Original Article

Interventional Neuroradiology
1–8
Endovascular treatment of complex ! The Author(s) 2020
Article reuse guidelines:
middle cerebral artery aneurysms sagepub.com/journals-permissions
DOI: 10.1177/1591019920946216
using TuBridge flow diverters journals.sagepub.com/home/ine

Feng Liang1,*, Yibing Yang1,*, Lijuan Luo1, Bingye Liao2, Guofeng Zhang1,
Siqi Ou1, Weiping Xiao1, Ning Guo1 and Tiewei Qi1

Abstract
Background: The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains
unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the
TuBridge flow diverter.
Methods: A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retro-
spectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm
features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results
included occlusion grade of aneurysm (O’Kelly–Marotta grading scale), patency of jailed branch(es), and in-stent stenosis.
Results: Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size
was 11.8
6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean
follow-up of 11.3
3.6 months. All patients had follow-up angiograms at a mean of 7.5
4.0 months after surgery. Of the
eight patients, there was 1 (12.5%) O’Kelly–Marotta grading scale A, 3 (37.5%) O’Kelly–Marotta grading scale B, 1 (12.5%)
O’Kelly–Marotta grading scale C, and 3 (37.5%) O’Kelly–Marotta grading scale D. Of the seven patients with jailed branch,
the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent
stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient.
Conclusion: Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge
flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle
cerebral artery aneurysms that are difficult to treat with either clipping or coiling.

Keywords
TuBridge flow diverter, endovascular treatment, middle cerebral artery aneurysm
Received 3 March 2020; accepted 8 July 2020

Background
Middle cerebral artery (MCA) aneurysms are primarily
treated with either microsurgical clipping or endovas-
cular coiling.1 However, fusiform aneurysms, recurrent
aneurysms, or aneurysms with distal branches arising
from the aneurysm sac remain difficult to treat.2
Morbidity or insufficient occlusion is not uncommon
after treatment of these types of aneurysms.3
In the past decade, the flow diverter device (FDD)
had become an important option for the treatment of
aneurysm.4 By producing a flow diversion effect, an
FDD induces intra-aneurysmal thrombosis while pre-
serving the normal flow in the parent artery and its
branches, eventually leading to healing of the neoin-
tima across the neck of the aneurysm.5,6
The TuBridge flow diverter (TFD; MicroPort,
Shanghai, China) is a nickel–titanium braided,
self-expandable stent-like device with flared ends
(Figure 1).7 TFDs are available in diameters of
2.5 mm to 6.5 mm and lengths of 12 mm to 45 mm.
The TFD is composed of either 64 microfilaments
(diameter 3.5 mm) or 48 microfilaments (diame-
ter < 3.5 mm). The TFD also contains two double-
helix platinum–iridium radiopaque microfilaments
1
Department of Neurosurgery, the First Affiliated Hospital of Sun Yat-sen
University, Guangzhou, China
2
Department of Operation Theater, the First Affiliated Hospital of Sun Yat-
sen University, Guangzhou, China
*These authors contributed equally to this paper.
Corresponding author:
Tiewei Qi, Department of Neurosurgery, the First Affiliated Hospital of
Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, China.
Email: qitiewei@163.com
2 Interventional Neuroradiology 0(0)
Figure 1. Photograph of the TFD. The flared ends of the TFD
improve wall apposition and the double-helix platinum–iridium
radiopaque microfilaments increase device visibility under
fluoroscopy.
that improve the visibility of the TFD under fluo-
roscopy. When fully opened, a TFD provides 30–
35% surface coverage at the nominal diameter.8
TFDs have been reported to be safe and effective
in the treatment of internal carotid artery (ICA)
aneurysms and vertebral artery (VA) aneurysms and
its use was approved by the Chinese Food and Drug
Administration in 2018.8,9 However, the safety and
efficacy of this device in treating MCA aneurysms
are unknown.
We have used TFDs to treat the complex MCA
aneurysms since 2018. Herein, we presented our pre-
liminary experience of the treatment of MCA aneur-
ysms with TFDs.
Methods
Patient characteristics and aneurysm features
The study was approved by the Local Institutional
Review board. We reviewed a prospectively main-
tained database of intracranial aneurysms and identi-
fied patients with MCA aneurysms treated with TFDs.
Data extracted included patient demographic informa-
tion, aneurysm features, complications, clinical out-
comes, and immediate postoperative and follow-up
angiography results. Aneurysm features including
location, morphology, size, and the diameters of the
proximal and distal parent arteries were obtained
by digital subtraction angiography (DSA) and
three-dimensional rotational angiography (3DRA).
Aneurysm location was classified as M1, MCA bifur-
cation, and M2. M1 was defined as MCA between the
origin and the bifurcation. And M2 was the MCA
from the bifurcation to the circular sulcus of the
insula. Aneurysm morphology was categorized as sac-
cular, fusiform, or dissecting. Aneurysm size was clas-
sified as small (<10 mm), large (10–24 mm), and giant
(25 mm). Information regarding the rupture status of
aneurysm and previous treatment of recurrent aneur-
ysms was also extracted.
Antiplatelet therapy
In all patients, dual antiplatelet therapy was initiated
at least five days before the procedure. In addition, all
patients received CYP2C19 genotyping. Aspirin
300 mg/day and clopidogrel 75 mg/day were used for
patients with genotype *1/*1, and aspirin 100 mg/day
and ticagrelor 180 mg/day were used for patients who
were not genotype *1/*1. Thrombelastograms (TEGs)
were performed to be certain that inhibition of ara-
chidonic acid (AA) was >50% and <90%, adenosine
diphosphate (ADP) >30% and <90% before the pro-
cedure. Dual antiplatelet therapy was continued until
six months after the procedure, followed by perma-
nent aspirin treatment at 300 mg/day.
Endovascular procedure
The endovascular procedure was performed under
general anesthesia. A 5-French diagnostic catheter
was navigated to the ipsilateral ICA and then
exchanged for a 6 F 90 cm Shuttle sheath (Cook,
Bloomington, Indiana, USA). A 6 F Navien catheter
(Medtronic, Minneapolis, Minnesota, USA) was
advanced within the Shuttle sheath to reach the cav-
ernous segment of ICA. A 0.029-inch T-track micro-
catheter (MicroPort, Shanghai, China) was
navigated into a straight portion of M2 or M3,
which was distal to the aneurysm, with a Synchro-
14 microwire (Stryker, Fremont, California, USA).
The TFD was advanced into the T-track microcath-
eter and then slowly unsheathed by alternately
advancing the delivery wire and pulling gently on
the microcatheter in order to obtain optimal stent
opening and wall apposition. The distal and proxi-
mal end of the stent should be landed at least 5 mm
away from the aneurysm neck.
When the TFD was deployed, a J-shaped-tip
Synchro-14 microwire together with the microcath-
eter was pushed back into the stent and massaged
it. Syngo Dyna CT (Siemens, Munich, Germany)
was performed to evaluate the wall apposition of
the stent. In the case of incomplete apposition,
ScepterC balloon (Microvention, Tustin, California,
USA) angioplasty was performed.
For concomitant coiling, an Envoy guide catheter
(Cordis, Fremont, California, USA) was advanced
into the ICA via contralateral femoral artery access.
Excelsior SL-10 microcatheter (Stryker, Fremont,
California, USA) was navigated into the aneurysm
sac to deliver Axium coils (Medtronic, Minneapolis,
Minnesota, USA).
Complications and follow-up
Procedure-related complications including hemor-
rhagic and thromboembolic events were recorded.
Symptomatic complications were defined as those
associated with transient or permanent neurological
deficits. Patients were followed up by an office visit or
telephone call at three months, six months, and there-
after every six months after the procedure. Clinical
outcomes were assessed using modified Rankin
Scale (mRS). Morbidity was defined as any increase
in the mRS score after the procedure.
Liang et al.
Angiographic outcomes
Angiographic outcome was assessed using the
O’Kelly–Marotta grading scale (OKM).10 Aneurysm
filling was graded as: A, complete (>95%); B, incom-
plete (5–95%); C, neck remnant (<5%); D, no filling
(0%). Stasis was graded as: 1, no stasis (clearance of
contrast within the arterial phase); 2, moderate stasis
(clearance of contrast prior to the venous phase); 3,
significant stasis (contrast persists in the aneurysm
into the venous phase and beyond). OKM aneurysm
filling of C or D was considered favorable aneurysm
occlusion.
On follow-up angiography, the “jailed” artery was
also evaluated. Jailed artery flow was classified into
three levels: unchanged (concentration of contrast
within the artery and diameter of the vessel are both
similar to that before the procedure); decreased
(either the concentration of contrast within the
artery or the diameter of the vessel is lower than
that before the procedure, or filling of contrast is
delayed to a greater degree) and occluded (the vessel
was not seen).
In-stent stenosis was also evaluated on follow-up
angiography. In-stent stenosis was defined as endo-
thelium growth beyond the limits of the stent wall,
which was seen as a “gap” between the intra-lumen
filling of contrast and the metallic mesh of the stent
on angiogram. Less than 25% loss of lumen was con-
sidered intimal hyperplasia. In-stent stenosis was cat-
egorized as mild (26–50%), moderate (51–75%), and
severe (>75%).11
Statistical analysis
Continuous variables were presented as means and
standard deviation (SD). Categorical variables were
presented as numbers and percentages. All statistical
tests were performed using STATA 13.0 software
(Stata Corporation, College Station, Texas, USA).
Results
Patient characteristics and aneurysm features
Eight patients with MCA aneurysms treated with
TFDs from July 2018 to December 2019 were identi-
fied in the database and included in the analysis.
There were four males and four females, with a
mean age of 54.4
10.4 years. The aneurysm was
located in M1 in 3 (37.5%) patients, in MCA bifur-
cation in 4 (50%) patients, and in M2 in 1(12.5%)
patient. The mean aneurysm size was 11.8
6.8 mm,
and there were 2 (25%) small aneurysms, 5 (62.5%)
large aneurysms, and 1 (12.5%) giant aneurysm.
Aneurysm morphology was saccular in 2 (75%)
patients and fusiform in 6 (75%) patients. The mean
diameters of the proximal parent artery and the distal
parent artery were 3.0
0.1 mm and 2.8
0.3 mm,
respectively. Seven of the aneurysms were unruptured
3
and one had ruptured one month before the proce-
dure. There were 2 (25%) recurrent aneurysms,
which were previously treated by clipping. The diam-
eters of these two aneurysms before clipping were
26 mm and 10 mm, respectively. Patient demographics
and aneurysm features are summarized in Table 1.
Angiography results
TFDs were successfully deployed in all eight patients
and all eight patients were treated with a single TFD.
Seven patients had “jailed” arteries; one patient with
an M2 aneurysm did not have a jailed branch (case 3).
Concomitant coiling was performed in 1 (12.5%)
patient (case 1, Figure 2). Coil-assisted stent deploy-
ment was performed in a patient with an M1 fusiform
aneurysm (case 7, Figure 3). Balloon angioplasty was
needed to improve wall apposition of the TFD in 1
(12.5%) patient (case 2, Figure 4).
Immediate angiogram after TFD deployment dem-
onstrated OKM filling grade A in 4 (50%) patients
and grade B in 4 (50%) patients. The stasis grading
scale was 1 in 4 (50%) patients and 3 in 4 (50%)
patients.
Follow-up angiograms were performed a mean of
7.5
4.0 months after surgery in all patients. Of the
8 aneurysms, 1 (12.5%) was OKM A, 3 (37.5%) were
OKM B, 1 (12.5%) was OKM C, and 3 (37.5%) were
OKM D. Thus, favorable aneurysm occlusion (OKM
C þ D) was obtained in 4 (50%) aneurysms. Stasis
grade was 1 in 2 (25%) patients, 2 in 1 (12.5%)
patient, and 3 in 2 (25%) patients. Of the seven
patients with jailed branch, the blood flow in the
jailed branch was unchanged in 4 (57.1%) patients,
decreased in 2 (28.6%) patients, and occluded in 1
(14.3%) patient. In-stent stenosis was detected in
three patients (37.5%) at a mean of six months. The
in-stent stenosis was mild in 2 (25%) patients and
moderate in 1 (12.5%) patient. Angiography results
are summarized in Table 1.
Complications and clinical outcomes
There were no procedure-related complications. At
the last follow-up, a mean of 11.3
3.6 months after
surgery, there were no morbidities and no mortalities.
Illustrative case
A 55-year-old female complained of intermittent
headache for five months (case 1, Figure 2).
Computed tomography angiography (CTA) demon-
strated a left MCA bifurcation fusiform aneurysm of
26 mm, involving distal M1 and both trunks of M2.
The aneurysm was reconstructed by clipping, which
achieved a volume reduction of >80% and preserva-
tion of both trunks of M2. Postoperative CTA dem-
onstrated the clipped aneurysm, a segmental stenotic
distal M1, a patent superior trunk of M2, and a
4 Interventional Neuroradiology 0(0)

Moderate
patent inferior trunk of M2. The patient was dis-

stenosis
In-stent
charged without any neurological deficits.

Mild

Mild
No
No
No
No

No
At six-month follow-up after surgery, angiography
branch flow demonstrated a major recurrence of the aneurysm

Unchanged

Unchanged
Unchanged

Unchanged
with a daughter sac close to the proximal end.

Decreased
Decreased
FU jailed

Occluded
Conventional clipping, coiling, or stent-assisted coil-
ing was not feasible for the recurrent aneurysm.
N/A Trapping of the aneurysm combined with extracrani-
al–intracranial (EC-IC) bypass would be difficult
(months)
FU OKM

D (18)

B1 (6)

B3 (6)
B3 (6)
A1 (6)
C2 (6)

because it was a reoperation. Therefore, it was decid-

D (6)

D (6)

ed to treat the aneurysm with a TFD. Dual antipla-

telet administration was begun five days before the
Increase of
mRS in FU

procedure (aspirin 300 mg/day and clopidogrel

(months)

No (18)
No (12)

(12)
(12)
(12)
(12)
(6)
(6)
75 mg/day). The operative plan was to land the
No
No
No
No
No
No

TFD in M1 and the superior trunk of M2. The prox-

F: female; FU: follow-up; M: male; MCA B: middle cerebral artery bifurcation; mRS: modified Rankin scale; N/A: not applicable; OKM: O’Kelly–Marotta grading scale.

imal and distal diameters of the parent artery were

Immediate

3.0 mm and 3.2 mm, respectively. The longest length

of TFDs with a caliber of 3.5 mm or less was only
OKM

B3

B3

B3
B3
A1

A1

A1
A1

35 mm, which was not long enough to cover at least

5 mm of both the proximal and distal parent arteries.
branch

Therefore, a 4.0 mm  45 mm TFD was implanted to

Jailed

Yes
Yes

Yes
Yes
Yes
Yes
Yes
No

rebuild M1 and the superior trunk of M2. The prox-

imal part of the aneurysm sac was loosely packed
Concomitant

with Axium coils in order to support the TFD to

pass through the angle of the vessel, as well as to
coiling

induce intra-aneurysmal thrombosis around the

Yes
No

No
No
No
No
No
No

daughter sac. The inferior trunk arose from the prox-

Yes (clipping)

Yes (clipping)

imal part of the aneurysm wall and the flow decreased

treatment)

immediately after the treatment. The patient

aneurysm
Recurrent

(previous

remained neurological intact after the procedure.

Six months after implantation of the TFD, the
No

No
No
No
No
No

proximal part of the aneurysm and the daughter sac

parent artery
Diameters of

were thrombosed and the inferior trunk of M2 was

distal, mm)
(proximal/

occluded. The distal portion of M1 exhibited moder-

Table 1. Demographic data, aneurysm features, clinical and angiographic results.

3.0/3.2
3.0/3.1

2.9/2.6
3.1/2.8
3.2/3.0
2.9/2.5
3.2/3.0
2.8/2.5

ate stenosis. At six months, dual antiplatelet was

switched to aspirin 300 mg/day. At 18-month
follow-up, the entire aneurysm was occluded and
(mm)
Size

the moderate stenosis of distal M1 was unchanged.

26

12
10
11
14
10
3

Collateral blood supply from the middle meningeal

artery to the distal vessels of the inferior trunk of
1 month before

M2 was noted on angiography. The patient was neu-

Rupture status

rological intact, with a mRS ¼ 0.

Unruptured

Unruptured
Unruptured
Unruptured
Unruptured
Unruptured
Unruptured
Ruptured

Discussion
TFDs have been reported to be safe and effective for
aneurysm

Fusiform

Fusiform
Fusiform
Fusiform
Fusiform
Fusiform
Saccular

Saccular

the treatment of ICA aneurysms and VA aneur-

Type of

ysms.7–9 However, to our knowledge, this is the first

report of using TFDs to treat MCA aneurysms.
MCA B

MCA B
MCA B

MCA B

The differences between the TFD and other FDDs

Site

M1

M2
M1

M1

Pipeline,12–14 Silk,15 and P6416,17 flow diverters have

(years)

been used for treating MCA aneurysms. Like the Silk

Age

55
52

62
50
61
30
61
64

and P64, the TFD is made of a nickel–titanium alloy

which exhibits shape memory and super-elasticity.
Sex

M
M
M

Platinum–iridium microfilaments that are radiopaque

F
F

improve visualization of the stent during deployment.

Case

Compared with the 48-strand Silk or Pipeline flow

1
2

3
4
5
6
7
8
Liang et al. 5

Figure 2. (a) CTA demonstrated a left MCA bifurcation giant aneurysm involving distal M1 and the superior trunk of M2. The inferior trunk
of M2 was not visible. (b) Post-clipping CTA demonstrated the reconstructed aneurysm with stenotic M1 and patent distal vessels. The
inferior trunk of M2 emerged (white arrow). (c) Six-month follow-up angiogram demonstrated a major recurrence of the aneurysm with a
daughter sac in the proximal part (white arrowhead). (d) Post-procedure un-subtracted image showed the TFD landed in M1 and the
superior trunk of M2 and loose packing of the aneurysm with coils. (e) Immediate postoperative angiogram demonstrated decreased flow
of the inferior trunk of M2 (black arrows). (f) Angiogram six months after surgery showed the proximal part of the aneurysm was
thrombosed, M1 was stenotic, and the inferior trunk of M2 was invisible. (g) On 18-month follow-up angiogram, the aneurysm was
completely occluded; the distal M1 and the superior trunk of M2 were reconstructed. However, the distal M1 was still moderately stenotic
and the inferior trunk of M2 was occluded (black arrowheads). (h) Eighteen-month follow-up angiogram of the external carotid artery
showed that a collateral blood supply was established from the middle meningeal artery to the distal vessels of inferior trunk of M2
(hollow arrows).

Figure 3. (a and b) Pre-procedure angiogram demonstrated a right proximal M1 fusiform aneurysm involving part of the ICA bifurcation.
(c and d) When the TFD was passing through the acute angle of the vessel, the aneurysm was temporally filled with a coil to support the
stent. (e) After the stent passed the acute angle, the coil was retrieved to inspect the wall apposition of the TFD. (f) Lateral view of the TFD
deployed with support of a coil in the aneurysm. (g and h) Post-procedure angiogram demonstrated decreased filling of the aneurysm
and patent jailed artery of A1. (i and j) Angiogram at six months after surgery showed the filling of aneurysm was decreased, the blood
flow of the jailed A1 was decreased, and ICA was mildly stenotic.
6 Interventional Neuroradiology 0(0)

Figure 4. (a and b) CTA and DSA demonstrated a left M1 perforator artery aneurysm of 3 mm (white arrow). (c) After stent deployment,
the wall apposition of the proximal end was not sufficient (white arrowhead). (d) Balloon angioplasty was performed to improve wall
apposition of the proximal end of the stent. (e and f) Immediate postoperative angiogram demonstrated improved wall apposition (black
arrow) and patent jailed perforators. (g and h) Angiogram at six months after surgery demonstrated that the aneurysm was completed
occluded (black arrowhead), the blood flow of the jailed perforators was unchanged, and M1 was mildly stenotic.

diverters, the larger TFD (3.5 mm) has more braid-
ed microfilaments, which decreases the shortening
rate of the flow diverter after full opening and offers
more appropriate pore attenuation. A design includ-
ing a greater number of braided microfilaments is also
seen in P64 diverter.
Therapeutic strategy for treating MCA aneurysms
In our center, microsurgical clipping is the preferred
method for treating MCA aneurysms. Coiling or
stent-assisted coiling is an alternative choice for elder-
ly patients with multiple comorbidities, comatose
patients with ruptured aneurysms, patients with
recurrent aneurysms after previous clipping, and for
patients with aneurysms deemed difficult to clip.
However, fusiform aneurysms, recurrent aneurysms,
and aneurysms with branches arising from the sac are
difficult to treat with the aforementioned methods.
For these aneurysms, treatment with an FDD has
become a new option.
FDDs and MCA aneurysms
FDDs have become the first-line treatment for the
ICA aneurysms, but not for MCA aneurysms because
the mechanism of FDD healing the aneurysm is not
consistent with the structure of MCA aneurysms.
MCA aneurysms are mostly located at the MCA
bifurcation and the bifurcating branches usually ema-
nate directly from the base of the aneurysm. Landing
the FDD in M1 and one trunk of M2 makes the other
trunk of M2 “jailed.” The “jailed” branch might be
occluded after FDD implantation, leading to cerebral
ischemia. Conversely, if the “jailed” branch remained
patent, the aneurysm might not be obliterated due to
the persistent flow.15
Occlusion of the jailed branch
The long-term rate of side branch occlusion after cov-
erage by a flow diverter in the treatment of ICA aneu-
rysm was 15.8–20%.18,19 Beyond the Circle of Willis,
50% of covered branches were occluded or nar-
rowed.20 Occlusion or reduced caliber of a jailed
branch was seen in 14–50% cases of MCA aneurysms
treated with a FDD and was one of the main causes
of morbidity.16,17,21 In this study, there were seven
aneurysms located at the M1 or MCA bifurcation,
in which the bifurcating branches or lenticulostriate
arteries emanated from the neck of the aneurysm or
directly from the sac of the aneurysm. Immediate
reduction of blood flow in these arteries was seen in
two cases. During follow-up, the jailed branch was
occluded or reduced in caliber in 42.9% (3/7) of the
cases; however, there was no symptomatic cerebral
ischemia noted in any patient.
About 5% of patients developed symptomatic
cerebral ischemia caused by jailed artery occlusion
or decreased flow.15 However, most patients tolerated
jailed artery occlusion or decreased flow without
symptoms or radiological findings.21 Gradual reduc-
tion of blood flow, instead of an abrupt change,
occurred in most cases.14 Thus, the territories sup-
plied by the jailed branch were able to recruit collat-
eral vessels from adjacent branches over time.22
Occlusion of the aneurysm
The relatively low occlusion rate comparing to clip-
ping was another reason why FDDs have not been
used for the treatment of MCA aneurysms. The com-
plete occlusion rate of FDDs in the treatment of
MCA aneurysms was reported to be 36.4–84%.12–17
In this series, the complete occlusion rate was 37.5%,
and favorable occlusion rate was 50%. The low
Liang et al.
complete occlusion rate might relate to three factors.
First, persistent flow in the jailed branch might hinder
thrombosis inside the aneurysm.15 The neck of the
aneurysm usually involves more than 1 of the bifur-
cating branches. An FDD is usually deployed in one
major branch and usually covers only part of the neck
of the aneurysm. The uncovered part of the neck
might have a persistent flow connection with the
jailed branch, making it more difficult to initiate
intra-aneurysmal thrombosis. As such, jailed branch
occlusion could facilitate obliteration of the aneu-
rysm.15 In case 1 in which the patient had an MCA
bifurcation aneurysm, the jailed inferior trunk of M2
and the aneurysm were noted to be occluded on
follow-up angiography. Second, in a curved vascular
segment, the constituent filaments of the device slide
over one another, making the porosity of the outer
curve less than that of the inner curve, and thus less
than the nominal porosity.23 This causes the flow
diverting effect of the outer curve to decrease. In
our series, six of eight aneurysms were located at
the outer curve of the vessel, which may have contrib-
uted to the low complete occlusion rate. Third, the
occlusion rate increases with the length of follow-
up.24 Fifty percent of aneurysms are completely
occluded no earlier than 12 months after surgery.12
In our study, only one aneurysm had angiographic
follow-up of more than 12 months. Thus, the low
complete occlusion rate may also be related to the
relatively short follow-up period.
Six aneurysms in this study were fusiform, includ-
ing one recurrent aneurysm. In case 1, we clipped and
reconstructed the giant fusiform aneurysm. However,
the aneurysm recurred in less than six months. In this
aneurysm, the lesion might have involved the entire
vessel wall, which may have allowed the unclipped
part of the artery wall to enlarge and form another
giant aneurysm. A flow diverter might be the optimal
solution for this kind of aneurysm. Flow diversion
might protect the vessel wall by both reducing the
direct impact of the blood flow and inducing intra-
aneurysmal thrombosis. However, unlike saccular
aneurysm, the formation of neointima which may
be crucial for minimizing the recurrence of the aneu-
rysm, was not found in histological studies of fusi-
form aneurysms.25
In-stent stenosis
It is worth noting that although there were no delayed
ischemic events, we found in-stent stenosis in 37.5%
of the cases. Neointimal formation was necessary to
cover the neck of aneurysm and block the inflow to
aneurysm sac. However, overreaction of intimal
hyperplasia might lead to in-stent stenosis. A possible
reason for in-stent stenosis formation after flow
diverter deployment is insufficient wall apposition,
which might lead to thrombus in-between the stent
mesh and arterial wall.26 One disadvantage of the
7
TFD is that due to the nature of the nickel–titanium
alloy, the visibility of the stent mesh is poor
under fluoroscopy; only the two platinum–iridium
radiopaque helix wires are highly visible. Therefore,
it is sometimes difficult to assess wall apposition of
the device. This may be a contributing factor to the
high incidence of stent stenosis in this study. It has
been reported that the rate of in-stent stenosis of flow
diverters is as high as 57%.27 However, with longer
follow-up in-stent stenosis might resolve spontane-
ously, and thus the rate will be lower.28,29
Limitations of the study
The limitations of this study are a relatively small
number of patients, and a short follow-up period.
However, the results of our preliminary experience
of the treatment of complex MCA aneurysms using
the TFD are encouraging. Patients with complex
MCA aneurysms may benefit because of less
procedure-related risk.
Conclusion
Our preliminary results demonstrated that the TFD is
safe and effective for the treatment of MCA aneur-
ysms. Given the high safety profile, the TFD could be
a new option for the treatment of complex MCA
aneurysms which are difficult to treat with clipping
or coiling. However, further study with a larger pop-
ulation and long-term follow-up is needed to define
the role of the TFD in the treatment of MCA
aneurysms.
Contributors
FL, LL, BL, GZ, SO, and WX acquired the data. FL and
YY analyzed the data and drafted the manuscript. NG and
TQ developed the project. All authors revised the paper
critically for important intellectual content and provided
final approval of the version published. All authors agree
to be accountable for all aspects of the work in ensuring
that questions related to the accuracy or integrity of any
part of the work are appropriately investigated and
resolved. FL and YY contributed equally as first authors.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Ethics approval
This study was approved by the Ethics Committee of the
First Affiliated Hospital of Sun Yat-sen University.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publication
of this article: This work was supported by Department of
Health of Guangdong Province (Grant number A2018067).
8 Interventional Neuroradiology 0(0)
ORCID iD
Tiewei Qi https://orcid.org/0000-0002-8435-6738
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