Tag: Pipeline embolization device

Posted on

Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients

J Neurosurg 130:1505–1512, 2019

Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%–40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling.

METHODS The authors performed a retrospective analysis of 115 patients with an aneurysm of the cavernous to ophthalmic segments of the internal carotid artery treated with clipping, coiling, or PED deployment between January 2011 and March 2017. Postoperative complications were defined as new neurological deficit, aneurysm rupture, recanalization, or other any operative complication that required reintervention.

RESULTS A total of 125 paraclinoid aneurysms in 115 patients were treated, including 70 with PED placement, 23 with coiling, and 32 with clipping. Eighteen (14%) aneurysms were ruptured. The mean aneurysm size was 8.2 mm, and the mean follow-up duration was 18.4 months. Most aneurysms were discovered incidentally, but visual impairment, which occurred in 21 (18%) patients, was the most common presenting symptom. Among these patients, 15 (71%) experienced improvement in their visual symptoms after treatment, including 14 (93%) of these 15 patients who were treated with PED deployment. Complete angiographic occlusion was achieved in 89% of the patients. Complications were seen in 17 (15%) patients, including 10 (16%) after PED placement, 2 (9%) after coiling, and 5 (17%) after clipping. Patients with incomplete aneurysm occlusion had a higher rate of procedural complications than those with complete occlusion (p = 0.02). The rate of postoperative visual improvement was significantly higher among patients treated with PED deployment than in those treated with coiling (p = 0.01). The significant predictors of procedural complications were incomplete occlusion (p = 0.03), hypertension, (p = 0.04), and diabetes (p = 0.03).

CONCLUSIONS In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.

Posted on

In-Pipeline Stenosis: Incidence, Predictors, and Clinical Outcomes

In-Pipeline Stenosis- Incidence, Predictors, and Clinical Outcomes

Neurosurgery 77:875–879, 2015

The Pipeline Embolization Device is a widely utilized flow diverter in the treatment of intracranial aneurysms.

OBJECTIVE: To assess the incidence, clinical significance, predictors, and outcomes of in-Pipeline stenosis (IPS).

METHODS: Angiographic studies in 139 patients treated between 2011 and 2013 were independently reviewed by 2 authors for the presence of IPS. Multivariable logistic regression analysis was conducted to determine predictors of IPS.

RESULTS: A total of 21 (15.8%) patients demonstrated some degree of IPS during the follow-up period at a mean time point of 6.7 months (range, 3-24 months). The stenosis was mild (,50%) in 11 patients, moderate (50%-75%) in 5, and severe (.75%) in 6. None were symptomatic or required further intervention. Sixteen of these 22 patients (73%) had IPS detected within 6 months. IPS was noted in 7.6% (1/13) of patients with posterior circulation aneurysms vs 16.7% (21/126) of those with anterior circulation aneurysms (P = .03). The rate of IPS was 60% (3/5) in patients who did not receive aspirin vs only 14.2% (19/134) in those who received aspirin (P = .02). In multivariable analysis, no aspirin therapy (odds ratio, 10.0; 95% confidence interval, 1.4-67.7; P = .02) and internal carotid artery aneurysm location (odds ratio, 3.1; 95% confidence interval, 1.1-8.8; P = .03) were strong independent predictors of IPS.

CONCLUSION: IPS is a common, early, and mostly benign complication. Patients with internal carotid artery aneurysms are more likely to develop IPS. Aspirin plays a key role in preventing IPS. The results of this study further support the safety of flow diverters.

Posted on

Incidence and Clinical Implications of Carotid Branch Occlusion Following Treatment of Internal Carotid Artery Aneurysms With the Pipeline Embolization Device

Incidence and Clinical Implications of Carotid Branch Occlusion Following Treatment of Internal Carotid Artery Aneurysms With the Pipeline Embolization Device

Neurosurgery 76:173–178, 2015

The use of flow diverters such as the pipeline embolization device (PED) for treatment of intracranial aneurysms carries the risk of side branch occlusion.

OBJECTIVE: To determine the incidence and clinical outcomes associated with supraclinoid internal carotid artery (ICA) branch occlusion after deployment of PEDs for ICA aneurysms.

METHODS: We reviewed patients who underwent endovascular treatment with PEDs for ICA aneurysms between June 2011 and March 2013. Forty-nine patients (43 women, mean age 56.36 1.8 years, 68 aneurysms) in whom PEDs traversed the origin of supraclinoid ICA branches (ophthalmic [OA], posterior communicating [PcommA], and anterior choroidal artery [AChA]) were selected for this study. Follow-up angiograms (mean follow-up, 12.8 6 0.8 months) were studied to determine the location of PEDs and the patency of ICA branches.

RESULTS: PEDs were placed across the ostia of 49 OAs, 14 PcommAs, and 11 AChAs. Multiple PEDs were deployed in 16 patients. Rate of branch occlusion was 4% (2/49) for the OA, 7.1% (1/14) for the PcommA, and 0% for the AChA. Patients with branch occlusion did not endure new neurological deficits. ICA branch occlusion was not associated with the number of PEDs covering the ostia (P = .76) or the origin of ICA branches from the aneurysm (P = .24).

CONCLUSION: The incidence of major supraclinoid ICA branch occlusion after treatment with PEDs was low. These events were not associated with new neurological deficits nor were they related to the number of PEDs deployed or the origin of ICA branches from the aneurysm.

Posted on

Increasing Flow Diversion for Cerebral Aneurysm Treatment Using a Single Flow Diverter

Increasing Flow Diversion for Cerebral Aneurysm Treatment Using a Single Flow Diverter

Neurosurgery 75:286–294, 2014

A neurovascular flow diverter (FD), aiming at inducing embolic occlusion of cerebral aneurysms through hemodynamic changes, can produce variable mesh densities owing to its flexible mesh structure.

OBJECTIVE: To explore whether the hemodynamic outcome would differ by increasing FD local compaction across the aneurysm orifice.

METHODS: We investigated deployment of a single FD using 2 clinical strategies: no compaction (the standard method) and maximum compaction across the aneurysm orifice (an emerging strategy). Using an advanced modeling technique, we simulated these strategies applied to a patient-specific wide-necked aneurysm model, resulting in a relatively uniform mesh with no compaction (C1) and maximum compaction (C2) at the aneurysm orifice. Pre- and posttreatment aneurysmal hemodynamics were analyzed using pulsatile computational fluid dynamics. Flow-stasis parameters and blood shear stress were calculated to assess the potential for aneurysm embolic occlusion.

RESULTS: Flow streamlines, isovelocity, and wall shear stress distributions demonstrated enhanced aneurysmal flow reduction with C2. The average intra-aneurysmal flow velocity was 29% of pretreatment with C2 compared with 67% with C1. Aneurysmal flow turnover time was 237% and 134% of pretreatment for C2 and C1, respectively. Vortex core lines and oscillatory shear index distributions indicated that C2 decreased the aneurysmal flow complexity more than C1. Ultrahigh blood shear stress was observed near FD struts in inflow region for both C1 and C2.

CONCLUSION: The emerging strategy of maximum FD compaction can double aneurysmal flow reduction, thereby accelerating aneurysm occlusion. Moreover, ultrahigh blood shear stress was observed through FD pores, which could potentially activate platelets as an additional aneurysmal thrombosis mechanism.

Posted on

Treatment of Blister-Like Aneurysms With the Pipeline Embolization Device

Treatment of Blister-Like Aneurysms With the Pipeline Embolization Device

Neurosurgery 74:527–532, 2014

Endovascular vessel reconstruction with the pipeline embolization device (PED) has become common practice. Data on the safety and efficacy of the PED in blister-like aneurysms (BLAs) are limited.

OBJECTIVE: To retrospectively present our experience with use of the PED in BLAs.

METHODS: A total of 8 patients harboring 8 BLAs were treated with the PED at our institution between November 2011 and April 2013.

RESULTS: Aneurysm size was 2.5 mm on average. Five patients had sustained a subarachnoid hemorrhage (SAH), 1 patient presented with sentinel headaches, and in 2 patients the aneurysm was incidentally discovered. Seven aneurysms arose from the ICA and 1 from the basilar artery. Placement of the PED was successful in all 8 patients. There were no procedural or perioperative complications in any of the patients. At the latest follow-up, all 8 patients achieved a favorable outcome (mRS 0-2). Angiographic follow-up was available for 6 patients at a mean time point of 3.9 months. Follow-up angiography showed 100% aneurysm occlusion in 5 patients and marked decrease in aneurysm size in 1 patient.

CONCLUSION: The findings of this study suggest that the PED may be a safe and effective treatment for BLAs. Given the limitations of other treatment modalities and the challenging nature of BLAs, flow diversion may be a valuable option for these lesions.

Posted on

Complications After Treatment With Pipeline Embolization for Giant Distal Intracranial Aneurysms With or Without Coil Embolization

Neurosurgery 71:E509–E513, 2012 DOI: 10.1227/NEU.0b013e318258e1f8

The Pipeline Embolization Device (PED) is a flow diverter designed to treat intracranial aneurysms through endoluminal parent vessel reconstruction. The role of adjunctive coil embolization is unknown.

CLINICAL PRESENTATION: This report details the authors’ experience with the PED in 2 patients with symptomatic, giant distal intracranial aneurysms (1 basilar artery and 1 M1 segment middle cerebral artery). Both patients had successful parent vessel reconstruction. In the first patient, the basilar artery aneurysm was treated with PEDs alone, and the patient experienced early fatal brainstem hemorrhage from aneurysm rupture. In the second patient, the M1 aneurysm was treated with 2 PEDs along with dense coil embolization, with a good initial angiographic result. This patient experienced acute thrombosis of the PED post-procedure, likely related to mass effect and thrombogenicity of the dense coil mass.

CONCLUSION: Flow diversion is an evolutionary step in the treatment of giant intracranial aneurysms. However, complete aneurysm occlusion occurs over a delayed period. The authors recommend placement of coils in addition to PED in the treatment of large or giant distal intracranial aneurysms in an attempt to protect the dome. However, robust packing is to be avoided because it can lead to acute PED thrombotic or compressive occlusion.

Proudly powered by WordPress