Complications associated with stent-assisted coil embolization of wide-neck intracranial aneurysms

doi:10.3969/j.issn.2095-4344.2017.34.016

Abstract

Abstract:

BACKGROUND: Stent-assisted coil embolization has become an important technique for the treatment of intracranial complex aneurysms. However, there is no systematic analysis of complications and prevention strategies related to this technique.

OBJECTIVE: To systematically analyze the complications related to stent-assisted coil embolization of intracranial aneurysms during perioperative and follow-up periods and to assess the safety of this method.

METHODS: A retrospective study of 232 consecutive patients with 239 wide-necked aneurysms who underwent stent-assisted coil embolization at the Department of Neurosurgery, General Hospital of Shenyang Military Command from July 2003 to December 2009 was performed. Angiographic results and clinical outcomes were evaluated. A variety of complications were analyzed. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcomes and follow-up angiography were evaluated.

RESULTS AND CONCLUSION: Stenting was successful in the 236 of 239 aneurysms. Procedure-related complications included thomboembolism (n=13), intraprocedural rupture (n=8), coil protrusions (n=5), new mass effect (n=3), vessel injury (n=3), and stent dislodgement (n=2). Procedure-related morbidity and mortality was 4.3% (10/232) and 1.3% (3/232), respectively. Nonprocedural complications attributable to subarachnoid hemorrhage in 129 patients with acute ruptured aneurysms were symptomatic vasospasm (18.6%, 24/129) and shunt-dependent hydrocephalus (7.0%, 9/129). Favorable clinical outcomes (mRS 0-2) were observed in 88.3% (205/232) of the patients, and no rehemorrhage of treated aneurysms occurred. Follow-up angiography was obtained in 155 patients (159 treated aneurysms). The overall recanalization rate was 14.5% (23/159). No stenting or coiling displacement occurred during the follow-up. Delayed complications included in-stent stenosis (n=2) and penetrating artery occlusion (n=2). In conclusion, our study indicates that stent-assisted coil embolization of intracranial aneurysm is a safe technique with low morbidity and mortality rates. Thromboembolism is the main cause of procedure-related disability and death. Nevertheless, further long-term follow-up is necessary to determine the durability of these promising results.

中国组织工程研究杂志出版内容重点：生物材料；骨生物材料; 口腔生物材料; 纳米材料; 缓释材料; 材料相容性；组织工程

Key words: Intracranial Aneurysm, Stents, Embolization, Therapeutic, Tissue Engineering

CLC Number:

R318

Zhao Yu-long, Zhang Hai-feng, Dong Yu-shu, Jiang Wei, Hao Guang-zhi, Liang Guo-biao, Gao Xu.

Complications associated with stent-assisted coil embolization of wide-neck intracranial aneurysms

[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(34): 5506-5512.

Figures/Tables 4

2.1.1 血栓形成接受治疗的232例患者中，13例围手术期血栓并发症，9例为破裂动脉瘤，4例为未破裂动脉瘤。9例在术中发现，4例因术后出现缺血症状发现。9例患者经超选择溶栓和微导丝机械溶栓实现完全或部分再通。随访中8例患者完全恢复，2例患者遗留轻度神经功能障碍，2例患者偏瘫，生活不能自理。1例68岁老年女性死亡，该患者入院时Hunt-Hess分级Ⅰ级，诊断为左侧后交通动脉瘤，术后6 h出现左侧肢体肌力下降，MRI扫描显示左侧大脑半球大面积梗死，立即行脑血管造影显示支架远端血栓形成，左侧颈内动脉闭塞，抗凝、局部溶栓治疗无效，患者出现脑疝，最终行开颅减压手术，但未能挽救患者生命。 2.1.2 术中破裂发生8例动脉瘤术中破裂，微导管穿出5例，弹簧圈穿出2例，1例由充盈球囊造成。3例后交通动脉瘤，2例眼动脉瘤，1例前交通动脉瘤，1例脉络膜前动脉瘤，1例基底动脉顶端动脉瘤。8例术中出血的动脉瘤均为破裂动脉瘤急性期，4例为栓塞微导管经支架网眼进入动脉瘤时所致。所有患者均立即给予鱼精蛋白中和肝素并迅速填塞弹簧圈直至出血停止。4例出血较多的患者(术后Fisher Ⅲ-Ⅳ级)行脑室外引流。5例导致不良后果发生，其中3例遗留神经功能障碍，2例死亡。 2.1.3 弹簧圈脱出 5例操作中发生弹簧圈脱出，其中4例为最后一个弹簧圈在解脱后部分环从支架网眼凸入载瘤动脉，1例为弹簧圈解旋进入载瘤动脉。该患者女性，71岁，双侧后交通动脉瘤，支架辅助栓塞第2个动脉瘤时输送第3枚弹簧圈致微导管头端退出动脉瘤，重新调整过程中弹簧圈解旋，后几个环干扰载瘤动脉血流，尝试多种方法撤回弹簧圈失败，遂将球囊导管送入导引导管，充盈球囊“挤住”弹簧圈的近端，同时撤回导引导管和球囊导管，将弹簧圈一级螺旋拉直至主动脉。所有患者均无临床症状。 2.1.4 占位效应 3例后交通大型动脉瘤术后出现动眼神经麻痹症状，考虑为大型动脉瘤填塞后占位效应所致。经激素治疗，1例患者完全恢复。 2.1.5 血管损伤所有操作中出现3例血管损伤。其中2例为球囊颈内动脉虹吸段血管夹层，随访时自愈，无后遗症。另1例为67岁老年女性患者，行右侧后交通动脉瘤Neuroform支架辅助栓塞治疗，术后1 h出现意识朦胧，头CT显示右侧侧裂内约30 mL血肿，考虑为交换导丝所致的大脑中动脉损伤，立即行血肿清除术，术中未发生止血困难，患者出院时左侧肢体轻偏瘫，随访时生活自理。 2.1.6 支架移位 2例治疗中发生支架移位，1例由微导管经支架网眼送入动脉瘤所致，1例由撤回支架与血管壁之间的微导管所致。前者采用Neuroform支架，移位后仍覆盖瘤颈，顺利完成弹簧圈填塞，后者采用Enterprise支架，移位后弹簧圈部分凸入载瘤动脉，颈内动脉血流中断(颈内动脉床突上段动脉瘤)，幸运的是支架释放后输送导管未撤回，立即送入另一个支架，并成功释放，将凸出部分弹簧圈压在支架与血管壁之间，血流完全恢复，无临床症状(图2)。"

2.2 蛛网膜下腔出血相关并发症 2.2.1 血管痉挛尽管所有129例急性期破裂动脉瘤均给予足量尼莫地平和/或腰穿释放血性脑脊液，24例(18.6%)患者发生症状性血管痉挛。其中5例术中载瘤动脉闭塞(前交通动脉瘤1例，后交通动脉瘤2例，基底动脉瘤2例)，术中立即超选择给予尼莫地平3 mg，罂粟碱30 mg，3例患者恢复良好，无临床症状，2例预后不良。58岁老年女性确诊基底动脉顶端动脉瘤行支架辅助栓塞术，术中基底动脉主干闭塞，立即经导引导管注射尼莫地平、罂粟碱等药物后血流恢复，术后患者出现意识障碍，MRI显示脑桥梗死，出院时患者仍意识朦胧，四肢肌力减弱，生活无法自理。另1例70岁老年男性患者，左侧颈内动脉床突上段动脉瘤(Hunt-Hess Ⅲ级)，栓塞后造影发现左侧颈内动脉C2-3段痉挛变窄，立即给予抗血管痉挛药物，血管痉挛明显缓解。但术后24 h患者出现意识障碍，CT显示左侧大脑半球梗死，脑血管造影显示前、后循环广泛血管痉挛，急诊行开颅减压手术，术后意识逐渐恢复，但遗留右侧肢体偏瘫、失语。 2.2.2 脑积水 129例蛛网膜下腔出血患者中，9例(6.9%)因脑积水行脑室外引流手术。其中1例因出血量大死亡，其余8例恢复良好，临床随访没有需要接受脑室腹腔分流术的慢性脑积水患者。 2.3 随访并发症 2.3.1 支架对载瘤动脉的影响 155例患者(159个动脉瘤)接受脑血管造影随访，总体再通率为14.5%。接受造影随访的患者中2例证实支架内狭窄。1例为45岁男性患者，椎动脉梭形动脉瘤Neuroform支架辅助栓塞术后3个月随访发现约50%支架内狭窄，无临床症状，未给予外科处理，继续双抗治疗，术后12个月再次造影显示狭窄消失。另1例为65岁男性患者，右侧后交通动脉瘤，术中放置1枚4.5 mm×15 mm Neuroform支架于颈内动脉C1段，术后约1年患者出现左侧肢体无力，于术后13个月行脑血管造影，显示支架内90%狭窄，遂给予球囊血管内成形术，术后狭窄明显改善，患者症状消失(图3)。 1例患者术后6个月造影时发现开口被Neuroform支架覆盖的眼动脉闭塞，由于供血由颈外动脉分支代偿，患者无任何临床症状。 "

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