Rajbeer Singh Sangha, MD

Zanaty M, Chalouhi N, Starke R, Guiherme B, Saigh M, Schwartz E, et al. Flow Diversion Versus Conventional Treatment for Carotid Cavernous Aneurysms. Stroke. 2014

With continuing advances in technology and healthcare, several endovascular options have emerged for the treatment of cavernous carotid aneurysms (CCA). These strategies include balloon-assisted coiling (BAC), stent-assisted coiling (SAC), carotid vessel destruction (CVD) and flow diversion. The reported recurrence rate and incomplete angiographic occlusion after treatment with conventional endovascular technique remains high, discouraging their use in complex aneurysms. Recently, Flow-diversion has been emerging as a novel treatment, however there is currently not enough data to establish its superiority over the conventional modalities.  The authors of this study compared the above treatment modalities looking at morbidity, mortality, evolution of mass symptoms and aneurysm occlusion/rate of retreatment. 

Analysis of 157 patients showed no difference in age, gender, and mean aneurysm size between those treated with PED and those treated with conventional endovascular procedures. The patients treated with PED had a significantly lower proportion of small size aneurysms (<10mm), significantly higher rate of improvement (92.16%) and a shorter follow-up duration. The rate of complete occlusion was 81.36% (48/59) for PED, 42.25% (39/71) for SAC, 27.27% (6/22) for coiling and 73.33% (11/15) for CVD.  The rate of major complications was 6.6% (11/167). Patients that were treated with PED or SAC had 3.84 lower odds to develop complications (OR= 0.26 p<0.05).

The authors make a compelling case through this study for the use of flow diversion (PED) technique for treatment of symptomatic CCA. The results of this study certainly do provide merit to the argument and given the low rate of complications, it is difficult to see why such a technique should not be aggressively studied further. Given the retrospective nature of the study and the possible biases which are acknowledged by the authors, a large multicenter trial would provide the power and validity required to show that PED is likely superior versus traditional endovascular methods that have been employed. It is refreshing to see an endovascular procedure which has lower rates of complication and less requirements for retreatment given the discouraging news that has been surrounding the field with recent studies the past few years.