally invasive treatment of IAs previously considered inoperable. Newer technologies allow not only a permanent occlusion of the IA but use engineering concepts combined with blood flow physiology to reconstruct the anatomic integrity of the parent artery. The chapter discusses the evolution of EVT and provides updated treatment guidelines based on landmark clinical trials.
WEB-assisted microwire navigation for the treatment of complex wide-neck intracranial aneurysms: Technical note
2020, Journal of Neuroradiology
Unfavorable aneurysm anatomy can make microwire navigation challenging, increasing the risk of complications. We present our experience of WEB-assisted microcatheterization in complex aneurysms.
Flow diversion was performed for three wide-neck large/giant intracranial aneurysms. A WEB was placed inside the sac, blocking the aneurysm neck and providing a contact surface to redirect the microwire across the aneurysm.
WEB-assisted microcatheterization appears an alternative strategy for the treatment of complex aneurysms.

View all citing articles on Scopus

View full text

Original ArticleShould indications for WEB aneurysm treatment be enlarged? Report of a series of 20 patients with aneurysms in “atypical” locations for WEB treatment

Abstract

Background and purpose

Materials and methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Patient and aneurysm population

Discussion

Conclusion

Disclosure of interest

J Neuroradiol.

Results of embolization used as the first treatment choice in a consecutive nonselected population of ruptured aneurysms: clinical results of the Clarity GDC study

Neurosurgery.

Clinical outcome of patients harbouring unruptured intracranial aneurysms treated by endovascular approach: results of the ATENA trial

Stroke.

Safety and efficacy of balloon remodeling technique during endovascular treatment of intracranial aneurysms: critical review of the literature

AJNR Am J Neuroradiol.

Endovascular treatment of unruptured intracranial aneurysms: Comparison of Safety of remodeling technique and standard treatment with coils

Radiology.

The remodelling technique for endovascular treatment of ruptured intracranial aneurysms is more efficacious than standard coiling with a similar safety

Radiology.

Stent-supported aneurysm coiling: a literature survey of treatment and follow-up

AJNR Am J Neuroradiol

Flow-diverter silk stent for the treatment of intracranial aneurysms: 1-year follow-up in a multicenter study

AJNR Am J Neuroradiol.

Endovascular treatment of intracranial aneurysms: current status

Stroke

Intrasaccular flow disruption: a new endovascular approach for the treatment of intracranial aneurysms. Results of a preliminary clinical evaluation in a multicenter series

AJNR Am J Neuroradiol.

Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study

Neurosurgery.

Original Article
Should indications for WEB aneurysm treatment be enlarged? Report of a series of 20 patients with aneurysms in “atypical” locations for WEB treatment