Endovascular treatment of complex aneurysms at the vertebrobasilar junction with flow-diverting stents: initial experience.

Meckel, Stephan; McAuliffe, William; Fiorella, David; Taschner, Christian A; Phatouros, Constantine; Phillips, Timothy John; Vasak, Paul; Schumacher, Martin; Klisch, Joachim

BACKGROUND Large or giant complex vertebrobasilar junction aneurysms have a dismal natural history and are often challenging to treat with standard endovascular or neurosurgical techniques. OBJECTIVE To report initial experience with endovascular treatment of these aneurysms using flow-diverting stents (FDS). METHODS Ten patients with FDS treatment of complex vertebrobasilar junction aneurysms were collected from 4 large cerebrovascular centers. Clinical/angiographic presentation and outcome were retrospectively analyzed. RESULTS Of 10 aneurysms, 7 presented with brainstem compression, 2 with ischemia, and 1 with subarachnoid hemorrhage, and 3 were recurrent after stent-assisted treatments. Eight were giant. Morphology was fusiform in 5, fusiform dissecting in 1, and multilobulated saccular in 4. Six were partially thrombosed. In addition to FDS (mean number of devices, 3.9; range, 1-9), contralateral vertebral artery sacrifice and adjunctive coiling were performed in 9 and 5 of the 10 patients, respectively. At follow-up, 5 of 10 were completely occluded, 4 showed minimal residual filling, and 1 was retreated with an additional FDS. Postinterventionally, worsening mass effect and ischemic complications were seen in 2 and 4 of 10, respectively. Clinical outcome was good in 6 (modified Rankin Scale score, 0-2). Four fatalities were related to sequelae of subarachnoid hemorrhage, late FDS thrombosis, progressive mass effect, and delayed intracranial hemorrhage. CONCLUSION FDS may be used to treat complex vertebrobasilar junction aneurysms with overall good angiographic outcome. A combined reconstructive/deconstructive approach appears useful to avoid endoleaks. FDS strategies, like other endovascular and neurosurgical approaches to these lesions, are associated with significant risk and therefore should be reserved for those cases in which alternative approaches either are deemed unsafe or are likely to be ineffective. ABBREVIATIONS FDS, flow-diverting stentPED, Pipeline Embolization DeviceSAH, subarachnoid hemorrhageVA, vertebral arteryVBJ, vertebrobasilar junction.