Pipeline embolization device for recurrence of previously treated aneurysms

OBJECTIVEThe utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms.METHODSThe authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group.RESULTSAll PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months.CONCLUSIONSThe treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.

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Very delayed discontinuation of telescoped Pipeline embolization devices: a case report

Interventional Neuroradiology ◽

10.1177/1591019918809932 ◽

2018 ◽

Vol 25 (2) ◽

pp. 182-186

Author(s):

Manoj Bohara ◽

Kosuke Teranishi ◽

Kenji Yatomi ◽

Takashi Fujii ◽

Takayuki Kitamura ◽

...

Keyword(s):

Internal Carotid ◽

Flow Diversion ◽

Total Occlusion ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Radiological Features ◽

Long Term Follow Up ◽

Aneurysm Occlusion

Background Flow diversion with the Pipeline embolization device (PED) is a widely accepted treatment modality for aneurysm occlusion. Previous reports have shown no recanalization of aneurysms on long-term follow-up once total occlusion has been achieved. Case description We report on a 63-year-old male who had a large internal carotid artery cavernous segment aneurysm. Treatment with PED resulted in complete occlusion of the aneurysm. However, follow-up angiography at four years revealed recurrence of the aneurysm due to disconnection of the two PEDs placed in telescoping fashion. Conclusion Herein, we present the clinico-radiological features and discuss the possible mechanisms resulting in the recanalization of aneurysms treated with flow diversion.

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Reconstructive endovascular treatment of basilar artery fenestration aneurysms: A multi-centre experience and literature review

The Neuroradiology Journal ◽

10.1177/19714009211042877 ◽

2021 ◽

pp. 197140092110428

Author(s):

Hanna Styczen ◽

Sebastian Fischer ◽

Matthias Gawlitza ◽

Lukas Meyer ◽

Lukas Goertz ◽

...

Keyword(s):

Endovascular Treatment ◽

Basilar Artery ◽

Flow Diversion ◽

High Rate ◽

Complete Occlusion ◽

Secondary Endpoints ◽

Aneurysm Occlusion ◽

Complications Rate ◽

Woven Endobridge

Background Data on outcome after endovascular treatment of basilar artery fenestration aneurysms (BAFAs) is limited. This study presents our multi-centre experience of BAFAs treated by different reconstructive techniques including coils, stent-assisted coiling (SAC), flow diversion and intra-saccular flow disruption with the Woven Endobridge (WEB). Methods Retrospective analysis of 38 BAFAs treated endovascularly between 2003 and 2020. The primary endpoint was complete aneurysm obliteration defined as Raymond–Roy occlusion classification (RROC) I on immediate and follow-up (FU) angiography. The secondary endpoints were procedure-related complications, rate of re-treatment, and clinical outcome. Results Endovascular treatment was feasible in 36/38 aneurysms (95%). The most frequent strategy was coiling (21/36, 58%), followed by SAC (7/36, 19%), WEB embolization (6/36, 17%) and flow diversion (2/36, 6%). A successful aneurysm occlusion (defined as RROC 1 and 2) on the final angiogram was achieved in 30/36 (83%) aneurysms including all patients presenting with baseline subarachnoid haemorrhage and 25/36 (69%) were occluded completely. Complete occlusion (RROC 1) was more frequently achieved in ruptured BAFAs (15/25, 60% v. 2/11, 18%; p = 0.031). Procedure-related complications occurred in 3/36 (8%) aneurysms. Re-treatment was executed in 12/36 (33%) aneurysms. After a median angiography FU of 38 months, 30/31 (97%) BAFAs were occluded successfully and 25/31 (81%) showed complete occlusion. Conclusion Reconstructive endovascular treatment of BAFAs is technically feasible with a good safety profile. Although in some cases re-treatment was necessary, a high rate of final aneurysm occlusion was achieved.

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Treatment of a Basilar Trunk Perforator Aneurysm With the Pipeline Embolization Device

Neurosurgery ◽

10.1227/neu.0000000000000308 ◽

2014 ◽

Vol 74 (6) ◽

pp. E697-E701 ◽

Cited By ~ 17

Author(s):

Nohra Chalouhi ◽

Pascal Jabbour ◽

Robert M. Starke ◽

Mario Zanaty ◽

Stavropoula Tjoumakaris ◽

...

Keyword(s):

Clinical Presentation ◽

Endovascular Coiling ◽

Complete Disappearance ◽

Parent Vessel ◽

Pipeline Embolization Device ◽

Microsurgical Clipping ◽

First Case ◽

Flow Through ◽

Neurologically Intact

ABSTRACT BACKGROUND AND IMPORTANCE: Basilar trunk perforator (BTP) aneurysms are rare lesions that pose significant challenges to microsurgical clipping and endovascular coiling. We present the intriguing case of a ruptured BTP aneurysm that was successfully treated with the Pipeline Embolization Device (PED). CLINICAL PRESENTATION: An elderly woman presenting with subarachnoid hemorrhage was found to have a 1.5-mm aneurysm arising from the proximal portion of a thin midbasilar perforator. The decision was made to treat this aneurysm with flow diversion in an attempt to preserve the patency of the perforator and to avoid the hazards associated with parent vessel trapping. A 3 × 12-mm PED was successfully deployed in the basilar trunk across the neck of the aneurysm, causing stasis in the aneurysm, with continuous flow through the parent vessel. The procedure and postoperative course were uneventful. A follow-up angiogram 2 weeks later showed complete disappearance of the aneurysm with preservation of the patency of the perforator. At the 6-month follow-up, the patient was asymptomatic and remained neurologically intact. CONCLUSION: We present the first case of a BTP aneurysm treated with the PED. The aneurysm was successfully occluded, and the patency of the feeding vessel was preserved. In light of the limitations of coiling and the hazards associated with microsurgery and parent vessel trapping, the PED may be a valuable option for BTP aneurysms.

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Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms

Interventional Neuroradiology ◽

10.1177/1591019918785911 ◽

2018 ◽

Vol 24 (6) ◽

pp. 615-623 ◽

Cited By ~ 2

Author(s):

V Hellstern ◽

M Aguilar-Pérez ◽

M AlMatter ◽

P Bhogal ◽

E Henkes ◽

...

Keyword(s):

Acute Phase ◽

Clinical Symptoms ◽

Demographic Data ◽

Flow Diversion ◽

Parent Vessel ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Microsurgical Clipping ◽

Safety Margins

Background Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. Methods A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. Results Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. Conclusions Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.

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Endovascular flow diversion for treatment of anterior communicating artery region cerebral aneurysms: a single-center cohort of 50 cases

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012946 ◽

2017 ◽

Vol 9 (7) ◽

pp. 679-685 ◽

Cited By ~ 37

Author(s):

Geoffrey P Colby ◽

Matthew T Bender ◽

Li-Mei Lin ◽

Narlin Beaty ◽

Judy Huang ◽

...

Keyword(s):

Cerebral Aneurysms ◽

Good Alternative ◽

Flow Diversion ◽

Definitive Treatment ◽

Endovascular Coiling ◽

Anterior Communicating Artery ◽

Microsurgical Clipping ◽

Alternative Treatment Option ◽

Procedural Success

BackgroundFlow diversion represents a novel but definitive treatment for recurrent and difficult-to-coil aneurysms of the anterior communicating artery (ACoA) region, of which reports are limited.ObjectiveTo determine the effectiveness of the Pipeline embolization device (PED) in treating aneurysms in the ACoA region.MethodsWe retrospectively reviewed an IRB-approved database of patients with an aneurysm at a single institution for patients with ACoA or A1–A2 aneurysms treated with PED. Data analyzed included demographics, aneurysm characteristics, procedural details, follow-up results, and outcomes.ResultsA total of 50 procedures were performed on 41 patients, including seven patients who underwent bilateral ‘H-pipe’ PED placement. The average age was 56 years and 46% of the patients were female. The average aneurysm size was 4.5 mm, and two large (>10 mm) aneurysms were treated. The vessel of origin was either the ACoA (26 aneurysms, 63%) or the A1–A2 junction (15 aneurysms, 37%). Eighteen patients (44%) had prior subarachnoid hemorrhage and 20 had previously been treated either with clipping (6 aneurysms, 15%) or coiling (14 aneurysms, 34%). Procedural success was achieved in 48/50 cases (96%) and two cases were aborted. Coils were deployed adjunctively in two cases (4%). Procedural outcomes included no deaths, one major ischemic stroke (2%), and two patients with intracranial hemorrhage (4%). Complete aneurysm occlusion was achieved in 81% of patients at 6 months and 85% of patients at last follow-up digital subtraction angiography.ConclusionsThe PED can be used safely and effectively in the treatment of aneurysms of the ACoA region. This represents a good alternative treatment option to microsurgical clipping and endovascular coiling.

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Cognitive Impairments and Associated Factors After Ruptured Anterior Communicating Artery Aneurysm Treatment in Low-Grade Patients <60 Years: A Multicenter Retrospective Study

10.21203/rs.3.rs-29771/v1 ◽

2020 ◽

Author(s):

Ning Ma ◽

Xin Feng ◽

Zhongxue Wu ◽

Daming Wang ◽

Aihua Liu

Keyword(s):

Regression Analysis ◽

Cognitive Impairment ◽

Cox Regression ◽

Cognitive Impairments ◽

Young Patients ◽

Endovascular Coiling ◽

Anterior Communicating Artery ◽

Cox Regression Analysis ◽

Microsurgical Clipping

Abstract Background Aneurysmal subarachnoid hemorrhage (SAH) is a kind of destructive cerebrovascular disease which could affect people's cognition, even the life expectancy. People with SAH are considered in a fatal situation, especially in the young population. This study aimed to investigate cognitive impairment and related factors in young patients with ruptured anterior communicating artery (ACoA) aneurysms.Methods We conducted a multicentre retrospective follow-up study at three hospitals in China. The young patients (18-50 years) who underwent ruptured ACoA aneurysm treatment by microsurgical clipping or endovascular coiling at three academic institutions in China from January 2015 to November 2017 were recruited. Patient cognition and life quality were assessed by using modified Telephone Interview for Cognitive Status (TICS-m), the modified Rankin Scale (mRS), and the instrumental activities of daily living (IADL) scale 2. Multiple cox-regression analysis was used to identify variables independently associated with cognitive impairment.Results Of the total of 59 patients, 54 (91.5%) achieved good clinical outcomes (mRS score 0-2) and 51 (86.4%) had excellent quality of life (IADL score 8). Ten (16.9%) patients showed cognitive impairments (TICS-m<27). The multivariate COX regression analysis showed that mRS scores of 3-5 at discharge, female sex, and aneurysm size <5 mm was independently associated with cognitive impairment. TICS-m scores at the latest follow-up were similar after open surgery and coiling. Conclusion In this relatively young sample that excluded patients with very poor-grade SAH or serious complications, microsurgical clipping led to better clinical outcomes than endovascular coiling, while cognitive outcomes were similar across treatment modalities. These results are not completely consistent with previous studies, and should therefore be considered in the clinical practice as well as further investigated in larger patient samples.

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

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014631 ◽

2019 ◽

Vol 11 (9) ◽

pp. 903-907 ◽

Cited By ~ 9

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.

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Regrowth of a Large Intracranial Aneurysm after On-Label Use of the Pipeline Embolization Device

Journal of Neurosciences in Rural Practice ◽

10.4103/jnrp.jnrp_273_18 ◽

2019 ◽

Vol 10 (01) ◽

pp. 142-144 ◽

Cited By ~ 2

Author(s):

Ching-Jen Chen ◽

M. Rao Patibandla ◽

Min S. Park ◽

M. Yashar Kalani

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Intracranial Aneurysm ◽

Internal Carotid ◽

Pipeline Embolization Device ◽

Complete Occlusion ◽

Residual Component ◽

First Case ◽

Aneurysm Occlusion

ABSTRACTDespite the widespread use of the pipeline embolization device (PED), no complete aneurysm regrowth after its placement has been reported in the literature. We report the first case of aneurysm regrowth after the initial follow-up angiography demonstrating near-complete occlusion of the aneurysm and remodeling of the vessel with on-label PED use for a large 20 mm × 24 mm × 22 mm (width × depth × height) cavernous segment internal carotid artery (ICA) aneurysm. The patient was treated with two overlapping PED (4.5 mm × 20 mm and 5 mm × 20 mm). Follow-up angiogram at 4 months after treatment demonstrated remodeling of the ICA with a small residual component measuring approximately 7 mm × 8 mm × 7 mm. However, at 10 months after treatment, there was a complete regrowth of the aneurysm with interval growth, now measuring 25 mm × 28 mm × 18 mm. Despite the high aneurysm occlusion rates reported with the PED, persistent aneurysm filling and aneurysm regrowth, although rare, should not be overlooked.

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One-year Angiographic Results After pCONus Stent-Assisted Coiling of 40 Wide-Neck Middle Cerebral Artery Aneurysms

Neurosurgery ◽

10.1093/neuros/nyw131 ◽

2017 ◽

Vol 80 (6) ◽

pp. 925-933 ◽

Cited By ~ 21

Author(s):

Benjamin Gory ◽

Marta Aguilar-Pérez ◽

Elisa Pomero ◽

Francis Turjman ◽

Werner Weber ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Cerebral Artery ◽

Endovascular Coiling ◽

Total Occlusion ◽

Complete Occlusion ◽

Neck Size ◽

Clinical Complications ◽

Middle Cerebral Artery Aneurysms ◽

Wide Neck

Abstract BACKGROUND: Bifurcation middle cerebral artery (MCA) aneurysms with wide neck are amenable to endovascular coiling with pCONus stent, a recent device dedicated to wide-neck bifurcation intracranial aneurysms. OBJECTIVE: To evaluate the 1-year angiographic follow-up of wide-neck MCA aneurysms treated with pCONus. METHODS: Forty MCA aneurysms (mean dome size, 7.7 mm; mean neck size, 5.6 mm) coiled with pCONus were retrospectively evaluated. “Recanalization” was defined as worsening, and “progressive thrombosis” was defined as improvement on the Raymond scale. RESULTS: Angiographic midterm (mean, 11.9 months; range, 3-20) follow-up was obtained in all aneurysms. Retreatment was performed in 9 aneurysms (22.5%) without clinical complications, and postoperative angiographic outcome included 2 complete occlusions and 7 neck remnants. Six aneurysms were followed after retreatment (mean, 8.8 months), and presented complete occlusion in 1 case, neck remnant in 4 cases, and aneurysm remnant in 1 case. Among the 31 aneurysms, follow-up showed complete occlusion in 67.7% (21/31), neck remnants in 29% (9/31), and aneurysm remnants in 3.3% (1/31). Adequate aneurysm occlusion (total occlusion and neck remnant) was obtained in 96.7% (30/31). Among these 31 aneurysms, improvement of the rate of occlusion was observed in 15 aneurysms (48.4%), and recurrence in 2 aneurysms (6.5%). There was no 1-year angiographic recurrence of 3- or 6-month totally occluded aneurysms. CONCLUSION: pCONus stent allows a safe coiling of wide-neck MCA aneurysms usually considered as surgical with a low recanalization rate for those adequately occluded at 3 to 6 months. Angiographic results improve over time due to progressive aneurysm thrombosis in around 50% of cases.

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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

Interventional Neuroradiology ◽

10.15274/inr-2014-10047 ◽

2014 ◽

Vol 20 (4) ◽

pp. 428-435 ◽

Cited By ~ 7

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.

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