Role of terminal and anastomotic circulation in the patency of arteries jailed by flow-diverting stents: from hemodynamic changes to ostia surface modifications

J Neurosurg. 2017 May;126(5):1702-1713. doi: 10.3171/2016.2.JNS152120. Epub 2016 May 20.


OBJECTIVE The outcome for jailing arterial branches that emerge near intracranial aneurysms during flow-diverting stent (FDS) deployment remains controversial. In this animal study, the authors aimed to elucidate the role of collateral supply with regard to the hemodynamic changes and neointimal modifications that occur from jailing arteries with FDSs. To serve this purpose, the authors sought to quantify 1) the hemodynamic changes that occur at the jailed arterial branches immediately after stent placement and 2) the ostia surface values at 3 months after stenting; both parameters were investigated in the presence or absence of collateral arterial flow. METHODS After an a priori power analysis, 2 groups (Group A and Group B) were created according to an animal flow model for terminal and anastomotic arterial circulation; each group contained 7 Large White swine. Group A animals possessed an anastomotic-type arterial configuration to supply the territory of the right ascending pharyngeal artery (APhA), while Group B animals possessed a terminal-type arterial configuration to supply the right APhA territory. Subsequently, all animals underwent FDS placement, thereby jailing the right APhAs. Mean flow rates and velocities inside the jailed branches were quantified using time-resolved 3D phase-contrast MR angiography before and after stenting. Three months after stent placement, the jailed ostia surface values were quantified on scanning electron micrographs. The data were analyzed using descriptive statistics and group comparisons with parametric and nonparametric tests. RESULTS The endovascular procedures were feasible, and there were no findings of in situ thrombus formation on postprocedural optical coherence tomography or ischemia on postprocedural diffusion-weighted imaging. In Group A, the mean flow rate values at the jailed right APhAs were reduced immediately following stent placement as compared with values obtained before stent placement (p = 0.02, power: 0.8). In contrast, the mean poststenting flow rates for Group B remained similar to those obtained before stent placement. Three months after stent placement, the mean ostia surface values were significantly higher for Group B (527,911 ± 306,229 μm2) than for Group A (89,329 ± 59,762 μm2; p < 0.01, power: 1.00), even though the initial dimensions of the jailed ostia were similar between groups. A statistically significant correlation was found between groups (A or B), mean flow rates after stent placement, and ostia surface values at 3 months. CONCLUSIONS When an important collateral supply was present, the jailing of side arteries with flow diverters resulted in an immediate and significant reduction in the flow rate inside these arteries as compared with the prestenting values. In contrast, when competitive flow was absent, jailing did not result in significant flow rate reductions inside the jailed arteries. Ostium surface values at 3 months after stent placement were significantly higher in the terminal group of jailed arteries (Group B) than in the anastomotic group (Group A) and strongly correlated with poststenting reductions in the velocity value.

Keywords: 3DRA = 3D rotational angiography; APhA= ascending pharyngeal artery; CCA = common carotid artery; CFD = computational fluid dynamics; DSA = digital subtraction angiography; ECA = external carotid artery; FDS = flow-diverting stent; MCA = middle cerebral artery; MR angiography; MRI; OCT = optical coherence tomography; RM = rete mirabile; ROI = region of interest; SEM = scanning electron microscopy; SSS = stent shear stress; collateral arteries; embolization; endothelialization; flow-diverting stent; interventional neurosurgery; ostium; pcMRA = phase-contrast MR angiography.

MeSH terms

  • Anastomosis, Surgical
  • Animals
  • Blood Flow Velocity
  • Carotid Artery, Common / physiopathology*
  • Carotid Artery, Common / surgery
  • Collateral Circulation / physiology
  • Disease Models, Animal
  • Endovascular Procedures*
  • Intracranial Aneurysm / etiology
  • Intracranial Aneurysm / physiopathology*
  • Intracranial Aneurysm / surgery
  • Regional Blood Flow / physiology*
  • Stents*
  • Swine
  • Vascular Patency / physiology*