Neurointerventional surgeon at Swedish Medical Center, MD talks about a new device treating aneurysms.
Interview conducted by Ivanhoe Broadcast News in 2023.
How common are brain aneurysms? What are they?
Kaminsky: Brain aneurysms affect anywhere between one and three percent of the world population, depending which publication you read, probably around two percent of everybody in the world has a brain aneurysm. In the U.S., we see about 30,000 aneurysms that have ruptured or burst every year. Most aneurysms are found incidentally, patients get imaged for another reason, we find the aneurysm and treat them.
Are they high-risk? What happens when you have an aneurysm?
Kaminsky: Most times, people don’t know that they have one. If they’re very small and round, the chance of them bursting or bleeding is very low. We tend to treat aneurysms once they reach a size of about 4-5 millimeters or if they have an irregular shape. You can imagine an aneurysm is like a birthday balloon, as you’re blowing that balloon up, the chance of it popping increases. If you were blowing the balloon up and it developed a little bump coming off it, another weak part, you can imagine that would be a higher risk of bursting. When we see aneurysms that have that lumpy bumpy shape, we feel that those have a higher risk of bursting so we tend to treat those even if they’re smaller.
Who is most at risk and who develops aneurysms?
Kaminsky: There is a small proportion that has a genetic component about 10% of those cases. But in general, things like high blood pressure, cigarette smoking, heavy alcohol use will cause a weakness of the blood vessel that can lead these aneurysms to form.
How are they commonly treated?
Kaminsky: So in 2023, the vast majority of aneurysms, probably 95 plus percent, are treated endovascularly, or in the inside of the blood vessel. That’s what me and my partners do, we basically put a small catheter into the artery, navigate it up into the head using X-ray guidance, and we basically block off theaneurysm so that blood can’t go into it. There’s a number of different ways we do that. We have small filaments called coils that we basically pack the aneurysm tight with metal so blood can’t get into it.We also have special stents called flow diverters that direct the blood flow away from the aneurysm. Now we have special devices that you actually place inside the sack of the aneurysm, like the contour device, that can allow you to use one device and be done. When we coil an aneurysm, we liken it to a Russian doll where you have the very tiny doll on the inside, bigger doll around it as you get larger and larger. Same thing with a coil, we put a larger coil to fill the circumference of the aneurysm, and then we pack a smaller coil until we pack multiple coils to the point where it’s filled with metal. That can take many coils in a larger aneurysm or something like the contour device is one device, so it leads to a shorter procedure time. The less time that you’re in there, the lower potential risk there is.
Talk to us about contour. What is it that you’re currently involved in a trial?
Kaminsky: So contour is what’s called an intrasaccular device. It basically is a woven mesh that looks like almost a cup that has a detachment zone on it. So you’re basically delivering this device on the inside of a catheter, and then it opens inside the aneurysm, and blocks the flow from going into it because of how tight that mesh density is.
What are the pros and cons? Talk to me about the old way versus the contour device.
Kaminsky: The contour device is a good option in a lot of aneurysms, but it’s not going to work for every type of aneurysm. It’s best for a more wide neck or the opening of the aneurysm is large, and you have a fairly symmetric type of configuration of where the normal blood vessel is. So a lot of times aneurysms form at a branch point. And if the branch point looks like this, the contour might not sit perfectly. But when you have a more symmetric branch point, it tends to sit better in that type of situation.
What are the benefits and the risks of contour?
Kaminsky: So a big benefit is not needing to have anything in the normal blood vessel. A lot of times when we treat with coils, we’ll put a stent or chicken wire mesh tube inside the normal blood vessel that keeps the coils in there so that they don’t come out and block normal blood flow. When you do that, you have to have the patient on medications so that they don’t form clot on that stent. When you just place something inside the aneurysm, the need for those medications is much less so that if somebody can’t be on medications like aspirin or plavix because of bleeding issues, contour is more beneficial in that type of situation because they won’t need to be on those medicines long-term. Like I mentioned earlier, the one device and done will lead to a shorter procedure time. The shorter the procedure, the lower the risk.
So you gave examples of who is a good candidate, who would not be a good candidate for the contour?
Kaminsky: It’s more so the shape and configuration of the aneurysm rather than the individual person that is a good candidate. It’s more what we’re looking at with the shape and how the aneurysm is directed.
Can you do a comparison of the two procedures, coils versus contour?
Kaminsky: Sure. If we’re comparing the procedure for coiling an aneurysm versus using a contour device, it’s almost an identical procedure. We’re putting a larger catheter in the neck, at the base of the skull, and then we’re tracking a small micro-catheter into the aneurysm. If we’re doing a coiling procedure, we’re delivering the coils through that micro-catheter into the aneurysm sack. And the same thing would be done with contour where you’re delivering the contour device through the microcatheter. So very similar type of procedure. The difference would be if I have to put multiple coils, you can imagine that’s going to take significantly longer than putting the one contour device and being done.
How long does a procedure like that take? What’s recovery like? Are these inpatient procedures?
Kaminisky: Yeah. So if it’s an elective aneurysm treatment, meaning it has not bled, it was found incidentally. If we’ve already looked at all the other blood vessels, treatment with the contour could take as little as 15 minutes. Typically, a coiling case would probably take closer to an hour . But certainly, if you’re only putting one device, it’s going to be much shorter. Recovery time is very minimal because we’re going through a needle hole into the artery. So typically what patients are limited on is no heavy lifting for a week. We don’t want them submerging the area, so no swimming pools, bathtubs, hot tubs for a week. Outside of that it’s not a big open surgery that has a long, painful recovery.
And I suspect there’s so much gratitude because these are patients who have an aneurysm without any signs or symptoms, right?
Kaminisky: Yeah. More often than not, they’re totally incidental and it’s something that has a high morbidity and mortality rate if it was to burst or bleed. So people are definitely very thankful that we treat this and eliminate that risk of bleeding.
And I know you didn’t treat Judy Sadler, but talk to me about what you know about her aneurysm or her case at all, whatever you know.
Kaminisky: So she had a pretty sizable anterior communicating artery aneurysm that had an oblong shape. Hers was found because she was having headaches and she got imaged, but the headaches were not from the aneurysm. She didn’t have any evidence of bleeding. Aneurysms typically don’t cause pain unless they have bled or they’re pressing on the covering of the brain, which has pain receptors. Hers was not either of those situations. So the imaging, fortunately, found the aneurysm and it was able to be treated with the contour device.
So, do you choose a good candidate for contour because of the shape?
Kaminisky: Yeah, the shape and the morphology of where the aneurysm was coming off the normal blood vessel really lent itself well to an intrasacular device like contour. It was able to sit there nicely and totally exclude the aneurysm from the circulation.
What’s the long term outcome?
Kaminisky: So part of the protocol for the clinical trial for contour is imaging follow ups, the main target is at 12 months. So when she gets her 12-month cerebral angiogram, we’ll see if the aneurysm is totally gone or if there’s any evidence of recurrence. Seeing that it is under trial, we’re still understanding what those potential percentages are for recurrence risk. If there’s no recurrence at 12 months, then she would get a special MRI called an MRA, or a CT scan with die, called a CTA once a year to just keep an eye on everything.
Are you still enrolling? How long does the trial take?
Kaminisky: So for the Contour trial, which was called NECC, we are still enrolling patients. The aneurysms have to be of specific size, specific aneurysm, neck size, and specific locations. So not every aneurysm qualifies for the trial, and the ones that do, they have to go before the trial screening board to be approved, and then once they’re approved, we can enroll the patients in the trial. They have not reached their target enrollment yet so it will continue until the target enrollment number is reached, and then once that’s done, all the patients that have been enrolled have to meet the endpoint at one year, and then publication materials will be started.
What else would you say about aneurysms or about this device?
Kaminisky: So there are a fair number of patients that are diagnosed with these incidental aneurysms that get lost to follow up. There are some recent publications that say 20 plus percent of these never see a specialist and can have catastrophic consequences by not following up. So I think if one of these is identified on an imaging study, then it’s very important to see a specialist like our team at RIA Neurovascular that can determine, does this need to be watched, should it be treated, and the appropriate treatment type so that a devastating outcome does not occur.
That’s a great ending. And to be clear, the worst case scenario is a burst aneurysm, does that become a stroke? What is the bursting aneurysm?
Kaminisky: So when an aneurysm ruptures or bursts or bleeds, it causes what’s called a subarachnoid hemorrhage. It is grouped under the larger heading of stroke. Most strokes are from lack of blood flow or ischemic, this would be considered a hemorrhagic stroke. But more specifically, it’s called a subarachnoid hemorrhage based on where the bleeding typically occurs from an aneurysm rupture. When that happens, an aneurysm bleeding in the brain, about 10% of people die immediately, the next 20% will not survive the hospital stay, the next third of patients will have a severe disability, leaving about a third of people who could make it out of the hospital and return back to their life. So that’s why it’s very important when we find these when they haven’t bled and treat them unless they’re extremely small and round.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Stephanie Sullivan
Stephanie.sullivan@healthonecares.com
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
