E-089 intra-navien deployment of the pipeline embolization device: a novel rescue strategy for failed device expansion

Abstract

Background The Pipeline embolization device (PED) is a braided flow diverter that requires a combination of meticulous maneuvers to assure proper device opening and expansion. Mechanical, anatomical, or technical challenges can result in a partially deployed PED with failed expansion. Methods We retrospectively reviewed a prospective, single-center aneurysm database to identify all patients who underwent endovascular treatment of intracranial aneurysms using the PED with the Navien distal intracranial catheter access platform. Cases requiring PED deployment within the Navien catheter were reviewed. Data were collected for patient demographics, aneurysm characteristics, and technical details of the interventional procedure. Results Eleven PED neurointerventions requiring intra-Navien PED deployment to fully open the PED were identified. Mean patient age was 55.5 ± 9.9 years (range 37–76 years). Mean aneurysm size was 12.5 mm ± 4.9 mm (range 2–42 mm). All aneurysms were located in the anterior circulation (ACA, n = 1; supraclinoid, n = 1; ophthalmic/paraophthalmic, n = 6; cavernous, n = 3; petrocervical, n = 1). Mean fluoroscopy time was 67.1 ± 20.5 min. Intra-Navien technique was used to open the proximal PED (n = 7) and the mid portion (n = 4). Post-processing of the PED with a balloon was used in 6 cases. Figure 1 illustrates a case example of intra-Navien PED deployment in a 6mm supraclinoid ICA aneurysm. (A) Arch aortogram (AP view), demonstrates type 2 arch. (B) 3-dimensional reconstruction of the 6mm supraclinoid ICA aneurysm (lateral view). (C-G) Intra-procedural native single-shot fluoroscopy lateral views of PED deployment where the stretched segment could not be opened by standard maneuvers. Black arrow = tip of Navien, white arrow = Marksman tip, black arrowhead = constrained segment of the device. (H) Lateral view demonstrates complete unsheathe of PED within the Navien. (I) Lateral view shows opening of the constrained segment using the intra-Navien technique with simultaneous unsheathe of the Navien while pushing on the Marksman. White arrowhead = previously constrained segment now opened with intra-Navien PED deployment. (J) Lateral view demonstrates completely deployed PED, widely open. (K) Lateral cine view demonstrates good vessel wall apposition of the device. (L) Final control DSA demonstrates significant contrast stasis in the aneurysm. Conclusion In circumstances when a partially deployed PED remains constrained despite exhaustion of standard maneuvers to facilitate opening, the technique of intra-Navien PED deployment is a valuable rescue strategy. This novel alternative method of PED deployment can be used to open a stretched device with successful completion of the PED implantation. Disclosures L. Lin: None. G. Colby: 2; C; Covidien and MicroVention. B. Jiang: None. N. Nundkumar: None. J. Huang: None. R. Tamargo: None. A. Coon: 1; C; Covidien. 2; C; Covidien and Stryker. 6; C; Proctor for Pipeline, Surpass, and FRED.