Comment

Comment by Andrea Salvati on November 14, 2010 at 6:11am

Dear dr Cheong,
so whay did you do with this patient? it is very interesting that the blood flow in the AVM has slowed very much following the stenting of the aneurysm. Was the patient still symptomatic in the follow-up?
The nidus of the AVM is diffuse and resembles a proliferative angiopathy; there also seem to be an aneurysm inside.
It is a very interesting case, thanks for sharing.
Andrea

Comment by Kuok Cheong U on April 20, 2010 at 2:07am

Hi to all: dear colleage, I have a case, a 42 year old female complain of headache recently, MRI shows massive AVM in the right frontal lobe. Diagnostic cerebral angiography performed found lobar shape wide neck berry aneurysm noted in the right carotid supra-ophthalmic segment; AVM nidus occupies almost the entire right frontal lobe. Pipeline technique applied for the aneursym with promising result, what to do next? I attach a MP4 file for your reference.
pipeline avm.mp4I propse second vascular intervention with onxy technqie 3 months to 6 months later, any comment?

Comment by Vasilios Katsaridis on December 14, 2009 at 2:25am

It seems that all of us are right since we are all thinking in the context of the environment in which each one of us is working, as you said.
Our decisions are certainly influenced by the availability of materials and by the reimbursement method applied.
But using a Ppeline does not mean the total cost is so much higher. In the case you showed, the total cost of the balloon stent and the coils might add up to the same or even higher than the cost of a Pipeline. This is the advantage of the Pipeline, you just place it without anything else and it does the job. Plus, when you don;t place any coils in the aneurysm it can shrink and even disappear. This is very important in cases with mass effect.
Regards to all
Vasilis

Comment by shakir HUSAIN on December 13, 2009 at 9:57pm

Vasilios, I agree with your philosophy. We should choose materials and methods according to best possible outcome that you can consider with a particular material. This will be environment specific, in your situation it is perfectly OK as the cost is born by the state or insurance. In developing world, and I am sure Ali's question carried same concern, most of the patients are not having money for the treatment and if they arrange at all, they sale their land or home etc. As a physician you are under lot of pressure while making any clinical decision and undertaking these procedure. So cost does remain a major concern not only for helping needy patients but also for making these procedures popular and in reach of masses across the world beyond western world.

I did a case about 6 years ago, of a LICA pseudo-aneurysm due to gun-shot injury in a young man in petrous part. We didn't have neuroform even at that time in India. I used coronary balloon mount stent and loose coiling with GDC-18 and preserved LICA. Patient doing well since then.
I am attaching pics as a file Vikram.pdfon site.

Alternatively, we could considered use of Graft stent in this case,

Anyway, great results that you have shown with this new idea. Congratulations. I would like to use it, for some of my patients with complex basilar top giant aneurysms.

Comment by Vasilios Katsaridis on December 13, 2009 at 4:49pm

By the way here are the 1 moth follow up images of the boy's case
The arrows show the patent lumen of the "carotid" reconstructed by the Pipelines

Comment by Vasilios Katsaridis on December 13, 2009 at 4:42pm

The boy had excellent ACOM but I was very reluctant to condemn him to a full lifetime of depending only on one carotid. You never now what could happen to him in the next 50-60 year that would follow.
So what is a Toyota compared to a young boy's life? We are not here to judge things in this way. We shoud be commited to giving our patients the best possible treatmet regardless of the cost, provided that this treatment is really beneficial to them.

Vasilis

Comment by Cagin Senturk on December 13, 2009 at 3:01pm

Hi to all,

I totally agree with Vasilis. One Pipeline system costs around 11000 euros, still cheaper than a medium size Toyota, may be one of those Yaris. But in a young patient where the only choice seems as the sacrification of the parent artery I prefer not to think about the cost if nobody can offer me a safer and cheaper treatment.
Vasilis, I don't know if this boy had a functional anterior or posterior communicating artery. Last week we did a case with a giant supraclinoid ICA aneurysm in a completely isolated ICA with no collaterals in a 20 years old boy. The only surgical alternative was to do a bypass and occlude the ICA and pray of course. And the anterior choroidal artery was coming out of the dome of the aneurysm. I will send the images tomorrow.
The only problem with these flow diverter stents is that we don't have long term results of the treatment even though only with Pipeline it has already been done almost 500 cases worldwide.

Thanks for the discussions and Best regards

Cagin

Comment by Vasilios Katsaridis on December 13, 2009 at 2:48pm

Dear Ali,
the truth is that Ppelines cost a lot (somewhere around 11,000 to 12,000 euros per stent all over Europe).
But what else would you propose as a treatment for a 10 year old boy with facial nerve paralysis from this giant aneurysm?
Carotid sacrifice? I would never do this to a young boy since there is a technology that can save his carotid.
Placing conventional stents and then coiling the aneurysm around the stents? I doubt that it would work and even if it did, it would cost twice as much.
When considering the cost of a certain material one should bear in mind the possibility of success of alternative therapies and their costs.
For me Pipeline is indicated absolutely in fusiform aneurysms or giant saccular ones. In these cases the benefit certainly outweighs the cost.
Best regards
Vasilis

Comment by Arshad Ali on December 13, 2009 at 11:39am

Dear Vasilios Katsaridis,how much your pt cost with 5 pipe line in one go. I heard talking colleagues in meetings one pipe line cost equal a Toyota car of current model.
Regards

Comment by Dr Hasibul Hasan Parag on December 13, 2009 at 11:26am

Its really a very good plateform 2 discuss and share experiences............

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