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Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations
Published on: October 20, 2017
Risk Assessment in Flow-Diverter Implantation of Vertebrobasilar Dolichoectasia: A Novel Three-Subtype Classification
Haochen Huang1, Zhe Ji1, Simin Wang1
1From the Department of Neurosurgery (H.H., S.W., J.L., T.Z., A.Q., C.H.), Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Department of Neurosurgery (Z.J.), Capital Medical University affiliated Beijing Friendship Hospital, No. 95 Yong'an Road, Xicheng District, Beijing, China.
Background And Purpose:
Vertebrobasilar dolichoectasia is a rare cerebrovascular disorder with a poor natural history. Flow diverters have emerged as a treatment option, but clinical outcomes remain heterogeneous and predictors of procedural risk are lacking. This study aimed to identify predictors of perioperative outcomes and develop an imaging-based classification for risk stratification.
Materials And Methods:
We retrospectively analyzed 59 consecutive patients with unruptured vertebrobasilar dolichoectasia who underwent flow-diverter implantation between 2018 and 2023. Clinical and angiographic follow-up was performed at 6 and 12 months and annually thereafter. Clinical outcomes were assessed with the mRS, and angiographic outcomes by occlusion status. Logistic regression identified predictors of perioperative unfavorable outcomes. Lesions were characterized by the location of maximal dilation relative to the AICA origin and the presence of intraluminal thrombus.
Results:
Complete 1-year clinical follow-up was available for all 59 patients. Angiographic follow-up was obtained in 34 patients (57.6%) at a median of 9 months. Perioperative unfavorable outcomes occurred in 16.9%, and complete occlusion was achieved in 44.1%. Intraluminal thrombus (P = .04) and AICA-distal location (P = .05) were independent predictors of unfavorable perioperative outcome. Lesions were classified into three subtypes: Type A (AICA-distal with thrombus), Type B (AICA-distal without thrombus), and Type C (AICA-proximal). Perioperative unfavorable outcomes were most frequent in Type A (50%) compared with Type B (12.5%, P = .04) and Type C (6.5%, P = .004). Procedure-related complications occurred in 50%, 62.5%, and 22.6% of Type A, B, and C lesions, respectively, with a significantly lower rate in Type C than in Type B (P = .007). At 1-year, unfavorable outcomes remained more common in Type A lesions than in Type C lesions (58.3% vs 16.1%, P = .02). Angiographic occlusion rates did not differ among subtypes.
Conclusions:
We propose a three-subtype classification for vertebrobasilar dolichoectasia based on intraluminal thrombus and lesion location relative to the AICA that may help stratify procedural risk with flow-diverter implantation. Type C lesions may represent relatively more suitable candidates for treatment, whereas Types A and B may carry higher risk and should prompt cautious patient selection. Prospective multicenter validation is warranted.
