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L. Pierot , C. Cognard , L. Spelle , J. Moret Reims, Toulouse, Paris - France

Safety and efficacy of the remodelling technique in the treatment of ruptured and unruptured intracranial aneurysms: Analysis in two prospective series (ATENA, CLARITY). L. Pierot , C. Cognard , L. Spelle , J. Moret Reims, Toulouse, Paris - France.

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L. Pierot , C. Cognard , L. Spelle , J. Moret Reims, Toulouse, Paris - France

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  1. Safety and efficacy of the remodelling technique in the treatment of ruptured and unruptured intracranial aneurysms:Analysis in two prospective series (ATENA, CLARITY) L. Pierot, C. Cognard, L. Spelle, J. Moret Reims, Toulouse, Paris - France Symposium Neuroradiologicum, October 4 – 9 2010, Bologna

  2. Remodelling? • Technique initially designed for the treatment of wide neck aneurysms • What is a wide neck? • > 4mm (Zubillaga, 1994) • Sac / collet < 2? 1.5?

  3. Remodelling: technique • Balloon placed in front of the aneurysm in the parent vessel • Inflated during deposition of each coil • Deflated between each coil • Removed at the end of the procedure

  4. Remodelling: technique variants • How to place the balloon? • In the parent vessel, in front of the neck • In the neck • Angle of attack • Remodelling 2 balloons

  5. Important issues • Is the remodelling technique associated with a higher risk of complications and morbi-mortality compared to standard coiling? • Are anatomical results improved by the remodelling technique?

  6. Remodelling Clinicalresults

  7. Remodelling: Complications • Sluzewski et al, 2006: • 1995 / 2005 - 757 patients - 827 aneurysms • Remodelling: 71 / 827 aneurysms (8.6%) • Complications: * P < 0.0001

  8. Remodelling: Complications • Shapiro et al, 2008: literature review

  9. Ruptured aneurysms (CLARITY) 782 patients Coiling 608 patients 77.7% Remodelling 160 patients 20.5% Stenting 14 patients 1.8%

  10. Ruptured aneurysms (CLARITY) Aneurysm location

  11. Ruptured aneurysms (CLARITY) Aneurysm size Neck size

  12. Ruptured aneurysms (CLARITY) TE complications Intraoperative rupture

  13. Ruptured aneurysms (CLARITY) Early rebleeding Global complications

  14. Ruptured aneurysms (CLARITY) Delayed ischemia Hydrocephalus

  15. Ruptured aneurysms (CLARITY) Treatment morbidity Treatment mortality

  16. Ruptured aneurysms (CLARITY) Treatment and SAH morbidity Treatment and SAH mortality

  17. Unruptured aneurysms (ATENA) Traitement sélectif 727 anévrismes Coiling 396 anévrismes 74.5% Remodelling 271 anévrismes 37,3% Stenting 57 anévrismes 7,8% Trispan: 3 anévrismes (0.4%)

  18. Unruptured aneurysms (ATENA) Aneurysm location

  19. Unruptured aneurysms (ATENA) Aneurysm size D-to-N ratio

  20. Unruptured aneurysms (ATENA)

  21. Unruptured aneurysms (ATENA)

  22. Remodelling Anatomicalresults

  23. Literature review (Schapiro) Initial occlusion Occlusion at FU

  24. Ruptured aneurysms (CLARITY) Initial occlusion Packing P=0.017 AO= Adequate Occlusion. AR=Aneurysm Remnant.

  25. Unruptured aneurysms (ATENA)

  26. Conclusions • Safety of the remodelling technique issimilar to standart coiling in bothruptured and unruptured aneurysms (ATENA, CLARITY, Literaturereview). • The remodelling technique seems to be more efficaciousthan the standart coiling on anatomical point-of-view. • The remodelling technique canbewidelyused in the treatment of ruptured and unruptured aneurysms.

  27. Publications • Endovascular treatment of Unruptured Intracranial Aneurysms : Comparison of Safety of remodeling technique and standard treatment with coils. L. Pierot, L. Spelle, X. Leclerc, C. Cognard, A. Bonafé, J. Moret Radiology, 2009, 251: 846-855. • The remodelling technique for endovascular treatment of ruptured intracranial aneurysms is anatomically more efficacious than standard coiling with comparable safety. L. Pierot, C. Cognard, R. Anxionnat, F. Ricolfi, and CLARITY investigators Radiology (in press)

  28. Principales séries • Moret J, Cognard C, Weill A, Castaings L, Rey A. The “remodelling technique” in the treatment of wide neck intracranial aneurysms. Intervent Neuroradiol 1997; 3: 21-35. • Aletich VA, Debrun GM, Misra M, Charbel F, Ausman JL. The remodelling technique of balloon assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago. J Neurosurg 2000; 93: 388-396.

  29. Principales séries • Cottier JP, Pasco A, Gallas S, Gabrillargues J, Cognard C, Drouineau J, Brunereau L, Herbreteau L. Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study. AJNR Am J Neuroradiol 2001; 22: 345-351. • Lefkowitz MA, Gobin YP, Akiba Y, Duckwiler GR, Murayam Y, Guglielmi G, Martin NA, Vinuela F. Balloon-assistedGuglielmidetachable coiling ofwideneckedaneurysms, II : clinicalresults. Neurosurgery 1999; 45: 531-537.

  30. Principales séries • Malek AM, Halbach VV, Phatouros CC, Lempert TE, Meyers PM, Dowd CF, Higashida RT. Balloon-assisted technique for endovascular coil embolization of geometrically difficult intracranial aneurysms. Neurosurgery 2000; 22: 19-26. • Nelson PK, Levy DI. Ballon-assisted coil embolization of wide-necked aneurysms of the internal carotid artery: medium term angiographic and clinical follow-up in 22 patients. AJNR Am J Neuroradiol 2001; 22: 19-26.

  31. Principales séries • Layton KF, Cloft HJ, Gray LA, Lewis DA, Kallmes DF. Balloon-assisted coiling of intracranial aneurysms: evaluation of local thrombus formation and symptomatic thromboembolic complications. AJNR Am J Neuroradiol 2007; 28: 1172-1175. • Sluzewski M, Von Rooij WJ, Beute GN, Nijssen PC. Balloon-assisted coil embolization of intracranial aneurysms: incidence, complications, and angiography results. J Neurosurg 2006; 105: 396-399.

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