E-131 endovascular reconstruction of intradural vertebral artery fusiform dissecting aneurysms with the pipeline embolization device

Abstract

Introduction/purpose Dissecting aneurysms of the vertebral artery (VA) are difficult to treat using current surgical and endovascular techniques. Currently, there is no consensus on management strategies of dissecting VA aneurysms. The characteristics of flow diverter stents appear to have ideal requirements for the treatment of dissecting VA aneurysms. In this study, we retrospectively analyzed the efficacy and safety of flow diverters in the treatment of such lesions. Materials and methods We identified six patients with six VA dissecting aneurysms either arising from the V4 or V3–V4 junction that were treated with the pipeline embolization device (PED) at our institution from July 2012 to February 2015. Among other parameters, technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcome were evaluated. Results Six patients, 3 females and 3 males, with a mean age of 52.8 years (age range 39–63 years) were identified. Vascular risk factors included hypertension (4/6), dyslipidemia (2/6), fibromuscular dysplasia (1/6) and smoking (1/6). The aneurysms were incidental findings in 3 cases, whereas the other 3 patients presented with neurological symptoms such as visual changes, ataxia, facial numbness or vertigo. Diagnostic angiography confirmed the presence of fusiform dissecting aneurysms centered at the V4 segment in 5 cases and at the vertebral V3–V4 junction in one case. PED placement was achieved in all cases and immediate angiography follow-up demonstrated intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of dysarthria was noted in one patient. Major procedure-related complications were not observed. 6-month follow-up (n = 5) demonstrated complete/near complete aneurysm obliteration in 4 and partial obliteration in 1 patient. At 1-year follow-up (n = 4) stable complete aneurysm occlusion was seen in 2 patients. One patient demonstrated progression from near complete to complete occlusion and the previously noted partial occlusion remained stable. No aneurysmal bleeding, in-stent stenosis or thromboembolic complication was observed. NIHSS and mRS scores remained unchanged from admission to discharge. Conclusion Our preliminary experience with endoluminal reconstruction of intradural dissecting VA aneurysms with the PED confirms this treatment approach to be feasible and safe with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies will need to provide further information on durable aneurysm obliteration in response to hemodynamic intravascular flow changes and the occurrence of delayed hemorrhage and in-stent thrombosis. The promising results obtained so far, however, appear to support the use of flow diverter in the treatment of dissecting intracranial VA aneurysms; especially in circumstances where maintaining parent artery and side branch patency is required. Disclosures A. Kuhn: None. F. Massari: None. J. Lozano: None. S. Hou: None. M. Howk: None. M. Perras: None. C. Brooks: None. P. Kan: None. M. Gounis: 1; C; NIH, Philips Healthcare, Covidien/eV3 Neurovascular, Codman Neurovascular, Stryker Neurovascular, Wyss Institute, Tay Sachs Foundation. 2; C; fee-per-hour consultation, Stryker Neurovascular. A. Wakhloo: 1; C; Philips Medical. 2; C; Stryker Neurovascular. 3; C; Harvard Postgraduate Course and Miami Baptist Vascular Institute. A. Puri: None.