Limits and possibilities in endovascular therapy

Dobrin Nicolaie*, Patrick Courtheoux**, Laurentiu Dimache* *Clinical Hospital No. 3, Iasi, Romania **CHU Caen, France

The start of the endovascular therapy in the neurosurgery field is closely related Egas Moniz, neurologist, Portuguese psychosurgeon 1874-1955. Egas Moniz is considered to be the father of angiography, and he had at that time a significant role in pshychosurgery, of which he was awarded the Nobel prize in 1949. An important opening in the intravascular approach was realized by Lussenhof, a neurosurgeon who described techniques of treating arteriovenous malformations through embolization with silastic. In the 70s Sebinenko, anticipating the advantages of minimal invasive surgery, accomplished the embolization of cerebral aneurisms with detachable latex balloons. The future of the interventions without laborious and invasive approaches with quick post interventional recovery starts to have a significant appeal. Serbinenkos technique is taken and developed by the western countries which at the beginning were using them for treating aneurism, AVMs or hyper vascular malformations with inoperable character. So the endovascular treatment begins to gain more uses, one being able to solve some inoperable lesions through classic techniques, and the other being minimal invasive, meaning reduced complications bound to the usual ways of approach with quick post interventional recovery. At the begging of 1990 evaluation studies began of what will revolutionize the technical approach of cerebral aneurism, is the GDC (Gugliemi detachable coils) detachable platinum spirals which accomplish an endovascular occlusion of aneurisms. In 1995, FDA approves these devices and in only 5 years over 70.000 embolization procedures are realized in over 300 medical centers around the world. We are talking of course the well developed countries USA and Western Europe.

In the same time the industry that produces these embolization devices developed more and more feasible systems, micro catheters and access micro guides reaching flexibilities and dimensions under 00.7 inches and the guiding catheter comply with the most inaccessible aspects and vascular ramifications. Endovascular approach opens new possibilities in the treatment of stroke through intra-arterial thrombolysis. Clinical studies begin to discuss between endarteriectomy and carotid stenting, of which take place over 50.000 procedures annually only in North America. In these circumstances, the so called field of cerebral endovascular procedures starts to expand at a rapid pace. A number of involved specialties are starting to show interest in the minimal invasive management of the patient with cerebrovascular problems, neurosurgery, neuroradiology and neurology. Here arises the problem in determining which specialty is the most suited to perform these procedures. For example, the carotid stenting procedures are done mostly by cardiologists. Therefore, cardiologists justify that they have more experience in stenting and angioplasty, neuroradiologists state that the carotid stenting procedures should be done by them because they have the most valuable experience in solving vascular pathology through neuro angiography, neurosurgeons and endovascular surgeons state that is their territory and radiologists that they have the most medical knowledge in the treatment of stroke. Obviously every specialty offers advantages and abilities in endovascular techniques but in this complex environment neurosurgery and neuroradiology come together having the experience or treating the difficult cases of vascular pathology and the practical abilities of manipulation of embolization devices in radiologic field. Fundamental progress is realized with the introduction of SAC (Stent assisted coiling) and BAC (Balloon assisted coiling) techniques which revolutionized the endovascular approach of aneurysms with large neck or vascular efferences aneurism. In these circumstances the competition began between these two efficient ways of treatment of spinal and cerebral vascular lesions. The so called classic way and the endovascular approach. For many decades the aneurysm surgery was the only way

to solv this type of pathology. Upon developing firstly of GDC type coils and then other endovascular treatment systems a new way of approach was underway. After the 1990s the endovascular techniques became wide spread having sometimes the tendency to replace the classic techniques. Therefore the ISAT studies have established their set ups to determine which is more efficient. The first results of ISAT trials were published in 2002 and relieved that in short term the result of the endovascular approach were superior of those of classic approach. The study had numerous critics like population randomization, medium age too small, the aneurysm dimensions were below 10mm. and mostly anterior circulation localization. The study was shut down in 2002. In 2008 an update of this study was initiated which led somehow to a turnover in the meaning that the high rate of post interventional recurrence of aneurysms is associated also with a high rate bleeding is comparison with that of the aneurysms treated through clipping . Finally the trial suggest that in the case of the treatment of cerebral aneurysms the advantage of endovascular approach cant be necessarily assumed for patients under 40 years. Still the development of the endovascular techniques is constantly rising and only from 2008 until now new devices like flow-divertors, hypercompliant ballons, fluid embolization systems manage to successfully resolve the most difficult vascular aspects. The possibilities and limits of the endovascular therapy seems to be inexhaustible in parallel with the developing of the acquisition and image processing ,tri-coaxial access systems which improve the stability of micro catheters and facilitate the access in difficult vascular territories with multiple ramifications. The endovenous approach opens efficient possibilities for treatment in the case of many pathological entities considered difficult to treat like stenting of the cerebral venous sinuses in the case of the benign intracranial pressure syndrome, endovenous resolve of the dural fistulae or cavernous-carotid fistulae. Another aspect disputed between close specialties is that of the ischemic stroke where the intra-arterial approach consist of different kinds, from the intra-arterial thrombolysis, arterial stenting ,recanalization of cloths, retrievals etc. begins to take shape in medical centers like first line treatment.

Anyway stationing is the microsurgery technique which seems to have brought less progress since the introduction of the operating microscope and micro tools. With all that the most sophisticated endovascular techniques fade in the point where there is a problem that can be solved only by surgical procedures. Also maintaining surgical experience becomes a necessity in the clinics where the endovascular approach is mostly used. The treatment of the cerebral vascular pathology both surgical and endovascular is a very delicate technique and the results are dependent by the infrastructure and also by experience and handiness. The studies show an efficient learning curve in the case of seniors which stretches on a 350-400 cases resolved in both situations. Maintaining a balance between the 2 ways of treatment is the best politic with the best results.
We present here some images to shoe the diversity of pathological aspects wich can be solved by endovascular way.

Fig.1 Rotationl 3D angiography, showing a aneurysm betweenleft ACS, cerebelar superior artery and left ACP, comunicating posterior artery , GDC embolisation.(Laboratorul de Diagnostic si Terapie Endovasculara Dr. Nicolaie DOBRIN, Spitalul Clinic Prof. Dr. Nicolae Oblu Iasi)

Fig.2 Bifurcation left ICA aneurysm with vasospasm complicatetd with periprocedural oclusion of left A1 and M1 segments wich wrer soved by BAC, bllon assited coilling, technique (Laboratorul de Diagnostic si Terapie Endovasculara Dr. Nicolaie DOBRIN, Spitalul Clinic Prof. Dr. Nicolae Oblu Iasi)

Fig. 3 ONYX embolisation of a left ACM, AVM we can se the complete obliteration of the AVM with the patency of the venous drainage (CHU-Caen, France Professeur Patrick COURTHEOUX)

Fig. 4 3D angiography study which show giant right ICA aneurysm , volume calculation and different endovascular angle work to prepare endovascular approach. (Laboratorul de Diagnostic si Terapie
Endovasculara Dr. Nicolaie DOBRIN, Spitalul Clinic Prof. Dr. Nicolae Oblu Iasi)

Bibliography

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