Therapeutic effect of local photothermal heating of gold nanoparticle-coated self-expandable metallic stents for suppressing granulation tissue formation in the mouse colon.

PURPOSE: To investigate the therapeutic effect of local photothermal (PT) heating on suppression of stent-induced granulation tissue formation in mouse colon. MATERIALS AND METHODS: A gold nanoparticle (GNP)-coated self-expandable metallic stent (SEMS) was prepared using a two-step synthesis process for local PT heating under near-infrared laser irradiation. Twenty-four mice were randomly divided into two groups of 12 and subjected to SEMS placement in the colon. Group A received a GNP-coated SEMS without local heating and Group B received a GNP-coated SEMS and underwent local heating at 55°C after SEMS placement. The therapeutic effect of local heating was assessed by comparing the histopathological, immunohistochemical, and endoscopic results. RESULTS: Four mice were excluded because of stent migration (n = 3, group B) or death (n = 1, group A). Stent-induced granulation tissue-related variables were significantly lower in group B than in group A (p < 0.001). In vivo endoscopic images, 4 weeks after stent placement, showed granulation tissue formation over the wire mesh in group A and relatively good patency of the stented colon with no definite irregularities in group B. There was more vascular endothelial growth factor (VEGF) positivity in group A than in group B. CONCLUSION: Local PT heating suppresses granulation tissue formation after stent placement in mouse colon.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND: Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases. METHODS: Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety. RESULTS: One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH. CONCLUSIONS: The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Colorectal stenting in England: a cross-sectional study of practice.

INTRODUCTION: UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England. METHODS: All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty). RESULTS: Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure. CONCLUSIONS: All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

Comparison of short-term outcome between diverting colostomy and colonic stent as a bridge to surgery for left colonic malignant obstruction.

The self-expanding metallic stent (SEMS) has been comprehensively investigated as a bridge to surgery. SEMS enables the control of acute colonic obstruction. However, comparison between SEMS and diverting colostomy as another bridge procedure was still challenging issue. Thus, the aim of this study was to compare these 2 procedures.In this retrospective cohort study, patients who received diverting colostomy and SEMS for acute left colonic obstruction between February 2016 and August 2018 were included. They were classified into the colostomy group (n = 27), including 5 patients who had SEMS failure previously, and the SEMS group (n = 23). The clinicopathologic parameters, pathologic results, and short-term outcomes were compared.No significant differences were found in clinicopathologic characteristics and complication rates between the 2 groups. After the bridge procedures, the SEMS group showed a higher rate of laparoscopic colonic resection than the colostomy group (100% vs 76%, P = .023). The colostomy group showed a higher rate of rectal cancer (24.0% vs 9.1%, P = .019) and later recovery of flatus (3 vs 2 days, P = .011) than the SEMS group. Additionally, the length of resected colon was longer in the colostomy group than in the SEMS group (33.9 vs 23.4 cm, P = .007).Although SEMS might permit higher laparoscopic resection rates and faster recovery of bowel habits than diverting colostomy, SEMS showed meaningful failure rate including migration and perforation. In addition, diverting colostomy showed acceptable complication rates and feasible performance. An individualized approach is necessary considering the advantages and disadvantages of both procedures.

Utility and Safety of a Novel Fully Covered Metal Stent in Unresectable Distal Malignant Biliary Obstruction.

BACKGROUND: Self-expandable metal stents (SEMSs) are widely used in patients with distal malignant biliary obstruction. A SEMS that can avoid occlusion as much as possible is desirable. AIMS: The aim of this multicenter single-arm prospective study was to assess the clinical effectiveness and safety of a novel fully covered braided SEMS. METHODS: We enrolled consecutive patients with distal malignant biliary obstruction between February 2016 and November 2017 at ten tertiary-care medical centers. RESULTS: We included 79 patients with a median age of 76 years; 47 (59.5%) patients were men. The technical and clinical success rate was 98.7% and 93.6%, respectively. Recurrent biliary obstruction occurred in 14 patients (17.9%); stent ingrowth, overgrowth, migration, and other occurred in five (6.4%), four (5.1%), four (5.1%), and one (1.3%) patients, respectively. All reinterventions in patients with recurrent biliary obstruction were successful via the transpapillary approach. Adverse events occurred in 15 patients (19.2%); cholangitis, pancreatitis, and others occurred in ten (12.8%), three (3.8%), and two (2.6%) patients, respectively. The stent patency probability at 6 months was 48.5%. Median time to stent patency was 171 days, median time to recurrent biliary obstruction was 536 days, and median survival time was 195 days. CONCLUSIONS: We confirmed the utility and safety of a novel fully covered braided SEMS with low axial force and high radial force in patients with malignance biliary obstruction. This novel SEMS is recommended in patients with distal malignant biliary obstruction.

Comparison of silicon and metallic bifurcated stents in patients with malignant airway lesions.

INTRODUCTION AND OBJECTIVE: Silicon and metallic are two types of stents in use. In this study, we compared complications and long-term survival among patients who received silicon or fully covered, bifurcated self-expandable metallic stents (SEMS) for a malignant tracheobronchial obstruction and/or tracheo/bronchial oesophageal fistulas. METHODS: Patients in whom Y-shaped stents were used from January 2013 to June 2017 in our interventional pulmonology unit were evaluated retrospectively from patient files. RESULTS: Of the 47 patients, 30 (23 males, 76.7%) were in the silicon stent group and 17 (14 males, 82.4%) were in the covered SEMS group. No differences between the groups were detected in ECOG status, pathological properties of the disease, radiotherapy or chemotherapy history before the procedure, symptoms at presentation, or comorbidities. The most common symptom was dyspnoea (96.7% and 100%), and the most common comorbidity was chronic obstructive pulmonary disease (26.7% and 23.5%). A total of 20 complications (42.6%) were seen, with no significant difference between the groups (silicon, 40%; SEMS, 47.1%; P = . 62). Mean survival was 164.51 ± 38.83 days for the silicon stent group and 254.45 ± 103.32 days for the SEMS group (P = .588). No differences were observed in 30-, 90- or 180-day mortality between the two groups (P = .966, .846 and .534, respectively). CONCLUSIONS: No significant differences in symptom palliation, insertion safety, complication rate or survival were detected between the two types of stent.

International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage.

BACKGROUND AND AIMS: High rates of technical and clinical success were reported for lumen-apposing metal stent (LAMS) placement for peripancreatic fluid collection (PFC) drainage. However, data on the adverse event (AE) rates are heterogeneous. The aim of this study was to evaluate the incidence, severity, management, and risk factors of AEs related to the use of LAMSs for drainage of PFCs in a large cohort of patients. METHODS: This is a multicenter, international, retrospective review from 15 centers of all patients who underwent placement of LAMSs for the management of PFCs. A nested case-control study was conducted in patients with (case) or without (control) AEs. RESULTS: Three hundred thirty-three procedures in 328 patients were performed (5 patients treated with 2 LAMSs). Technical success was achieved in 321 patients (97.9%). Three hundred four patients were finally included in the study (7 excluded for lost to follow-up information; 10 excluded for deaths unrelated to LAMSs). The rate of clinical success was 89.5%. Seventy-nine LAMS-related AEs occurred in 74 of 304 patients (24.3%), after a mean time of 25.3 days (median, 18 days; interquartile range, 6-30) classified as 20 (25.3%) mild, 54 (68.4%) moderate, or 5 (6.3%) severe. On multivariable analysis compared with control subjects, cases were more likely to have walled-off necrosis (WON) versus pancreatic pseudocysts (odds ratio, 2.18; 95% confidence interval, 1.09-4.46; P = .028), whereas cases were less likely to have undergone tract (balloon) dilation (yes vs no; odds ratio, .47; 95% confidence interval, .22-.93; P = .034). CONCLUSIONS: Data from this large international retrospective study confirm that the use of LAMSs for management of PFCs has excellent technical and good clinical success rates. The rate of AEs, however, is not negligible and should be carefully considered before using these stents for drainage of PFCs and in particular for WON. Further prospective studies are needed to confirm these findings. (Clinical trial registration number: NCT03544008.).

Usefulness of fully covered self-expandable biliary metal stents for the treatment of post-sphyncterotomy ERCP bleeding.

BACKGROUND: post-sphyncterotomy endoscopic retrograde cholangiopancreatography (ERCP) bleeding is an adverse event with an estimated incidence rate of 1.34%. There is no established consensus about how to treat this particular type of gastrointestinal bleed. Placement of fully covered self-expandable biliary metal stents (FCSEBMS) has been evaluated as an alternative treatment with positive outcomes and a low complication rate. AIM: to report the results of a cohort of patients with post-sphyncterotomy bleeding treated in a tertiary care referral hospital with FCSEBMS. METHODS: a retrospective cases series study was performed including all post-ERCP bleeds treated with FCSEBMS (immediate or delayed) from January 2015 to June 2017. Clinical data, laboratory results and endoscopic reports were collected in order to evaluate the rebleeding rate after endoscopic treatment. Two different scenarios were considered: a) prophylactic stent placement after effective endoscopic treatment; and b) stents placed for the treatment of an active postsphyncterotomy bleed, refractory to standard endoscopic therapy. RESULTS: twenty-two patients (14 male, eight women) diagnosed with postsphyncterotomy bleeding were treated with FCSEBMS placement. The stents were placed prophylactically in 15 patients, while the stents were placed as a treatment for a refractory bleed in seven patients. No differences were found between both groups except for a higher anticoagulation rate in the treatment group. Clinical success was achieved in all but one patient, with no complications in relation to stent placement. Distal migration was described in two of the 22 patients included in the study. CONCLUSIONS: temporary placement of FCSEBMS seems to be a technically feasible treatment option for post-ERCP bleeding with a high clinical success rate. The complication rate was low, although randomized studies are needed.

Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction.

BACKGROUND: Although self-expandable metal stent (SEMS) placement as bridge to surgery (BTS) in patients with left-sided obstructing colonic cancer has shown promising short-term results, it is used infrequently owing to uncertainty about its oncological safety. This population study compared long-term oncological outcomes between emergency resection and SEMS placement as BTS. METHODS: Through a national collaborative research project, long-term outcome data were collected for all patients who underwent resection for left-sided obstructing colonic cancer between 2009 and 2016 in 75 Dutch hospitals. Patients were identified from the Dutch Colorectal Audit database. SEMS as BTS was compared with emergency resection in the curative setting after 1 : 2 propensity score matching. RESULTS: Some 222 patients who had a stent placed were matched to 444 who underwent emergency resection. The overall SEMS-related perforation rate was 7·7 per cent (17 of 222). Three-year locoregional recurrence rates after SEMS insertion and emergency resection were 11·4 and 13·6 per cent (P = 0·457), disease-free survival rates were 58·8 and 52·6 per cent (P = 0·175), and overall survival rates were 74·0 and 68·3 per cent (P = 0·231), respectively. SEMS placement resulted in significantly fewer permanent stomas (23·9 versus 45·3 per cent; P < 0·001), especially in elderly patients (29·0 versus 57·9 per cent; P < 0·001). For patients in the SEMS group with or without perforation, 3-year locoregional recurrence rates were 18 and 11·0 per cent (P = 0·432), disease-free survival rates were 49 and 59·6 per cent (P = 0·717), and overall survival rates 61 and 75·1 per cent (P = 0·529), respectively. CONCLUSION: Overall, SEMS as BTS seems an oncologically safe alternative to emergency resection with fewer permanent stomas. Nevertheless, the risk of SEMS-related perforation, as well as permanent stoma, might influence shared decision-making for individual patients.

Palliative interventions for patients with incurable locally advanced or metastatic thoracic esophageal carcinoma.

BACKGROUND: The aim of this study was to assess the clinical outcomes of palliative interventions for patients with incurable locally advanced or metastatic esophageal carcinoma. METHODS: A total of 131 patients with thoracic esophageal carcinoma who underwent palliative interventions were enrolled. Insertion of a self-expandable metallic stent (SEMS), tube enterostomy for enteral nutrition (EN), and palliative esophagectomy (PE) were performed in 38, 65, and 28 patients, respectively. The clinicopathological characteristics and clinical outcomes of each group were retrospectively reviewed. RESULTS: Patients in the EN group frequently received chemoradiotherapy (P < 0.01). SEMS insertion, but not PE or EN, improved the mean dysphagia score after the intervention (P < 0.01). For the SEMS, EN, and PE groups, the occurrence of intervention-related complications was 31.6, 10.8, and 96.4%, respectively, the median survival time was 88, 208, and 226 days (P < 0.01), and the mean ratio of duration of home care to survival time was 28.9, 38.5, and 39.6% (P = 0.95). CONCLUSIONS: SEMS insertion effectively relieved obstructive symptoms, but had no survival benefit. Tube enterostomy showed a low complication rate and has the potential to improve survival in combination with additional treatment, with no palliation of obstructive symptoms.

Oncologic Outcomes of Self-Expandable Metallic Stent as a Bridge to Surgery and Safety and Feasibility of Minimally Invasive Surgery for Acute Malignant Colonic Obstruction.

BACKGROUND: Although self-expandable metal stents (SEMS) are widely used as a bridge to surgery (BTS) in patients with malignant colorectal cancer obstruction, there has been some debate about their effect on long-term oncological outcomes. Furthermore, data on the safety and feasibility of minimally invasive surgery (MIS) combined with stent placement are scarce. We aimed to determine the long-term oncological outcomes of SEMS as a BTS, and the short-term outcomes of SEMS used with minimally invasive colorectal surgery. METHODS: Data from patients who were admitted with malignant obstructing colon cancer between January 2006 and December 2015 were retrospectively reviewed; 71 patients underwent direct surgery and 182 patients underwent SEMS placement as a BTS. Long-term and short-term outcomes of the groups were compared. In a subgroup analysis of the BTS group, the short-term outcomes of conventional open surgery and MIS were compared. RESULTS: There were no differences in long-term oncologic outcomes between groups. The primary anastomosis rate was higher in the stent group than in the direct surgery group. In the stent group, postoperative complication rates were lower in the minimally invasive group than in the open surgery group. Time to flatus and time to soft diet resumption were shorter in the minimally invasive group, as was length of hospital stay. CONCLUSIONS: Elective surgery after stent insertion does not adversely affect long-term oncologic outcomes. Furthermore, MIS combined with stent insertion for malignant colonic obstruction is safe and feasible.

Predictores de necesidad de marcapasos permanente y alteraciones de la conducción con el implante transcatéter de una nueva válvula aórtica autoexpandible / Predictors of need for permanent pacemaker implantation and conduction abnormalities with a novel self-expanding transcatheter heart valve

Introducción y objetivos: La incidencia de implante de marcapasos permanente (IMP) y nuevas alteraciones de la conducción (AC) con la ACURATE neo (Symetis S.A., Eclubens, Suiza) no se ha estudiado en detalle. Nuestro objetivo fue analizar sus predictores, evaluándose los factores relacionados con el paciente y con el dispositivo, tal como la profundidad del implante y la relación entre el dispositivo y el anillo (RDA). Métodos: De una población multicéntrica, se realizaron 2 análisis: nuevos IMP (n = 283), e IMP/nuevas AC en pacientes sin AC previas o marcapasos (n = 232). Resultados: En el 9,9% de los pacientes se necesitó nuevo IMP, que se asoció con un mayor índice de masa corporal, mayor proporción de bloqueo de rama derecha y bradicardia. Ni el implante de la prótesis ni la RDA difirieron entre pacientes con o sin IMP. En el análisis multivariante ni la RDA (OR = 1,010; IC95%, 0,967-1,055; p = 0,7), ni la profundidad del implante (OR = 0,972; IC95%, 0,743-1,272; p = 0,8) fueron predictores de IMP. Solo el índice de masa corporal, la bradicardia y el bloqueo de rama derecha persistieron como predictores independientes. El IMP/nueva aparición de AC ocurrió en el 22,8% de los pacientes y se asoció con un mayor EuroSCORE logístico. Ni la profundidad del implante ni la RDA eran diferentes en pacientes con o sin IMP/nueva aparición de AC (7,3 ± 1,9 frente a 7,1 ± 1,5 mm; p = 0,6 y 41,0 ± 7,9 frente a 42,2 ± 10,1%; p = 0,4). El único predictor de IMP/nuevo inicio de AC fue un mayor EuroSCORE logístico (OR = 1,039; IC95%, 1,008-1,071; p = 0,013). Conclusiones: La proporción de nuevos IMP y nueva aparición de AC eran inferiores con la ACURATE neo. Estos hechos están principalmente influenciados por las características de los pacientes y no por los factores dependientes del dispositivo

Introduction and objectives: The incidence of permanent pacemaker implantation (PPI) and new conduction abnormalities (CA) with the ACURATE neo (Symetis S.A., Eclubens, Switzerland) has not been studied in detail. We aimed to analyze their predictors, evaluating patient- and device-related factors, including implantation depth and device-to-annulus ratio (DAR). Methods: Two analyses of a multicenter population were performed: new PPI in pacemaker-naive patients (n = 283), and PPI/new-CA in patients without prior CA or pacemaker (n = 232). Results: A new PPI was required in 9.9% of patients, who had a higher body mass index, higher rate of right bundle branch block and bradycardia. Neither implantation depth nor DAR differed in patients with PPI compared with those without. In the multivariable analysis neither DAR (OR, 1.010; 95%CI, 0.967-1.055; P = .7) nor implantation depth (OR, 0.972; 95%CI, 0.743-1.272; P = .8) predicted PPI. Only high body mass index, bradycardia and right bundle branch block persisted as independent predictors. PPI/new-onset CA occurred in 22.8% of patients and was associated with a higher logistic EuroSCORE. Neither implantation depth nor DAR differed in patients with PPI/new-CA vs those without (7.3 ± 1.9 vs 7.1 ± 1.5 mm; P = .6 and 41.0 ± 7.9 vs 42.2 ± 10.1%; P = .4). The only predictor of PPI/new-CA was a higher logistic EuroSCORE (OR, 1.039; 95%CI, [1.008-1.071]; P = .013). Conclusions: New PPI and new-onset CA rates were low with the ACURATE neo. These were mainly influenced by patient characteristics and not by device-depending factors

Short- and long-term clinical outcomes of self-expandable metal stents inserted for colorectal obstruction and efficacy of different insertion techniques.

OBJECTIVES: (1) To evaluate the short- and long-term clinical outcomes of patients after colorectal stent placement and (2) to assess the safety and efficacy of the stents for the resolution of colorectal obstruction according to the insertion technique. METHODS: Retrospective cohort study which included 177 patients with colonic obstruction who underwent insertion of a stent. RESULTS: A total of 196 stents were implanted in 177 patients. Overall, the most common cause of obstruction was colorectal cancer (89.3%). Ninety-two stents (47%) were placed by radiologic technique and 104 (53%) by endoscopy under fluoroscopic guidance. Technical success rates were 95% in both groups. Clinical success rates were 77% in the radiological group and 81% in the endoscopic group (p>0.05). The rate of complications was higher in the radiologic group compared with the endoscopic group (38% vs 20%, respectively; p=0.006). Among patients with colorectal cancer (158), 65 stents were placed for palliation but 30% eventually required surgery. The multivariate analysis identified three factors associated with poorer long-term survival: tumor stage IV, comorbidity and onset of complications. CONCLUSIONS: Stents may be an alternative to emergency surgery in colorectal obstruction, but the clinical outcome depends on the tumor stage, comorbidity and stent complications. The rate of definitive palliative stent placement was high; although surgery was eventually required in 30%. Our study suggests that the endoscopic method of stent placement is safer than the radiologic method.

Use of Flow Diversion for the Treatment of Distal Circulation Aneurysms: A Multicohort Study.

OBJECTIVE: The safety and efficacy of flow diversion for distal circulation aneurysms of the cerebral vasculature has not been well evaluated. The objective of this study was to assess the use of flow diversion for distal circulation aneurysms (defined as at or beyond the M1, P1, and A1 segments of the middle cerebral artery, posterior cerebral artery, and anterior cerebral artery, respectively) in an international multicenter cohort. METHODS: Clinical and radiologic records from all patients undergoing flow diversion treatment of distal circulation aneurysms at 3 academic centers (2 in the USA and 1 in Europe) from 2014 until 2017 were retrospectively reviewed. RESULTS: Forty-six patients (mean age, 58.2 years; 33 women) harboring 46 aneurysms who underwent treatment with either the Pipeline Embolization Device (Medtronic Inc., Dublin, Ireland) or the Flow Re-Direction Endoluminal Device (MicroVention, Tustin, California, USA) were included in these analyses. Thirty-four aneurysms (74%) were located in the anterior circulation and 12 (26%) were located in the posterior circulation. With a mean follow-up of 13.0 months, complete (100%) and near-complete (90%-99%) occlusion was noted in 36 aneurysms (78.2%). Angiographic evidence of side branch or perforator vessel coverage was present in 35 aneurysms (76.1%) but was not associated with failure to occlude at follow-up (P = 0.06). All patients had good functional outcomes after treatment (modified Rankin Scale score 0-2). There were 2 cases (4.3%) of perforator vessel stroke and no hemorrhagic complications. CONCLUSIONS: Flow diversion for aneurysms beyond the circle of Willis has occlusion rates comparable to alternative treatments and low morbidity. The clinical significance of flow limitation through covered side branches requires further investigation.

The Use of Flow Diversion in Vessels ≤2.5 mm in Diameter-A Single-Center Experience.

BACKGROUND: Flow diversion has become an accepted treatment strategy for aneurysms; however, there are limited data on the use of these devices in small vessels ≤2.5 mm in diameter. METHODS: We performed a retrospective review of our prospectively maintained database to identify all patients treated with flow diversion between September 2009 and January 2018. We identified all patients in whom the average parent artery was ≤2.5 mm in diameter. Ruptured aneurysms were excluded from the analysis as were patients who had adjunctive coiling at the time of flow diversion. RESULTS: We identified 29 patients (22 female, 76%) with average age 56.2 ± 15.9 years (range, 21-83 years). Most aneurysms were classified as saccular (n = 21, 72.4%), with 7 fusiform aneurysms (24.2%) and 1 presumed dissecting aneurysm (3.4%). The average parent artery diameter was 2.1 ± 0.37 mm (range, 1.3-2.5 mm). Delayed angiographic follow-up was available for 18 patients at an average of 19.4 months after treatment. Fifteen patients showed Raymond-Roy classification grade 1 occlusion (94%) and 1 patient with complete filling showed Raymond-Roy classification grade 3 (6%). Four patients (13.7%) underwent repeat treatment with implantation of another flow-diverting stent in a telescoping manner. At 90 days, 2 patients had a modified Rankin Scale (mRS) score of 6, 1 from an unrelated cause and 1 from the enlarging compressive dissecting aneurysm and intraparenchymal hemorrhage. All the remaining patients had an mRS score ≤2 at 90 days, with 24 patients (83%) with an mRS score of 0. CONCLUSIONS: Flow diverters can be implanted into small vessels with a high rate of technical success and good rates of aneurysm occlusion. Dedicated devices to target these vessels should be developed.

Safety and Efficacy of Flow Diverter Treatment for Blood Blister-Like Aneurysm: A Systematic Review and Meta-Analysis.

OBJECTIVE: To clarify the safety and efficacy of flow diverter (FD) treatment for blood blister-like aneurysm (BBA) through a systematic review and literature analyzing perioperative and long-term clinical and angiographic outcomes. METHODS: We performed a comprehensive review of the current literature for studies with >2 patients related to FD treatment of BBAs published. A random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, aneurysm recurrence, rebleeding, perioperative mortality, perioperative stroke, procedure-related morbidity and mortality, long-term neurological morbidity and mortality, and overall good neurologic outcome. RESULTS: We included 15 noncomparative studies with a total of 165 target BBAs. Complete occlusion rates were 72% (95% confidence interval [CI], 0.59-0.85). Recurrence occurred in 13% (95% CI, 0.04-0.29) and rebleeding in 3% (95% CI, -0.02 to 0.07) of patients. Procedure-related morbidity and mortality were 26% (95% CI, 0.19-0.33) and 3% (95% CI, -0.01 to 0.07), respectively. The rate of long-term good outcomes was 83% (95% CI, 0.77-0.89). Subgroup analysis indicated that a single FD strategy for BBA seemed to have a higher rate of good outcomes compared with an overlapped FD strategy (89.9% vs. 61.9%; odds ratio, 1.42; 95% CI, 1.25-14.98, P = 0.02). Complete occlusion rate and procedure-related morbidity rate did not see any significant difference between these 2 strategies. CONCLUSIONS: Our meta-analysis suggests that in selected cases, FD can be safe and effective. A single FD strategy may result in a higher rate of good outcomes compared with an overlapped FD strategy. Ultimately, treatment of BBA should be considered on a case-by-case basis to maximize patient benefits and limit the risk of perioperative complications.

The utility and efficacy of self-expandable metal stents for treating malignant gastric outlet obstructions in patients under best supportive care.

PURPOSE: Self-expandable metallic stents (SEMSs) may be used to effectively palliate malignant gastric outlet obstructions (GOOs), but their utility and efficacy in patients under best supportive care (BSC) have not been explored. METHOD: In this multicenter retrospective study, we reviewed data on patients under BSC who underwent endoscopic SEMS placement to treat malignant GOO without chemotherapy. We evaluated the safety and efficacy of the procedure. RESULTS: We enrolled a total of 208 patients. SEMS placement was technically successful in 207 (99.5%) and clinically successful in 164 (78.8%). The mean procedure time was 25.6 ± 2.8 min. Stent dysfunction later developed in 30 (14.4%) patients, of whom 90% (27/30) underwent reintervention. The procedure-related mortality rate was 1.44%; all deaths were due to pneumonia. Subgroup analysis by Karnofsky performance status (KPS) revealed that neither technical success, stent dysfunction, reintervention rate, procedure-related pneumonia or death, nor death within 14 days differed between patients with good and poor KPS. However, the clinical success rate and the median survival time were significantly lower and shorter, respectively, in those with poor KPS (p < 0.001). CONCLUSIONS: Duodenal SEMS placement is an effective palliative treatment for malignant GOO in BSC patients. Although the GOO score did not dramatically improve in patients with poor KPS, the procedure was safe and palliatively feasible. Procedure-related pneumonia was fatal; thus, it is essential to proceed with great caution. TRIAL REGISTRATION: Clinical trial registration number: UMIN000028367.

Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms.

OBJECTIVE: We present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes. METHODS: We retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded. RESULTS: 47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23-73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7-12.1) and 3.2 mm (range 1.5-7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9-12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0-2. CONCLUSION: Stenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.

Treatment of Small and Tiny Aneurysms Before and After Flow Diversion Era: A Single Center Experience of 409 Aneurysms.

OBJECTIVE: To explore whether we should use the Pipeline embolization device (PED) as the primary treatment modality for small and tiny aneurysms at anterior circulation. METHODS: This retrospective study included 409 cases of small and tiny aneurysms, including aneurysms treated by the PED (n = 77), coiling (n = 51), and stent-assisted coiling (SAC) (n = 281). We also made a comparison regarding the safety and efficacy among these treatment modalities. RESULTS: A total of 55 patients with 77 small aneurysms were treated with PEDs. Technical success was achieved in 98.4% of procedures. The complete occlusion rate was 75.9% (44/58). Both the morbidity and mortality rates were 1.8%. Comparing the 3 treatment modalities, the technical event rate tended to be the highest in the PED group (4.8% vs. 2.0% and 1.1%; PED vs. Coil vs. SAC; P = 0.100), and the use of a PED neither significantly shortened the procedure duration (127.2 ± 62.8 vs. 115 ± 37.1 and 112.8 ± 40.6 minutes, P = 0.322) nor lowered the complication rate (11.1% vs. 9.8% and 6.1%; P = 0.281). SAC had the highest occlusion rate (75.9% vs. 75.8% and 94.0%; P < 0.001) and lowest morbidity rate (0.8% vs. 4.2% and 1.8%; SAC vs. Coil vs. PED; P = 0.099). Ipsilateral multiple aneurysms were more frequently seen in the PED group (33.8% vs. 3.9% and 3.2%; P < 0.001). Procedure duration tended to be lower in the PED group versus the SAC group (122.7 ± 57.4 vs. 157.5 ± 22.2 minutes; P = 0.060). For these aneurysms, the PED group had the highest occlusion rate (80.0% vs. 50.0% and 66.7%; P = 0.516). CONCLUSIONS: The PED is an alternative treatment for small and tiny aneurysms. However, SAC remains the safest and most efficient treatment modality. The PED should be reserved for ipsilateral multiple aneurysms.

Single-stage flow diversion with adjunctive coiling for cerebral aneurysm: outcomes and technical considerations in 72 cases.

BACKGROUND: Adjunctive coiling may improve occlusion outcomes when combined in a single stage with cerebral aneurysm flow diversion. This technique has not been well described. OBJECTIVE: To present a series of aneurysm patients treated by single-stage flow diversion with adjunctive coiling, describing technical considerations and outcomes. METHODS: This was a retrospective cohort study using an IRB-approved database of procedures performed at a single institution. Treatment selection was based on large aneurysm size, morphological irregularity, branch vessel location, and wide neck. RESULTS: A total of 72 Pipeline with adjunctive coiling (PAC) procedures were performed on 69 patients. Average aneurysm size was 11.0 mm and 86% were wide-necked. Three progressively complex techniques were performed approximately equally: 27 sequential (38%), 23 jailed single-intermediate (32%), and 22 bifemoral jailed microcatheter (31%) cases. Aneurysm dome (P=0.0223) and neck size (P=0.001) increased with procedural complexity and there was a trend toward increased procedure length, radiation exposure, and stent thrombosis. A 'light' coil pack was used with an average packing density of 14% that did not vary by technique. Of the three major complications (4.2%), none were observed with the sequential approach (0%), one with the jailed single-intermediate (4.3%), and two with bifemoral cases (9.1%) (P=0.116). Complete occlusion was achieved in 85% of PAC cases at 6 months and 96% at 12-month follow-up angiography. CONCLUSIONS: There are multiple approaches to flow diversion with adjunctive coiling, each with technical challenges, suitable to different types of aneurysms. Flow diversion with coiling can expedite and improve occlusion outcomes without a significant increase in morbidity.