Técnicas para o diagnóstico, planejamento terapêutico e tratamento endovascular com Stent diversor de fluxo dos aneurismas do complexo comunicante anterior
Arquivos
Data
2023-03-02
Autores
Pagiola, Igor Campostrini 
Orientadores
Carrete Junior, Henrique
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
O complexo comunicante anterior é um dos locais mais frequentes de aneurismas intracranianos. Além disso, os aneurismas dessa região apresentam maior risco de ruptura se comparados com outras topografias, podendo romper com tamanho menores que os demais. Em virtude da grande variação anatômica nesta região, o profundo conhecimento da anatomia com estudos diagnósticos deve ser realizado para a escolha da melhor terapêutica para esses aneurismas. Dentre os tratamentos disponíveis, a abordagem microcirúrgica ou endovascular dos aneurismas do complexo comunicante anterior são desafiadores, mas muitas vezes necessários. A enorme variedade anatômica associada a alta incidência de aneurismas na topografia da artéria comunicante anterior (AcoA), nos levou a estudar técnicas com a angiografia por subtração digital (ASD), definição de um protocolo com a ASD e técnicas avançadas de aquisição de imagem como a aquisição rotacional 3D associado a ferramenta de overlay que permite fundir as imagens das duas artérias cerebrais anteriores (ACA). Utilizando esse protocolo, a análise da anatomia do complexo comunicante anterior é realizada em detalhes e define todas as possíveis variações anatômicas, relação do aneurisma com os segmentos A1 e a artéria comunicante anterior auxiliando no planejamento terapêutico desses aneurismas. Também avaliamos, especificamente, o tratamento com Stent diversor de fluxo (DF) dos aneurismas do complexo comunicante anterior em um centro de referência mundial nesse tipo de procedimento. Avaliando essa grande série de casos, propusemos uma nova classificação dessa região para inferir prováveis riscos de complicações tromboembólicas, taxa de cura do aneurisma e qual técnica de liberação do Stent seria mais favorável para cada tipo anatômico definido pela classificação. A nova classificação do complexo comunicante anterior foi dividida em 4 tipos anatômicos definidos pela diferença do calibre dos segmentos A1 da ACA (H1 – mesmo diâmetro, H2 – diferença menor que 50%, H3 – diferença maior ou igual que 50% e Y – ausência de A1 em um dos lados.). Além dos tipos anatômicos, analisamos 3 técnicas básicas de liberação do Stent DF (técnica “I”– Stent posicionado do segmento A1 para o A2 ipsilateral-; técnica em “H” – um Stent DF em cada lado, duas técnicas “I” e a técnica em “Chicane” quando o Stent é colocado de A1 de um lado para o A2 contralateral). Quando separamos os aneurismas em cada tipo anatômico da nova classificação proposta tivemos 56.6% no grupo H1, 26.6% H2, 16.6% no H3 e nenhum paciente no grupo Y. A oclusão completa do aneurisma ocorreu em 83.3% do grupo H1, 66.7% no H2 e 60% no H3. O grupo H3 apresentou 1.38 mais chances de não obter oclusão completa. Na série estudada houve uma taxa de complicação tromboembólica de 26.7% com 3.3% de complicações sintomáticas. Avaliando as complicações tromboembólicas em cada grupo da nova classificação observamos: 17.6% no grupo H1, 25% no grupo H2 e 60% no grupo H3. Não houve complicações hemorrágicas no grupo estudado. O grupo H3 apresentou 4 vezes mais chance de complicações tromboembólicas que os demais grupos. A realização da técnica de overlay para o estudo da região do complexo comunicante anterior nas ASD facilita a compreensão da anatomia e relação dos segmentos A1 com o aneurisma. O calibre dos segmentos A1 das ACA poderá alterar a hemodinâmica após a implantação de um Stent DF. Essas diferenças podem alterar tanto a taxa de oclusão do aneurisma quanto a taxa de complicações tromboembólicas durante o procedimento. O tratamento dos aneurismas do complexo comunicante anterior com Stent DF é factível e pode se tornar ainda mais seguro com uma melhor definição anatômica utilizando técnicas avançadas de imagem. Essa melhor definição anatômica permite uma nova classificação para indicação mais precisa desse tipo de dispositivo, tanto no tratamento de primeira intenção como nos casos de recanalização após outras técnicas dos aneurismas do complexo comunicante anterior.
The anterior communicating complex is one of the most frequent sites of intracranial aneurysms. In addition, aneurysms in this region have a higher risk of rupture when compared to other topographies, and may rupture with a smaller size than the others. Due to the great anatomical variation in this region, a deep knowledge of the anatomy with diagnostic studies must be carried out in order to choose the best therapy for these aneurysms. Among the available treatments, the microsurgical or endovascular approach to anterior communicating complex aneurysms is challenging, but often necessary. The enormous anatomical variety associated with the high incidence of aneurysms in the topography of the anterior communicating artery (AcoA) led us to study techniques such as digital subtraction angiography (DSA) and define a protocol with DSA and advanced image acquisition techniques such as 3D rotational acquisition associated with an overlay tool that allows merging the images of the two anterior cerebral arteries (ACA). Carrying out the analysis of the anatomy of the anterior communicating complex in detail and defining all possible anatomical variations and the relationship of the aneurysm with the A1 segments and the anterior communicating artery that can help in the therapeutic planning of these aneurysms. We also specifically evaluated DF Stent treatment of anterior communicating complex aneurysms at a world-renowned center for this type of procedure. Evaluating this large series of cases, we propose a new classification of this region to infer probable risks of thromboembolic complications, aneurysm healing rate and which stent release technique would be more favorable for each anatomical type of this classification. The new classification of the anterior communicating complex was divided into 4 anatomical types defined by the caliber of the A1 segments of the ACA (H1=same diameters; H2=<50% difference in diameters; H3= ≥50% difference; and Y=no A1 segment.). In addition to the anatomical types, we analyzed 3 basic techniques for releasing the DF Stent (“I” technique – Stent positioned from the A1 to the ipsilateral A2 segment-; “H” technique – one DF Stent on each side (two “I” techniques and the “Chicane” technique when the stent is placed from A1 on one side to the contralateral A2. When we separate the aneurysms in each anatomical type of the new proposed classification we will have: 56.6% in group H1, 26.6% in H2, 16.6% in H3 and none patient in group Y. Complete occlusion occurred in 83.3% of group H1, 66.7% of H2 and 60% of H3. Group H3 had 1.38 more chances of not achieving complete occlusion. In the studied series there was a thromboembolic complication rate of 26.7 % with 3.3% of symptomatic complications. Evaluating thromboembolic complications in each group of the new classification, we observed: 17.6% in the H1 group, 25% in the H2 group and 60% in the H3 group. There were no bleeding complications in the studied group. The H3 group presented 4 times more likely to have thromboembolic complications than the other groups. The performance of the overlay technique for the study of the region of the anterior communicating complex in the DSA facilitates the understanding of the anatomy and relationship of the A1 segments with the aneurysm. The caliber of the A1 segments of the ACA may alter hemodynamics after implantation of a DF Stent. These differences can change both the rate of aneurysm occlusion and the rate of thromboembolic complications during the procedure. The treatment of anterior communicating complex aneurysms with DF Stent is feasible and can become even safer with better anatomical definition using advanced imaging techniques. This better anatomical definition provided a new anatomical classification for a more precise indication of this type of device both in the treatment of first intention and in cases of recanalization after other techniques of aneurysms of the anterior communicating complex.
The anterior communicating complex is one of the most frequent sites of intracranial aneurysms. In addition, aneurysms in this region have a higher risk of rupture when compared to other topographies, and may rupture with a smaller size than the others. Due to the great anatomical variation in this region, a deep knowledge of the anatomy with diagnostic studies must be carried out in order to choose the best therapy for these aneurysms. Among the available treatments, the microsurgical or endovascular approach to anterior communicating complex aneurysms is challenging, but often necessary. The enormous anatomical variety associated with the high incidence of aneurysms in the topography of the anterior communicating artery (AcoA) led us to study techniques such as digital subtraction angiography (DSA) and define a protocol with DSA and advanced image acquisition techniques such as 3D rotational acquisition associated with an overlay tool that allows merging the images of the two anterior cerebral arteries (ACA). Carrying out the analysis of the anatomy of the anterior communicating complex in detail and defining all possible anatomical variations and the relationship of the aneurysm with the A1 segments and the anterior communicating artery that can help in the therapeutic planning of these aneurysms. We also specifically evaluated DF Stent treatment of anterior communicating complex aneurysms at a world-renowned center for this type of procedure. Evaluating this large series of cases, we propose a new classification of this region to infer probable risks of thromboembolic complications, aneurysm healing rate and which stent release technique would be more favorable for each anatomical type of this classification. The new classification of the anterior communicating complex was divided into 4 anatomical types defined by the caliber of the A1 segments of the ACA (H1=same diameters; H2=<50% difference in diameters; H3= ≥50% difference; and Y=no A1 segment.). In addition to the anatomical types, we analyzed 3 basic techniques for releasing the DF Stent (“I” technique – Stent positioned from the A1 to the ipsilateral A2 segment-; “H” technique – one DF Stent on each side (two “I” techniques and the “Chicane” technique when the stent is placed from A1 on one side to the contralateral A2. When we separate the aneurysms in each anatomical type of the new proposed classification we will have: 56.6% in group H1, 26.6% in H2, 16.6% in H3 and none patient in group Y. Complete occlusion occurred in 83.3% of group H1, 66.7% of H2 and 60% of H3. Group H3 had 1.38 more chances of not achieving complete occlusion. In the studied series there was a thromboembolic complication rate of 26.7 % with 3.3% of symptomatic complications. Evaluating thromboembolic complications in each group of the new classification, we observed: 17.6% in the H1 group, 25% in the H2 group and 60% in the H3 group. There were no bleeding complications in the studied group. The H3 group presented 4 times more likely to have thromboembolic complications than the other groups. The performance of the overlay technique for the study of the region of the anterior communicating complex in the DSA facilitates the understanding of the anatomy and relationship of the A1 segments with the aneurysm. The caliber of the A1 segments of the ACA may alter hemodynamics after implantation of a DF Stent. These differences can change both the rate of aneurysm occlusion and the rate of thromboembolic complications during the procedure. The treatment of anterior communicating complex aneurysms with DF Stent is feasible and can become even safer with better anatomical definition using advanced imaging techniques. This better anatomical definition provided a new anatomical classification for a more precise indication of this type of device both in the treatment of first intention and in cases of recanalization after other techniques of aneurysms of the anterior communicating complex.
Descrição
Citação
PAGIOLA, Igor Campostrini. Técnicas para o diagnóstico, planejamento terapêutico e tratamento endovascular com Stent diversor de fluxo dos aneurismas do complexo comunicante anterior. 2023. 60 f. Tese (Doutorado em Radiologia Clínica) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP). São Paulo, 2023.