Multipleclinical studies have demonstrated the safety and efficacy of surgical clipping or endovascular coiling, which are typical treatment methods for ruptured aneurysms.1,2Traditional therapy is unsatisfactory for aneurysms that are blisterlike, dissecting, or fusiform and have a higher risk of rebleeding. In these cases, conventional treatment results are typically accompanied by an increased risk of perioperative complications, rebleeding, or aneurysm recurrence. The flow diverter (FD) lowers the blood flow in the aneurysm after surgery, and endothelial cells cover the device to reconstruct the parent artery for the long term, eventually leading to aneurysm occlusion.3Given the positive long-term results of FDs in the treatment of unruptured aneurysms,4there has been a gradual endeavor to use these devices in ruptured aneurysms, especially for the types of aneurysms that are difficult to treat by traditional methods. Nonetheless, challenges remain.
In contrast to traditional methods, FDs take weeks to months to occlude the aneurysm, during which time rerupture of the unoccluded aneurysm could negatively affect the patient’s health.5In contrast to other devices, an FD has a more extensive metal coating than conventional stents and relies more on antiplatelet medications to reduce the risk of periprocedural thromboembolic problems.6Due to concerns over rebleeding and bleeding complications associated with extraventricular drainage (EVD), the use of antiplatelet agents is currently not standardized. On the one hand, effective coil embolization of the aneurysm sac prior to FD implantation may minimize rerupture events resulting from delayed occlusion of the aneurysm,5and on the other hand it may supply an appropriate application of antiplatelet medicines to effectively avoid ischemic events without raising the risk of rebleeding.
Insufficient clinical trials exist to confirm the aforementioned notion. In order to provide more evidence-based protocols and clinical decisions for the treatment of ruptured aneurysms with FDs, we retrospectively analyzed the multicenter experience of FD implantation combined with coil embolization for the treatment of ruptured aneurysms along with the application of antithrombotic drugs to evaluate the perioperative safety and long-term effectiveness of these treatments.
开云体育世界杯赔率
Patients
The ethics committees of the First Affiliated Hospital of Zhengzhou University and Beijing Tiantan Hospital approved this retrospective, two-center clinical study, and informed consent was obtained from all patients or next of kin before treatment. A total of 61 patients with all types of ruptured aneurysms treated with FDs between February 2018 and June 2022 at the two aforementioned high-volume centers were screened retrospectively according toFig. 1, with 41 cases eventually included. The demographic information, clinical disease characteristics, aneurysm characteristics, procedure details and complications, follow-up imaging studies, and outcomes of all patients were collected and analyzed by two specialized neurointerventionalists to assure the accuracy of the data.
Flowchart for patient screening for inclusion in study.
Procedure and Perioperative Antiplatelet Regimen
All patients underwent general anesthesia with tracheal intubation, and intraoperative systemic heparinization (heparin 50–70 U/kg) was administered. A 6- to 8-Fr long sheath (Cook Medical) and Navien 058 catheter (ev3) were placed through the femoral artery. Depending on the width of the aneurysm neck and the diameter of the parent artery, a different type or brand of FD device was selected, including Pipeline Flex (ev3), Surpass Streamline (Stryker), and Tubridge (MicroPort). Following the path diagram, the Navien 058 catheter was guided to a suitable position by a microwire and a microcatheter including Marksman (ev3) and T-track (MicroPort Medical). The microwire guided the microcatheter for FD delivery across the aneurysm neck to the distal parent artery (Surpass Streamline devices do not require microcatheter delivery), and we replaced the previous microwire with a Synchro microwire (0.014 inch × 300 cm; Stryker). An Echelon-10 microcatheter for coiling (ev3) was placed into the aneurysm. After delivering the FD along the microcatheter or intermediate catheter to the desired position, the FD was partially released to the aneurysm neck. The coils were then inserted, and once the proper coiling was finished, the FD was finally fully released.
Intravenous tirofiban (loading dose of 10 µg/kg, push time < 3 minutes, followed by a maintenance dose of 0.1 μg·kg−1·min−1) was applied after partial intraoperative FD release and continued for 12–24 hours postoperatively. Patients were administered a loading dose of a dual-antiplatelet regimen (aspirin 300 mg + clopidogrel 300 mg) before withdrawal of tirofiban for 4 hours to ensure that platelet function was continuously inhibited. A dual-antiplatelet regimen (aspirin 100 mg/day + clopidogrel 75 mg/day) for 3–6 months followed by a single-antiplatelet regimen (aspirin 100 mg/day preferably) is indicated for patients on a long-term basis during the follow-up phase. The duration of the dual-antiplatelet regimen would be determined by the results of the first imaging (digital subtraction angiography [DSA]) performed during the follow-up period (3–6 months after discharge). If DSA images demonstrate complete occlusion of the aneurysm (O’Kelly-Marotta [OKM] grade D) or no in-stent stenosis (stenosis < 20%), clopidogrel would be withdrawn and aspirin would be continued for 1 year; if not, the dual-antiplatelet regimen would be continued for 6 months or longer.
Definition and Evaluation of Clinical Outcomes
The efficacy endpoint was the assessment of the degree of aneurysm occlusion by DSA during the follow-up period. The OKM grade categorizes the degree of aneurysm occlusion into the following four grades: A, complete filling; B, partial filling of the aneurysm body (aneurysm visualization 5%–95%); C, filling of the aneurysm neck only (aneurysm visualization < 5%); and D, complete occlusion. We define grade C or D as effectiveness for long-term follow-up.
The safety endpoint concerned procedure-related perioperative complications, including cerebral ischemic and hemorrhagic events. Ischemic events refer to a new neurological deficit that lasts > 24 hours and can be confirmed by brain CT or MRI in the area of the parent artery, or a deficit outside the area of the parent artery without corresponding vasospasm confirmed by DSA. Ischemic events that occurred in other regions with corresponding vasospasm or that improved following blood pressure and blood volume regulation and the use of drugs to relieve cerebral vasospasm were judged to be subarachnoid hemorrhage (SAH)–related delayed cerebral ischemia, and were excluded. Hemorrhagic events include intracranial hemorrhage and hemorrhage associated with EVD or continuous lumbar drainage. Intracranial hemorrhage refers to any new SAH, brain parenchyma, or intracerebroventricular space or increased hemorrhage in those areas when compared with preoperative intracranial CT images.
Statistical Analysis
Descriptive statistical analysis methods are used for data presentation. Continuous variables are shown as median and IQR, and categorical variables are shown as number and percentage. All analytical results were obtained using IBM SPSS 27 Statistics software (IBM Corp.).
Results
Participant Characteristics
Forty-one individuals with a total of 41 ruptured aneurysms were included in this study; all received treatment with an FD combined with coils. Patient and aneurysm baseline characteristics are shown inTable 1．病人的平均年龄是51年(差42–60 years), and 22 of them were women (53.7%). Among all patients, 34/41 (82.9%) had a Hunt-Hess grade of I–II and 30/41 (73.2%) had a Fisher grade of 0–2. Of all ruptured aneurysms, 15/41 (36.6%) were found in the vertebrobasilar circulation, with a median maximum diameter of 7.31 mm (IQR 3.70–11.75 mm). Furthermore, the type of aneurysm was characterized as saccular (maximum diameter > 20 mm [2]), dissecting (6), blisterlike (10), or fusiform (7) in 25/41 cases (61.0%).
Patient and lesion characteristics in a cohort with ruptured aneurysms
| All Cases, n = 41 | |
|---|---|
| Patient characteristics | |
| Age in yrs, median (IQR) | 51 (42–60) |
| Sex, no. (%) | |
| Male | 19 (46.3%) |
| Female | 22 (53.7%) |
| Hypertension, no. (%) | 20 (48.8%) |
| Diabetes, no. (%) | 2 (4.9%) |
| CAD, no. (%) | 4 (9.8%) |
| 目前的吸烟者,不。（%） | 8 (19.5%) |
| Hunt-Hess grade, no. (%) | |
| I | 27 (65.9%) |
| II | 7 (17.1%) |
| III | 6 (14.6%) |
| IV | 1 (2.4%) |
| V | 0 |
| Fisher grade, no. (%) | |
| 0 | 1 (2.4%) |
| 1 | 17 (41.5%) |
| 2 | 12 (29.3%) |
| 3 | 10 (24.4%) |
| 4 | 1 (2.4%) |
| mRS score at discharge, no. (%) | |
| 0–2 | 36 (87.8%) |
| 3–6 | 5 (12.2%) |
| 动脉瘤characteristics | |
| Location, no. (%) | |
| ICA C6 | 12 (29.3%) |
| ICA C7 | 8 (19.5%) |
| MCA | 5 (12.2%) |
| ACA, AcomA | 1 (2.4%) |
| VA intracranial | 11 (26.8%) |
| PICA | 1 (2.4%) |
| BA | 3 (7.3%) |
| Type, no. (%) | |
| Saccular | 18 (43.9%) |
| Fusiform | 7 (17.1%) |
| Blisterlike | 10 (24.4%) |
| Dissecting | 6 (14.6%) |
| Max diam in mm, median (IQR) | 7.56 (3.55–11.88) |
ACA = anterior cerebral artery; AcomA = anterior communicating artery; BA = basilar artery; CAD = coronary atherosclerotic disease; diam = diameter; ICA = internal carotid artery; ICA C6 = ophthalmic segment of ICA; ICA C7 = posterior communicating segment of ICA; max = maximum; MCA = middle cerebral artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery.
Perioperative Outcome and Complications
As demonstrated inTable 2, the median time to the procedure for aneurysm rupture in patients was 7 days (IQR 3–15 days), with 80.5% (33/41) being ≤ 15 days. OKM grading was completed in all patients immediately after the procedure, with a total of 15 cases (36.6%) of complete or near-complete occlusion. All invasive maneuvers related to draining of CSF are performed after surgery. Intermittent translumbar puncture drainage and continuous lumbar drainage were completed in 23 cases in all, but EVD was used in none of the cases.
Procedure and follow-up characteristics in patients with ruptured aneurysms
| All Cases, n = 41 | |
|---|---|
| Procedure characteristics | |
| 时间从断裂在天FD,中值(差) | 7 (3–15) |
| FD type, no. (%) | |
| PED | 30 (73.2%) |
| Tubridge | 9 (22.0%) |
| Surpass Streamline | 2 (4.9%) |
| Postop OKM grade, no. (%) | |
| A | 3 (7.3%) |
| B | 23 (56.1%) |
| C | 9 (22.0%) |
| D | 6 (14.6%) |
| Drainage of CSF, no. (%) | |
| Lumbar puncture | 19 (46.3%) |
| Continuous lumbar drainage | 4 (9.8%) |
| EVD | 0 |
| FU outcome | |
| Patients w/ FU, no. (%) | 25 (61.0%) |
| Time to FD placement in mos, median (IQR) | 8.0 (6.0–15.5) |
| FU OKM grade, no. (%) | |
| A | 0 |
| B | 2 (8.0%) |
| C | 3 (12.0%) |
| D | 20 (80.0%) |
FU = follow-up; PED = Pipeline embolization device.
Perioperative complications were observed in 5 cases (12.2%), including 3 ischemic and 2 hemorrhagic cases (details of the cases with complications are provided inTable 3). In 2 of the ischemic cases, the occlusion of a basilar perforator occurred during the usage of tirofiban. The other case suffered from cortical thromboembolic cerebral infarction during the oral dual-antiplatelet medications, and no significant intrastent thrombosis was identified on immediate DSA. All ischemic cases were discharged with a favorable prognosis (modified Rankin Scale [mRS] score < 2). As for the hemorrhagic complications, 1 case was an aneurysm that occurred after the administration of dual-antiplatelet medicines on the 3rd postoperative day and was graded B in the OKM system immediately after treatment, with visible contrast at the dome and body of the aneurysm (Fig. 2). In the other case of hemorrhage, the aneurysm was located in the ophthalmic segment of the right internal carotid artery, and a large hemorrhage in the left lateral ventricle was discovered on CT scans on the 1st day of postoperative dual-antiplatelet medication. Both patients with hemorrhagic cases refused surgical treatment and failed to achieve favorable prognostic criteria at discharge (mRS score > 3).
Details of perioperative hemorrhagic and ischemic cases in patients with complications
| Hemorrhagic Cases | Ischemic Cases | ||||
|---|---|---|---|---|---|
| Case 1 | Case 2 | Case 1 | Case 2 | Case 3 | |
| Age (yrs) | 70 | 44 | 32 | 71 | 52 |
| Hunt-Hess grade | 3 | 3 | 1 | 1 | 2 |
| Fisher grade | 3 | 3 | 1 | 2 | 2 |
| 动脉瘤 | |||||
| Location | Rt ICA C6 | Rt ICA C6 | BA | VA V4 | Lt ICA C7 |
| Type | Blisterlike | Blisterlike | Dissecting | Saccular | Saccular |
| Neck size (mm) | 2.87 | 3.85 | 3.52 | 1.38 | 5.38 |
| Max diam (mm) | 5.99 | 5.61 | 4.55 | 2.54 | 7.81 |
| Time from rupture to FD (days) | 13 | 7 | 15 | 8 | 9 |
| FD type | PED | PED | PED | Surpass | PED |
| Postop OKM grade | B | C | B | D | C |
| Event type | Rerupture | Lt IVH | PO | PO | TE |
| Event at day | 3 | 2 | 1 | 1 | 5 |
| mRS score at discharge | 4 | 5 | 1 | 1 | 0 |
IVH = intraventricular hemorrhage; Lt ICA C7 = posterior communicating segment of left ICA; PO = perforator occlusion; Rt ICA C6 = ophthalmic segment of right ICA; TE = thromboembolism; VA V4 = intracranial segment of VA.
A:Preoperative CT image of SAH.B and C:Rebleeding in the right frontal and temporal lobes with breakthrough into the lateral ventricles.D and E:Preoperative 2D (panel D) and 3D (panel E) DSA images of ruptured aneurysm (black arrows).F:Postoperative DSA image of treated aneurysm showing partial residual at dome and body of the lesion (white arrow).
Clinical and Radiological Results in Follow-Up
Overall, 25 patients completed posttreatment follow-up with a median time of 8.0 months (IQR 6.0–15.5 months). There was no rerupture of the aneurysm or ischemic stroke in any of these patients who were followed after discharge. All imaging evaluations of aneurysms were conducted using DSA. Partial contrast filling of the aneurysm (OKM grade B) was still observed on DSA in only 2 patients at 7 months after discharge, whereas the rest had complete or near-complete occlusion of the aneurysm (OKM grade C or D).
Discussion
Currently, given concerns about the high thrombogenic effect of an FD and the higher risk of rebleeding due to its delayed aneurysm occlusion feature, the therapeutic use of FDs for ruptured aneurysms is still controversial, and the best evidence-based procedural method and perioperative management protocols are still being discussed. We primarily studied the clinical effects of FDs combined with coil embolization for diverse types of ruptured aneurysms treated with an appropriate perioperative antiplatelet regimen. This study found that the aforementioned treatment strategy ensured both a relatively low complication rate perioperatively and a high rate of aneurysm occlusion throughout a long-term follow-up.
Early treatment of ruptured aneurysms is primarily aimed at lowering the risk of rebleeding to improve the prognosis, because the mortality rate rises to > 80% after rerupture of the aneurysm. With the difficulty of surgical clipping or traditional endovascular treatment for large saccular, blisterlike, fusiform, or dissecting aneurysms, an FD presents alternative options for treating these types of ruptured aneurysms.7,8The risk of FD and postoperative aneurysm rebleeding has been the focus of relevant studies for ruptured aneurysms. Acute phase (within 15 days of bleeding) and aneurysm size > 20 mm are risk factors for rebleeding of aneurysms following FD placement,9and this earlier study revealed rebleeding in 11% (5/44) of patients, of whom 80% (4/5) did not have a coil.
We suggested that additional coil embolization could to a certain extent offset the higher risk of rebleeding in FD treatment of ruptured aneurysms. The presence of coils in the aneurysm, in synergy with the FD, further lowers the influence of blood flow on the aneurysm wall and develops greater stasis of blood flow.10Moreover, the stasis and the 3D scaffold-like coil design enable thrombus formation within the aneurysm to interfere with blood flow to the aneurysm wall, specifically the rupture site.11A study conducted by applying computational fluid dynamics demonstrated that an FD combined with coiling considerably reduced the intraaneurysmal flow velocity and shear stress on the aneurysm wall compared to an FD alone, and further lowered the risk of aneurysm rupture and accelerated thrombosis.12Recent retrospective studies have also validated the benefit of this treatment strategy in lowering the risk of perioperative rebleeding.7,13,14In addition, the technique of coil packing differs from traditional dense packing in stent-assisted treatment of aneurysms, preferring loose packing (aneurysms and necks) and the use of basket coils with sizes somewhat less than the measurement.13,15It allows surgeons not only to reduce the pressure of coils on the aneurysm wall in the process of packing and to avoid excessive tension on the aneurysm wall, but also to further reduce the volume of the aneurysm during follow-up to lessen its occupying effect. In our study, only 1 individual (2.4%) suffered from perioperative aneurysm rebleeding. Notably, in this case, the contrast at the dome and the body of the aneurysm were clearly visible on immediate DSA imaging obtained following the procedure (Fig. 2). An unsuitably smaller size of basket coil and excessive residual aneurysm outside the coils may also be adverse factors for minimizing risk of rebleeding, even if the subsequent coils are more densely packed. It challenges the surgeon’s operating skills and clinical experience.
The effect of occlusion for ruptured aneurysms in long-term follow-up is a key component in evaluating effectiveness. Previous studies with FD for ruptured aneurysms have shown > 80% complete occlusion rates during the follow-up period.6,16A higher degree of flow stasis and thrombotic conditions within the aneurysm generated by adjunctive coiling lead to quicker endothelialization of the FD and total occlusion of the aneurysm throughout the follow-up period.17Adjunctive coiling was reported to improve the rate of complete occlusion by 74% versus FD alone at 1-year follow-up in an investigation that included 387 patients with unruptured aneurysms.10For ruptured blisterlike aneurysms, adjunctive coiling can still yield significant occlusion rates over the long term.14In our study, we found similar long-term results with a median follow-up of 8 months and a complete occlusion (OKM grade D) rate of 80% (20/25). Notably, the results are still subject to some restrictions. First, the overall sample size of our study was relatively small and the follow-up rate of angiography was low (25/41, 61%), which limits the reliability of the result. Second, our study adopts OKM grade to evaluate the validity of the follow-up period. Although the OKM grade is valid for assessing intracranial aneurysms treated with flow-directed stents alone,18the presence of coils in the aneurysm may interfere with the surgeon’s assessment of the degree of contrast stasis and aneurysm occlusion for FDs inserted with adjunctive coil embolization.
Given the risk of aneurysm rebleeding and hemorrhage associated with EVD and the potential higher risk of ischemic events with adjunctive coiling,11the type, timing, and dosage of antiplatelet regimens in patients who receive an FD for the treatment of ruptured aneurysms are still not standardized or recommended clearly. In the previous clinical studies, most of the antiplatelet regimens used were either a preoperative loading dose of aspirin (300 mg) and clopidogrel (300 mg) or a standard dose of aspirin (100 mg/day), clopidogrel (75 mg/day), or prasugrel (50 mg/day) administered continuously for 1–5 days. Although this regimen minimizes the incidence of perioperative ischemic events, it remains unsatisfactory for the following reasons: 1) Concerning the effect of platelet inhibition: first, aspirin or clopidogrel resistance is found in a portion of the population, and the short interval between the loading dose and the procedure does not allow for a timely evaluation of the antiplatelet impact. Second, there are individual variations in the delayed onset of action of oral antiplatelet drugs and the time to peak effect, and it is difficult to achieve a good match between the high platelet inhibition rate and the timing of the procedure. Both of the abovementioned factors may be adverse to a decrease in ischemic events. 2) EVD-associated hemorrhage: the abovementioned medications increase the risk of this type of hemorrhage, and hence it is recommended that EVD be conducted before the administration of antiplatelet drugs.19However, other patients had an indication for EVD only when aggravation of hydrocephalus occurred after the FD was inserted and oral antiplatelet medications were used, which made the clinical decision more passive. 3) Gastrointestinal hemorrhage: this is a common complication of SAH,20and the use of oral antiplatelet medications, especially when administered in loading doses, substantially enhances the risk. The inhibitory effect of IIb/IIIa receptor antagonists (tirofiban, etc.) on platelet function is not affected by individualized differences, and onset of the effect is just minutes after a loading dose is given intravenously, allowing precise control of the degree and timing of platelet inhibition.21Immediate administration of tirofiban at the time of stent release guarantees that platelet function is inhibited while minimizing the potential risk of bleeding associated with pretreatment antiplatelet drugs. Furthermore, because of the short half-life of tirofiban (1.4–4.8 hours), for those who require EVD due to postoperative changes in their condition, most patients experience gradually restored platelet function 2–4 hours after tirofiban withdrawal. Even if tirofiban is continued for several days after EVD, it is regarded to demonstrate satisfactory safety.22
The incidence of perioperative ischemic events in early studies ranged from 10% to 30%, in cases in which a low dose of IIb/IIIa receptor antagonists was applied.9,23In our study, although perioperative ischemic events occurred in a relatively small number of cases—just 3 (7.3%)—the following issues should not be neglected. First, 1 patient who stopped tirofiban 12 hours after the procedure and was given a loading dose of dual-antiplatelet drugs suffered a cerebral embolism 24 hours later. Early withdrawal of tirofiban and antiplatelet resistance may increase the incidence of such events, although immediate DSA did not find in-stent thrombosis. In addition, the other 2 ischemic occurrences entailed obstruction of a perforator of the basilar artery. Therefore, for posterior circulation cases, especially those needing partial or complete coverage of the basilar artery by the FD, the risk of perforator occlusion remains high even with the application of tirofiban in the perioperative phase.
Recently, besides an FD combined with or without coil embolization, staged treatment strategies, multiple FDs, and a covered stent have also been tried for early endovascular therapy of ruptured aneurysms. Staged treatment refers to FD placement in the recovery period after subtotal coiling in the acute phase. After the possible rupture point (dome or daughter lobule) is packed as thoroughly as possible in the process of coiling, the other parts of the aneurysm are loosely packed.24The nondense packing of aneurysms alone and the uncertain expertise in identifying rupture-prone sites make the risk of rerupture during the period before FD placement a considerable concern.24Multiple FDs may furthermore exert a flow-diverting effect to lower blood flow and pressure within the aneurysm.25然而,增加金属在多个FDs覆盖also indicates a higher prevalence of perioperative ischemic events due to activation of the blood coagulation system by the devices’ coating,26and FD overlapping may raise the risk of restenosis or occlusion of the parent artery in the long term. Covered stents are more effective than FD in blocking blood flow into the aneurysm and occluding the lesion.27Poor flexibility of the covered stent makes it difficult to position when access is tortuous. The risk of ischemic stroke due to greater thrombogenicity and the covering of branch arteries and rebleeding due to in-stent leakage also restrict its use in ruptured intracranial aneurysms.
在我们的研究中也是有限度的。首先,作为一个再保险trospective study, there is selection bias in the inclusion of patients. Although the number of cases included in this study exceeds the number in relevant studies published to date, multicenter studies are still needed to provide a larger sample size due to the heterogeneity of aneurysm morphology, size, bleeding time, and FD type, especially for possible subgroup analysis to evaluate treatment effects for aneurysm type. Second, the absence of brain MRI in a group of patients without postoperative neurological deficits may overlook silent, intraoperative diagnostic angiography–related thrombotic events, which may also adversely affect patients’ cognitive function and psychological health. Future prospective studies could consider a study design that overcomes these concerns. Third, our study had a relatively high rate of loss to follow-up (16/41, 39%), and the bias was noted. The 80% rate of complete aneurysm occlusion over the follow-up period suggested by our findings requires confirmation by more research. Furthermore, considering the potential lower compliance with the medication regimen among the dropout group, our study might not precisely describe FD-related ischemic events in the follow-up period.
Conclusions
Application of an FD device for the treatment of ruptured aneurysms, with adjunctive coil embolization, is an effective approach to lower the risk of rerupture of aneurysms in the perioperative period. Evidence-based perioperative antiplatelet regimens ensure a low rate of perioperative ischemic events without increasing the risk of bleeding associated with the abovementioned treatment strategies. More accurate personalized recommendations for the use of FDs with coil embolization still need to be analyzed and generalized in clinical studies with larger samples.
Disclosures
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Author Contributions
Conception and design: Guan, Chen, Gong, Y Li. Acquisition of data: Guan, Chen, Gong, You, D Li, Y Li. Analysis and interpretation of data: Guan, Chen, Gong, Xu, D Li, Y Li. Drafting the article: Chen, Gong, D Li. Critically revising the article: Guan, Chen, Gong, Y Li. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Guan. Statistical analysis: Chen, Gong, Xu. Administrative/technical/material support: all authors. Study supervision: Guan, Chen, Gong, Y Li.
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23 ↑
AlpayK,HinkkaT,LindgrenAE,et al.Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms．J Neurointerv Surg．2022;14(7):699–703．
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24 ↑
HowardBM,FrerichJM,MadaelilTP,et al.插头和管箍tegy for treatment of ruptured intracranial aneurysms．J Neurointerv Surg．2019;11(1):43–48．
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25 ↑
UchiyamaY,FujimuraS,TakaoH,et al.Hemodynamic investigation of the effectiveness of a two overlapping flow diverter configuration for cerebral aneurysm treatment．Bioengineering (Basel)．2021;8(10):143．
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26 ↑
TanLA,KeigherKM,MunichSA,MoftakharR,LopesDK．Thromboembolic complications with Pipeline Embolization Device placement: impact of procedure time, number of stents and pre-procedure P2Y12 reaction unit (PRU) value．J Neurointerv Surg．2015;7(3):217–221．
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27 ↑
LiuLX,ZhangCW,XieXD,WangCH．威利斯的应用覆盖支架在大树下面atment of blood blister-like aneurysms: a single-center experience and systematic literature review．World Neurosurg．2019;123:e652–e660．
