title: Delayed complications after flow-diverter stenting: reactive in-stent stenosis and creeping stents.
abstract: We assessed the frequency and severity of changes in stent configuration and location after the treatment of intracranial aneurysms, and patterns of in-stent stenosis. We retrospectively reviewed data for consecutive aneurysm patients managed with endovascular implantation of flow-diverter stents (Silk Flow Diverter [Balt Extrusion, Montmorency, France] and Pipeline Embolization Device [ev3/Coviden, Minneapolis, MN, USA]) from October 2011 to July 2012. Routine 2, 6, 9-12, and 16-20 month follow-up angiograms were compared, with a focus on changes in stent configuration and location from immediately after deployment to angiographic follow-up, and the incidence and development of in-stent stenosis. Thirty-four patients with 42 aneurysms met inclusion criteria. The Silk device was implanted in 16 patients (47%, single device in 15), the Pipeline device in 18 (53%, single device in 16). On first follow-up angiography, in-stent stenosis was observed in 38% of Silk devices and 39% of Pipeline devices. In-stent stenosis was asymptomatic in 12 of 13 patients. One woman presented with transient ischemic attacks and required stent angioplasty due to end tapering and mild, diffuse in-stent stenosis. Configuration and location changes, including stent creeping and end tapering were seen in 2/16 patients (13%) with Silk devices, and 0/18 patients with Pipeline devices. We describe stent creeping and end tapering as unusual findings with the potential for delayed clinical complications. In-stent stenosis, with a unique behavior, is a frequent angiographic finding observed after flow-diverter stent implant. The stenosis is usually asymptomatic; however, close clinical and angiographic monitoring is mandatory for individualized management.
authors: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel; Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address: jcohenns@yahoo.com.
authors: José E
authors: JE
authors: Cohen
authors: Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors: John Moshe
authors: JM
authors: Gomori
authors: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors: Samuel
authors: S
authors: Moscovici
authors: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors: Ronen R
authors: RR
authors: Leker
authors: Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
authors: Eyal
authors: E
authors: Itshayek
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000783:Aneurysm / Q000601:surgery*; D002533:Cerebral Angiography; D002648:Child; D003251:Constriction, Pathologic / Q000209:etiology / Q000628:therapy*; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Brain aneurysm; Complications; Flow-diverter stent; In-stent stenosis; Stent migration