Audience

Neurology, risk manager

Issue

FDA received reports associated with the use of these devices in the treatment of unruptured brain aneurysms that suggest some events of peri-procedural stroke and/or death may have been related to procedural risks or patient selection-related factors. These factors include patients who had serious comorbidities resulting in a reduced life expectancy, or who were intolerant to required anticoagulation or antiplatelet therapy.

Background

Neurovascular stents used for stent-assisted coiling (SAC) are intended to treat wide-neck, intracranial, saccular aneurysms, arising from various-sized parent vessel diameters depending on the manufacturers’ intended use (eg, >2 millimeters and <4.5 millimeters). Wide-neck is defined as having a neck width >4 millimeters or a dome-to-neck ratio <2. These devices are available from multiple manufacturers and have been approved by FDA through the Humanitarian Device Exemption (HDE) regulatory pathway, after demonstrating safety and probable benefit for their intended use.

Recommendation

When using neurovascular stents for SAC, the FDA recommends that health-care providers:

• Consider and discuss with your patients the benefits and risks of neurovascular stent devices and procedures, as well as the availability of any alternative management modality.
• For smaller brain aneurysms, or for patients with reduced life expectancy, in the absence of other risk factors, the risks of treatment may outweigh the benefits. Therefore, the patient should be properly informed of the rates of serious adverse events and the rupture risk as part of the decision-making to undergo intervention.
• Be aware that neurovascular stent devices for SAC are approved for the treatment of brain aneurysms of limited characteristics and parent vessel sizes, and the FDA has not evaluated the safety and probable benefit outside those parameters. Consult the specific device manufacturer’s product labeling for further information.
• Avoid use of neurovascular stents for SAC in patients who are not candidates for systemic anticoagulation and/or not able to receive antiplatelet medications as use of the devices require peri-procedural anticoagulation and/or antiplatelet therapy. Thrombosis in or around the stent may result in serious harm, including ischemic stroke and death.