A2, M2, P2 aneurysms and beyond: results of treatment with pipeline embolization device in 65 patients

2019 ◽  
Vol 11 (9) ◽  
pp. 903-907 ◽  
Author(s):  
Christopher T Primiani ◽  
Zeguang Ren ◽  
Peter Kan ◽  
Ricardo Hanel ◽  
Vitor Mendes Pereira ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
Vascular Pathology ◽  
Parent Vessel ◽  
Rare Type ◽  
Pipeline Embolization Device ◽  
Aneurysm Size

BackgroundIntracranial aneurysms located in the distal vessels are rare and remain a challenge to treat through surgical or endovascular interventions.ObjectiveTo describe a multicenter approach with flow diversion using the pipeline embolization device (PED) for treatment of distal intracranial aneurysms.MethodsCases of distal intracranial aneurysms defined as starting on or beyond the A2 anterior cerebral artery, M2 middle cerebral artery, and P2 posterior cerebral artery segments were included in the final analysis.Results65 patients with distal aneurysms treated with the PED were analyzed. Median aneurysm size at the largest diameter was 7.0 mm, 60% were of a saccular morphology, and 9/65 (13.8%) patients presented in the setting of acute rupture. Angiographic follow-up data were available for 53 patients, with a median follow-up time of 6 months: 44/53 (83%) aneurysms showed complete obliteration, 7/53 (13.2%) showed reduced filling, and 2/53 (3%) showed persistent filling. There was no association between patient characteristics, including aneurysm size (P=0.36), parent vessel diameter (P=0.27), location (P=0.81), morphology (P=0.63), ruptured status on admission (P=0.57), or evidence of angiographic occlusion at the end of the embolization procedure (P=0.49). Clinical outcome data were available for 60/65 patients: 95% (57/60) had good clinical outcome (modified Rankin Scale score of 0–2) at 3 months.ConclusionsThis large multicenter study of patients with A2, M2, and P2 distal aneurysms treated with the PED showed that flow diversion may be an effective treatment approach for this rare type of vascular pathology. The procedural compilation rate of 7.7% indicates the need for further studies as the flow diversion technology constantly evolves.

scholarly journals Endovascular Treatment of Intracranial Aneurysms in the Flow Diverter Era: Frequency of Use and Results in a Consecutive Series of 550 Treatments in a Single Centre

2014 ◽  
Vol 20 (4) ◽  
pp. 428-435 ◽  
Author(s):  
Willem Jan van Rooij ◽  
Ratna S Bechan ◽  
Jo P. Peluso ◽  
Menno Sluzewski
Keyword(s):  
Intracranial Aneurysms ◽  
Flow Diverter ◽  
Flow Diversion ◽  
Consecutive Series ◽  
Complication Rates ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Permanent Neurological Deficit ◽  
Flow Diverters

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

Early postmarket results with PulseRider for treatment of wide-necked intracranial aneurysms: a multicenter experience

2020 ◽  
Vol 133 (6) ◽  
pp. 1756-1765 ◽  
Author(s):  
Visish M. Srinivasan ◽  
Aditya Srivatsan ◽  
Alejandro M. Spiotta ◽  
Benjamin K. Hendricks ◽  
Andrew F. Ducruet ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Anterior Communicating Artery ◽  
Parent Vessel ◽  
Aneurysm Neck ◽  
Off Label ◽  
Fda Approval ◽  
Class 1

OBJECTIVETraditionally, stent-assisted coiling and balloon remodeling have been the primary endovascular treatments for wide-necked intracranial aneurysms with complex morphologies. PulseRider is an aneurysm neck reconstruction device that provides parent vessel protection for aneurysm coiling. The objective of this study was to report early postmarket results with the PulseRider device.METHODSThis study was a prospective registry of patients treated with PulseRider at 13 American neurointerventional centers following FDA approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and perioperative events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications.RESULTSA total of 54 aneurysms were treated, with the same number of PulseRider devices, across 13 centers. Fourteen cases were in off-label locations (7 anterior communicating artery, 6 middle cerebral artery, and 1 A1 segment anterior cerebral artery aneurysms). The average dome/neck ratio was 1.2. Technical success was achieved in 52 cases (96.2%). Major complications included the following: 3 procedure-related posterior cerebral artery strokes, a device-related intraoperative aneurysm rupture, and a delayed device thrombosis. Immediately postoperative Raymond-Roy occlusion classification (RROC) class 1 was achieved in 21 cases (40.3%), class 2 in 15 (28.8%), and class 3 in 16 cases (30.7%). Additional devices were used in 3 aneurysms. For those patients with 3- or 6-month angiographic follow-up (28 patients), 18 aneurysms (64.2%) were RROC class 1 and 8 (28.5%) were RROC class 2.CONCLUSIONSPulseRider is being used in both on- and off-label cases following FDA approval. The clinical and radiographic outcomes are comparable in real-world experience to the outcomes observed in earlier studies. Further experience is needed with the device to determine its role in the neurointerventionalist’s armamentarium, especially with regard to its off-label use.

Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up

2018 ◽  
Vol 130 (1) ◽  
pp. 259-267 ◽  
Author(s):  
Matthew T. Bender ◽  
Geoffrey P. Colby ◽  
Li-Mei Lin ◽  
Bowen Jiang ◽  
Erick M. Westbroek ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Flow Diversion ◽  
Single Institution ◽  
Anterior Circulation ◽  
Complete Occlusion ◽  
Aneurysm Size ◽  
Branch Vessel ◽  
Aneurysm Occlusion ◽  
Anterior Circulation Aneurysms

OBJECTIVEFlow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence.METHODSData from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors’ institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence.RESULTSFollow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used.CONCLUSIONSThis is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.

scholarly journals Predictors of success following endovascular retreatment of intracranial aneurysms

2015 ◽  
Vol 21 (4) ◽  
pp. 426-432 ◽  
Author(s):  
Justin R Mascitelli ◽  
Eric K Oermann ◽  
J Mocco ◽  
Johanna T Fifi ◽  
Srinivasan Paramasivam ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Univariate Analysis ◽  
Successful Outcome ◽  
Predictors Of Success ◽  
Parent Vessel ◽  
Aneurysm Size ◽  
Outcome Group ◽  
Treatment Type ◽  
Small Aneurysm

Introduction Although approximately one in every 10 patients undergoing coil embolization of intracranial aneurysms requires retreatment, the factors that are associated with outcome following retreatment remain to be fully elucidated. Methods This is a single-center, retrospective review of 43 patients with 58 intracranial aneurysms that were retreated from 2004 to 2014. Aneurysms undergoing first time or microsurgical retreatment were excluded. Retreatment types were grouped into those without permanent parent vessel support (stand-alone and balloon-assisted coiling) versus those with permanent parent vessel support (stent-assisted coiling, stand-alone stenting, and flow diversion). The Modified Raymond Roy Classification was used to group aneurysms at all angiographic follow-up points either in the successful outcome group (Class I or II) or the unsuccessful outcome group (Class IIIa or IIIb). Results Of aneurysms with follow-up, 50% were in the successful group and 50% in the unsuccessful group. In univariate analysis, small aneurysm size ( p < 0.001), previous treatment type ( p = 0.022), retreatment type ( p = 0.001), and initial occlusion class ( p = 0.005) were all associated with angiographic outcome. In multivariate analysis, small aneurysm size ( p = 0.005, odds ratio (OR) 24.56, confidence interval (CI) 2.68–225.4) and retreatment type with permanent parent vessel support, namely stent-assisted coiling ( p = 0.017, OR 31.1, CI 1.89–517.7), were associated with retreatment success. Conclusions Small aneurysm size and retreatment with permanent parent vessel support, namely stent-assisted coiling, are predictors of success following endovascular retreatment of intracranial aneurysms. These findings could be useful in the effort to both prevent and predict treatment failure following endovascular retreatment.

Matched Comparison of Flow Diversion and Coiling in Small, Noncomplex Intracranial Aneurysms

Neurosurgery ◽  
2017 ◽  
Vol 81 (1) ◽  
pp. 92-97 ◽  
Author(s):  
Nohra Chalouhi ◽  
Badih Daou ◽  
Guilherme Barros ◽  
Robert M. Starke ◽  
Ameet Chitale ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Intracranial Aneurysms ◽  
Flow Diversion ◽  
First Line ◽  
Complex Aneurysms ◽  
Aneurysm Size ◽  
Aneurysm Morphology ◽  
Baseline Characteristics ◽  
Matched Comparison

Abstract BACKGROUND: Flow diversion is typically reserved for large, giant, or morphologically complex aneurysms. Coiling remains a first-line treatment for small, morphologically simple aneurysms. OBJECTIVE: To compare coiling and flow diversion in small, uncomplicated intracranial aneurysms (typically amenable to coiling). METHODS: Forty patients treated with the pipeline embolization device (PED) for small (&lt;10 mm), morphologically simple aneurysms that would have also been amenable to coiling were identified. These patients were matched in a 1:1 fashion with 40 patients with comparable aneurysms treated with coiling. Matching was based on age, gender, aneurysm size, and aneurysm morphology. RESULTS: The 2 groups were comparable with regard to baseline characteristics including age, gender, and aneurysm size. The complication rate did not differ between the 2 groups (2.5% with coiling vs 5% with PED; P = .6). Multivariate analysis did not identify any predictor of complications. Complete occlusion (100%) at follow-up was significantly higher in patients treated with PED (70%) than coiling (47.5%, P = .04). In multivariate analysis, treatment with PED predicted aneurysm obliteration (P = .04). A significantly higher proportion of coiled patients (32.5%) required retreatment compared with flow diversion (5%, P = .003). In multivariate analysis, coiling predicted retreatment (P = .006). All patients achieved a favorable outcome (modified Rankin Scale: 0-2) regardless of group. CONCLUSION: This matched analysis suggests that flow diversion provides higher occlusion rates, lower retreatment rates, and no additional morbidity compared with coiling in small, simple aneurysms amenable to both techniques. These results suggest a potential benefit for flow diversion over coiling even in small, uncomplicated aneurysms.

scholarly journals Safety and efficacy of the Pipeline Embolization Device in 100 small intracranial aneurysms

2015 ◽  
Vol 122 (6) ◽  
pp. 1498-1502 ◽  
Author(s):  
Nohra Chalouhi ◽  
Mario Zanaty ◽  
Alex Whiting ◽  
Steven Yang ◽  
Stavropoula Tjoumakaris ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Complication Rates ◽  
Anterior Circulation ◽  
Pipeline Embolization Device ◽  
Safety And Efficacy ◽  
Aneurysm Size ◽  
Long Term Follow Up ◽  
Aneurysm Occlusion ◽  
Small Aneurysms

OBJECT Flow diverters are increasingly used for treatment of intracranial aneurysms. In most series, the Pipeline Embolization Device (PED) was used for the treatment of large, giant, complex, and fusiform aneurysms. Little is known about the use of the PED in small aneurysms. The purpose of this study was to assess the safety and efficacy of the PED in small aneurysms (≤ 7 mm). METHODS A total of 100 consecutive patients were treated with the PED at the authors' institution between May 2011 and September 2013. Data on procedural safety and efficacy were retrospectively collected. RESULTS The mean aneurysm size was 5.2 ± 1.5 mm. Seven patients (7%) had sustained a subarachnoid hemorrhage. All except 5 aneurysms (95%) arose from the anterior circulation. The number of PEDs used was 1.2 per aneurysm. Symptomatic procedure-related complications occurred in 3 patients (3%): 1 distal parenchymal hemorrhage that was managed conservatively and 2 ischemic events. At the latest follow-up (mean 6.3 months), 54 (72%) aneurysms were completely occluded (100%), 10 (13%) were nearly completely occluded (≥ 90%), and 11 (15%) were incompletely occluded (< 90%). Six aneurysms (8%) required further treatment. Increasing aneurysm size (OR 3.8, 95% CI 0.99–14; p = 0.05) predicted retreatment. All patients achieved a favorable outcome (modified Rankin Scale Score 0–2) at follow-up. CONCLUSIONS In this study, treatment of small aneurysms with the PED was associated with low complication rates and high aneurysm occlusion rates. These findings suggest that the PED is a safe and effective alternative to conventional endovascular techniques for small aneurysms. Randomized trials with long-term follow-up are necessary to determine the optimal treatment that leads to the highest rate of obliteration and the best clinical outcomes.

Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial Aneurysms

Neurosurgery ◽  
2011 ◽  
Vol 68 (4) ◽  
pp. 903-915 ◽  
Author(s):  
Tim E. Darsaut ◽  
Nicole M. Darsaut ◽  
Steven D. Chang ◽  
Gerald D. Silverberg ◽  
Lawrence M. Shuer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Clinical Outcome ◽  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Medical Center ◽  
Posterior Circulation ◽  
Giant Aneurysms ◽  
Aneurysm Size ◽  
Clinical Series

Abstract BACKGROUND: Risk factors for poor outcome in the treatment of very large (≥20-24 mm) and giant (≥25 mm) intracranial aneurysms remain incompletely defined. OBJECTIVE: To present an aggregate clinical series detailing a 24-year experience with very large and giant aneurysms to identify and assess the relative importance of various patient, aneurysm, and treatment-specific characteristics associated with clinical and angiographic outcomes. METHODS: The authors retrospectively identified 184 aneurysms measuring 20 mm or larger (85 very large, 99 giant) treated at Stanford University Medical Center between 1984 and 2008. Clinical data including age, presentation, and modified Rankin Scale (mRS) score were recorded, along with aneurysm size, location, and morphology. Type of treatment was noted and clinical outcome measured using the mRS score at final follow-up. Angiographic outcomes were completely occluded, occluded with residual neck, partly obliterated, or patent with modified flow. RESULTS: After multivariate analysis, risk factors for poor clinical outcome included a baseline mRS score of 2 or higher (odds ratio [OR], 0.23; 95% confidence interval [CI]: 0.08-0.66; P = .01), aneurysm size of 25 mm or larger (OR, 3.32; 95% CI: 1.51-7.28; P &lt; .01), and posterior circulation location (OR, 0.18; 95% CI: 0.07-0.43; P &lt; .01). Risk factors for incomplete angiographic obliteration included fusiform morphology (OR, 0.25; 95% CI: 0.10-0.66; P #x003C; .01), posterior circulation location (OR, 0.33; 95% CI: 0.13-0.83; P = .02), and endovascular treatment (OR, 0.14; 95% CI: 0.06-0.32; P &lt; .01). Patients with incompletely occluded aneurysms experienced higher rates of posttreatment subarachnoid hemorrhage and had increased mortality compared with those with completely obliterated aneurysms. CONCLUSION: Our results suggest that patients with poor baseline functional status, giant aneurysms, and aneurysms in the posterior circulation had a significantly higher proportion of poor outcomes at final follow-up. Fusiform morphology, posterior circulation location, and endovascular treatment were risk factors for incompletely obliterated aneurysms.

Long-term Follow-up of In-stent Stenosis After Pipeline Flow Diversion Treatment of Intracranial Aneurysms

Neurosurgery ◽  
2016 ◽  
Vol 78 (6) ◽  
pp. 862-867 ◽  
Author(s):  
Seby John ◽  
Mark D. Bain ◽  
Ferdinand K. Hui ◽  
M. Shazam Hussain ◽  
Thomas J. Masaryk ◽  
...  
Keyword(s):  
Intimal Hyperplasia ◽  
Intracranial Aneurysms ◽  
Clinical Symptoms ◽  
Flow Diversion ◽  
Parent Vessel ◽  
Stent Occlusion ◽  
Clinical Consequences ◽  
Metallic Mesh ◽  
Stent Stenosis

Abstract BACKGROUND: There is scant information on in-stent stenosis after flow diversion treatment of intracranial aneurysms with the Pipeline Embolization Device (PED). OBJECTIVE: To assess the incidence, severity, nature, and clinical consequences of in-stent stenosis on angiographic follow-up after treatment with the PED. METHODS: A retrospective study of patients who underwent aneurysm treatment with the PED was conducted. In-stent stenosis was assessed on subsequent follow-up angiography. Intimal hyperplasia was defined as a uniform growth process beyond the limits of the metallic mesh at &lt;25%. In-stent stenosis represented an area of parent vessel narrowing, most often focal, graded as mild (25%-50%), moderate (50%-75%), or severe (&gt;75%). RESULTS: Between June 2011 and April 2015, 80 patients were treated with the PED. Angiographic follow-up was available for 51 patients (representing 76% of available or 64% of all patients). Mean follow-up was 12.5 months. In-stent stenosis was detected in 5 patients (9.8%) at a median of 6 months. Stenosis was mild in 4 of 5 (80%) and moderate in 1 of 5 (20%) patients. There were no cases of severe stenosis. No stenosis caused flow limitation, clinical symptoms, or required re-treatment. Additional follow-up angiography was available in 2 of 5 stenosis patients showing marked improvement. Sixteen patients (31%) had intimal hyperplasia, and 28 patients (55%) had no stenosis. Asymptomatic stent occlusion occurred in 2 patients (4%) related to medication noncompliance. CONCLUSION: Treatment with the PED was associated with a 9.8% rate of in-stent stenosis, detected on first angiographic follow-up, at a median of 6 months. None were symptomatic or required re-treatment, and they showed significant improvement on follow-up.

Reduced Efficacy of the Pipeline Embolization Device in the Treatment of Posterior Communicating Region Aneurysms with Fetal Posterior Cerebral Artery Configuration

Neurosurgery ◽  
2017 ◽  
Vol 82 (5) ◽  
pp. 695-700 ◽  
Author(s):  
Anil K Roy ◽  
Brian M Howard ◽  
Diogo C Haussen ◽  
Joshua W Osbun ◽  
Sameer H Halani ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Clinical Symptoms ◽  
Posterior Cerebral Artery ◽  
Neurological Complications ◽  
Class I ◽  
Class Iii ◽  
Pipeline Embolization Device ◽  
Independent Association ◽  
Incomplete Occlusion

Abstract BACKGROUND Aneurysms at the origin of the posterior communicating artery (PcommA) have been demonstrated to be effectively treated with the pipeline embolization device (PED). Much less is known about the efficacy of the PED for aneurysms associated with a fetal posterior cerebral artery (fPCA) variant. OBJECTIVE To study PED treatment efficacy of PcommA aneurysms, including fPCA aneurysms. METHODS A prospectively maintained university database of aneurysm patients treated with the PED was retrospectively reviewed. Demographics, treatment details, and imaging were reviewed for all PcommA and fPCA aneurysms. RESULTS Out of a total of 285 patients treated with PED, 50 patients (mean age 57.5 ± 12.2 yr, 42 females) with unruptured PcommA (9 fPCA) aneurysms were identified. Mean follow-up duration was 14.0 ± 11.6 mo (48 patients). Roy-Raymond class I occlusion on follow-up magnetic resonance or catheter angiography (mean time 11.7 ± 6.8 mo) was achieved in 30 patients (62.5%), class II occlusion in 11 patients (22.9%) and class III occlusion in 7 patients (14.5%). The PcommA was occluded in 56% of patients without any clinical symptoms. No deaths or permanent neurological complications occurred. In fPCA aneurysms, class I occlusion was seen in 1 patient, class 2 occlusion in 2 patients, and class III occlusion in 6 patients. Multivariate analysis revealed an independent association between incomplete occlusion and fPCA configuration (OR 73.65; 95% CI: 5.84-929.13; P = .001). CONCLUSION The PED is a safe and effective treatment for PcommA aneurysms, although fetal anatomy should increase consideration of traditional endovascular techniques or surgical clipping.

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