Pipeline Embolization Device Procedures Research Articles

Mortality after treatment of intracranial aneurysms with the Pipeline Embolization Device

BackgroundThe Pipeline Embolization Device (PED) is reported to be a safe treatment tool for aneurysms. However, mortality occurs in a few cases, and this has not been clearly studied. We...

Exploring the Feasibility of Pipeline Embolization Device Compared With Stent-Assisted Coiling to Treat Non-saccular, Unruptured, Intradural Vertebral Artery Aneurysms.

Object: The pipeline embolization device (PED) has been used to treat non-saccular, unruptured, intradural vertebral artery aneurysms at some institutions. However, there is an absence of large controlled studies validating the feasibility of this treatment. This study aimed to explore the therapeutic feasibility of PED by comparing PED treatment with controlled stent-assisted coiling (SAC).Materials and Methods: Thirty-two PED procedures were matched in a 1:2 manner with 64 SAC procedures based on patient age, sex, aneurysm size, and aneurysm location. Technical factors, procedural complications, angiographic results, and clinical outcomes were analyzed and compared.Results: There was no statistically significant difference in technical factors and procedural complications between the two groups (PED vs. SAC, 9.4 vs. 4.7%, P = 0.397). In multivariate analysis, smoking and therapeutic modality were identified as independent predictors of occlusion. Smoking was a risk factor for aneurysm obliteration [hazard ratio (HR) 0.53; 95% confidence interval (CI), 0.31–0.89; P = 0.018]. Aneurysms treated with PED were more likely to achieve obliteration over time compared with aneurysms treated with SAC (HR 2.97; 95% CI, 1.79–4.93; P < 0.001). The rate of favorable clinical outcomes (modified Rankin Scale (mRS), 0–2) was similar between the two groups (PED vs. SAC, 100 vs. 96.9%, P = 0.551). In the SAC group, one patient had neurological deficit with an mRS of four at the latest follow-up. There was no mortality in either group.Conclusions: The PED and SAC groups showed similar technical factors, procedural complications, angiographic results, and favorable clinical outcomes. Aneurysms treated with PED were more prone to obliteration over time than aneurysms treated with SAC. These outcomes suggest, based on short-term follow-up, PED is a safe and feasible strategy for the treatment of non-saccular, unruptured, intradural vertebral artery aneurysms.

Application of the Pipeline Embolization Device for Giant Vertebrobasilar Dissecting Aneurysms in Pediatric Patients.

Objective: To evaluate the feasibility and effectiveness of the pipeline embolization device (PED) for the treatment of pediatric giant vertebrobasilar dissecting aneurysms (VBDAs).Methods: We retrospectively reviewed our institutional clinical database and identified 2,706 patients who presented with a diagnosis of intracranial aneurysms from January 2016 to June 2018. Among this group, 153 patients were diagnosed with VBDAs, and 54 of these patients underwent PED therapy. The PED technique was used in four patients who were 18 years old or younger at the time of presentation (two males, two females; mean age 9.25 years; age range 8–11 years).Results: All four included pediatric patients were managed with the PED. One patient (25%) was treated with the PED alone, while three (75%) were treated with the PED and coils. One patient died from brainstem infarction or compression of the brainstem, while follow-up of the other three patients revealed favorable outcomes. The mass effect was reduced in cases 1, 2, and 3 on follow-up MRI performed 6 months after the PED procedure.Conclusions: PEDs could be feasible in the treatment of pediatric giant VBDAs. However, the safety and efficacy of this method have not been clarified in this special pediatric population, and long-term follow-up is still necessary.

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

OBJECTIVE Flow 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. METHODS Data 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. RESULTS Follow-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. CONCLUSIONS This 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.

Outcome Analysis of the Flow Diversion with Pipeline Embolization Device for the Surgical Treatment of Unruptured Large and Giant Paraclinoid Carotid Aneurysms

Background: Both the high frequency of recurrence of large or giant paraclinoid aneurysms (PA) of the internal carotid artery and the occurrence of intra- and postoperative complications, leading to unsatisfactory results of surgical treatment of this group of patients, make the stated problem urgent. Flow-diverter embolization devices are actively used in many large international neurosurgical centers for the treatment of cerebral aneurysms of different morphology, size, and localization. Currently, there are very few reports on the effectiveness of the use of flow diverting stents in the surgical treatment of large and giant PA of the internal carotid artery. The results of these studies are controversial and largely contradictory. Aim: Outcome analysis of the use of Pipeline embolization device (PED) for the surgical treatment of large and giant carotid PA. Methods: The study enrolled 37 patients (25 women, 12 men; mean age 51.7±10.7 years) who were divided into those treated with the PED alone versus those treated with the PED and concurrent coil embolization. The average follow-up period was 19.7±3.8 months. Results: In 56.7% of cases, PA caused the development of an insignificant neurological deficit (Modified Rankin Scale 1−2). In 18.9% of patients, PA provoked a gross neurologic deficit (MRS 3−5). 24.3% of patients with PA did not have any clinical-neurological manifestations. After the surgery, neurologic status improved in 32.4% of patients, remained the same — in 45.9% of cases, and the degree of neurologic deficit increased in 21.6%. PED procedure was performed in 70.2% of patients. In 29.7% of cases, the dislocation of large or giant PA of the internal carotid artery from the systemic blood stream was performed using PED and concurrent coil embolization. At the indicated period of patient observation, complete occlusion of large and giant carotid PA was achieved in 75.6% of cases, almost complete and partial occlusion — in 24.3%. The incidence of thromboembolic and hemorrhagic complications was 10.8% and 8.1%, respectively. Mortality rate among patients was 2.7%. Conclusions: The use of PED is an effective method for occluding large or giant PA of the internal carotid artery. Nevertheless, this method of endovascular treatment of PA is associated with a high complication incidence.

Declining complication rates with flow diversion of anterior circulation aneurysms after introduction of the Pipeline Flex: analysis of a single-institution series of 568 cases.

OBJECTIVEThe second-generation Pipeline embolization device (PED), Flex, has several design upgrades, including improved opening and the ability to be resheathed, in comparison with the original device (PED classic). The authors hypothesized that Flex is associated with a lower rate of major complications.METHODSA prospective, IRB-approved, single-institution database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion. The PED classic was used from August 2011 to January 2015, and the Pipeline Flex has been used since February 2015.RESULTSA total of 568 PED procedures (252 classic and 316 Flex) were performed for anterior circulation aneurysms. The average aneurysm size was 6.8 mm. Patients undergoing treatment with the Flex device had smaller aneurysms (p = 0.006) and were more likely to have undergone previous treatments (p = 0.001). Most aneurysms originated along the internal carotid artery (89% classic and 75% Flex) but there were more anterior cerebral artery (18%) and middle cerebral artery (7%) deployments with Flex (p = 0.001). Procedural success was achieved in 96% of classic and 98% of Flex cases (p = 0.078). Major morbidity or death occurred in 3.5% of cases overall: 5.6% of classic cases, and 1.9% of Flex cases (p = 0.019). On multivariate logistic regression, predictors of major complications were in situ thrombosis (OR 4.3, p = 0.006), classic as opposed to Flex device (OR 3.7, p = 0.008), and device deployment in the anterior cerebral artery or middle cerebral artery as opposed to the internal carotid artery (OR 3.5, p = 0.034).CONCLUSIONSFlow diversion of anterior circulation cerebral aneurysms is associated with an overall low rate of major complications. The complication rate is significantly lower since the introduction of the second-generation PED (Flex).

Pipeline embolization of posterior communicating artery aneurysms associated with a fetal origin posterior cerebral artery

Background and purposeFlow diversion may have advantages in the treatment of posterior communicating artery (PComA) aneurysms associated with a fetal origin posterior cerebral artery (PCA), which can be challenging to treat with conventional techniques. However, a PComA incorporated into the aneurysm may prevent or delay aneurysm occlusion. Also, coverage of a fetal origin PCA risks infarction of a large vascular territory. The purpose of this study was to examine the safety and effectiveness of using the Pipeline Embolization Device (PED) to treat PComA aneurysms associated with a fetal origin PCA. Patients and methodsRetrospective review of PComA aneurysms associated with a fetal origin PCA treated with the PED at two neurovascular centers was performed. Periprocedural complications and clinical and angiographic outcomes were reviewed. ResultsSeven female patients underwent a total of seven PED procedures to treat seven PcomA aneurysms associated with a fetal origin PCA. The symptomatic complication rate was 14% (1/7) per patient and 13% (1/8) per procedure. Angiographic follow up was obtained for 6 of 7 aneurysms. Follow-up DSA at 5–7 months after treatment demonstrated complete occlusion of 17% (1/6) of aneurysms. One aneurysm was retreated with a second PED and occlusion was demonstrated 36 months after the second treatment, yielding an overall complete occlusion rate of 33% (2/6). ConclusionsPED treatment was largely ineffective at treating PComA aneurysms associated with a fetal origin PCA, and should only be considered when conventional treatment options, including microsurgical clipping, are not feasible.

Pipeline Embolization Device for Small Intracranial Aneurysms: Evaluation of Safety and Efficacy in a Multicenter Cohort.

To date, the use of the flow-diverting Pipeline Embolization Device (PED) for small intracranial aneurysms (≤ 7mm) has been reported only in single-center series. To evaluate the safety and efficacy of the PED in a multicenter cohort. Five major academic institutions in the United States provided data on patient demographics, aneurysm features, and treatment characteristics of consecutive patients with aneurysms ≤ 7mm treated with a PED between 2009 and 2015. Radiographic outcome was assessed with digital subtraction angiography. Clinical outcome was measured with the modified Rankin Scale. The cumulative number of aneurysms ≤ 7mm treated with PED at the 5 institutions was 149 in 117 patients (age, 54years [range, 29-87years]; male to female, 1-5.9). Aneurysms were most commonly located in the paraophthalmic segment (67.1%) of the internal carotid artery. Radiographic outcome at last follow-up was available for 123 aneurysms (82.6%), with a complete occlusion rate of 87%. Thromboembolic and symptomatic procedural complications occurred in 8.7% and 6% of the aneurysms treated, respectively. There was 1 mortality (0.9%) unrelated to the PED procedure. Multivariable logistic regression identified size < 4mm, balloon angioplasty to open the device, and simultaneous treatment of multiple aneurysms as predictors of procedural complications. Good clinical outcome was achieved in 96% of electively treated patients. In the largest series on PED for small aneurysms to date, data suggest that treatment with the flow-diverting PED is safe and efficacious, with complication rates comparable to those for traditional endovascular techniques.

Biaxial system using the Benchmark intracranial guide catheter for placement of a Pipeline Embolization Device for intracranial aneurysms.

The Benchmark (Penumbra, Alameda, CA) is a novel intracranial guide catheter that provides optimized proximal stability combined with a hyperflexible and atraumatic tip. We assessed the use of a biaxial catheter system consistent with the Benchmark and Marksman microcatheter for placement of a Pipeline embolization device (PED) for intracranial aneurysms. We reviewed consecutive patients with aneurysms undergoing Pipeline embolization for an aneurysm using the biaxial system from April to October 2015 at a major academic institution in the United States. Benchmark performance was measured by the number of 90° turns the catheter could safely cross. Landing and final positions of the Benchmark were recorded. A total of 26 procedures were performed in 25 patients (mean age 59.5 ± 10.3 years; male:female = 1:4). In one case (3.8%) the biaxial system had to be substituted for a traditional triaxial system. The Benchmark was able to cross one, two, or three 90° turns in 48%, 40%, and 8% of cases, respectively. There was one (3.8%) thromboembolic event and no arterial dissections. In the period from January 2014 to March 2015 and prior to adopting the biaxial system we encountered three thromboembolic events (6.4%) and one (2.1%) dissection potentially related to the triaxial system in 47 PED procedures. Preliminary experience shows that a biaxial system using the Benchmark is a safe and efficacious alternative to the traditional triaxial guide catheter system for placement of PED and may reduce the complexity and duration of the procedure.

P-025 does platelet function testing have a role in patients undergoing pipeline embolization device deployment: Abstract P-025 Table 1

Introduction/purpose There are conflicting reports regarding the utility of platelet function tests in patients undergoing treatment with Pipeline Embolization Device (PED) for intracranial aneurysms. Herein, we report the correlation between platelet function testing and the incidence of complications in a series of patients who underwent PED placement. Unlike prior reports, patient procedures at our institutions were not canceled or postponed based on platelet function tests. Materials and methods A retrospective analysis of the patients with unruptured, intracranial aneurysms treated with PED device (s) at two academic hospitals was performed between June 2012 and March 2015. Patient demographics, location of intracranial aneurysm, size and number of PEDs deployed were documented for each patient. The dual antiplatelet regimen prior to and following PED deployment was documented. All patients received Aspirin 325 mg and Plavix 75 mg daily, 5 days prior to the procedure, and continued the treatment for six months. Platelet function testing was performed on the day of or the day after PED deployment using the VerifyNow (Accumetrics) system for Aspirin (ARU) and P2Y12 Reaction Units (PRU) (Plavix). Therapeutic platelet function testing for Aspirin was defined as an ARU less than 550. PRUs > 70 or Results A total of 39 PEDs were deployed in 32 procedures performed on a total of 27 patients with unruptured, intracranial aneurysms (average age, 55 ± 14 years; 4 (15%) male). There were 3 (9%) procedures in which neither platelet function test was obtained. No procedure was delayed or canceled based on the results of platelet function testing. There were no immediate or delayed thrombotic or hemorrhagic complications. Clinical follow up ranged from 18 days to 2 years post procedure. Conclusion In our experience, the wide range of ARU and PRU values did not have any impact on the incidence of thromboembolic or hemorrhagic complications in the peri-operative or immediate post- operative period. It may be unwise to cancel or postpone PED procedures based on single PRU value measurements, since this can lead to unnecessary cost escalations for the patient and the facility. A well designed randomized control trial may offer the best answer regarding the utility of platelet function testing in the treatment of patients with intra-cranial aneurysms using flow diverters. Disclosures H. Zacharatos: None. D. Sandhu: None. R. Tummala: None. A. Grande: None. B. Jagadeesan: None.

O-005 Frequency of Post-Procedural Diffusion Weighted Imaging Abnormalities and Association with Delayed Ipsilateral Intracerebral Haemorrhages in Patients Undergoing Endovascular Treatment of Cerebral Aneurysms with the Pipeline Embolization Device

PurposeTo determine the frequency and predictors of post-procedural diffusion-weighted-imaging (DWI) abnormalities in patients with cerebral aneurysms treated with the Pipeline Embolization Device (PED).MethodsTwo interventional neuroradiologists reviewed post-procedural MRI examinations performed...

E-039 Safety and Efficacy of Flow Diverter Treatment for Carotid-Ophthalmic Aneurysms

Introduction/purposeThe purpose of this study was to determine the efficacy and safety of flow diversion technology in the treatment of aneurysms of carotid-ophthalmic aneurysms.Materials and methodsThis study retrospectively reviewed outcomes...

P-013 Predicting Mass Effect Exacerbation after Pipeline Embolization of Intracranial Aneurysms

IntroductionIn this study, we investigated the clinical and procedural predictors associated with interval growth manifested as new or worsened mass effect after Pipeline Embolization Device (PED) placement for treatment of...

Use of thromboelastography to tailor dual-antiplatelet therapy in patients undergoing treatment of intracranial aneurysms with the Pipeline embolization device

BackgroundPlatelet function testing is controversial and not well studied in patients with neurovascular disease.ObjectiveTo evaluate the performance of thromboelastography (TEG) as a platelet function test in neurovascular patients treated with...

Abstract W MP31: Thrombotic and Hemorrhagic Complications After Pipeline Embolization - A Platelet Aggregation and Transcranial Doppler Study

In this study, we sought to determine the correlation between the pre-treatment platelet aggregation, and the respective occurrence of thrombotic and hemorrhagic complications after pipeline embolization device (PED) for treatment of intracranial aneurysms. In addition, we evaluated the cerebral hemodynamics and the presence of silent emboli after PED placement in some patients utilizing transcranial Doppler (TCD). Methods: We analyzed the clinical and imaging characteristics of 46 consecutive patients who underwent 48 PED procedures. All patients received double antiplatelet therapy with Clopidogrel 75mg and Aspirin 325mg daily for at least 3 days prior to the planned procedure. Platelet aggregation testing was performed in 41/48 (86%) procedures. Based on the initial ADP % inhibition, patients were divided in 3 groups in the present study: 1) poor responders: &lt;50%, 2) satisfactory responders: 50-75%, and 3) over-responders: &gt; 75% Results: Hemorrhagic complications requiring escalation of care occurred in 15% (7/48) of all procedures, including 3 patients with symptomatic ICH. 2/3 ICHs occurred in a remote vascular territory in reference to the treated aneurysm, one of which was fatal. Thrombotic complications occurred at a rate of 13% (6/48), of which 3 (9%) were symptomatic. Permanent complication-related morbidity and mortality at 6 months was 4% (2/48). Of all patients with available platelet aggregation testing (n=41), 13 (31%) were poor Clopidogrel responders. Of those, 6 were switched to an alternative antiplatelet regimen. Thrombotic complications occurred mostly in the poor responders group who had no change in their regimen (27% vs. 4%; p=0.05). Intracranial hemorrhage occurred entirely in the over-responders group, (0% vs. 14%; p=0.08). None of the TCD demonstrated presence of silent emboli. In addition, 10/11 patients had elevated flow velocities after the PED placement. Conclusions: 1. Pre-treatment Clopidogrel response, measured by ADP % inhibition may predict thrombotic and/or hemorrhagic complications after PED placement. 2. Distal embolization likely occurs mostly during, but not after the procedure as suggested by the TCD data in this study.

Last-Recorded P2Y12 Reaction Units Value Is Strongly Associated with Thromboembolic and Hemorrhagic Complications Occurring Up to 6 Months after Treatment in Patients with Cerebral Aneurysms Treated with the Pipeline Embolization Device

A recent study identified a preprocedural P2Y12 reaction units value of <60 or >240 as a strong independent predictor of perioperative thromboembolic and hemorrhagic complications after treatment of cerebral aneurysms with the Pipeline Embolization Device. This study aimed to determine whether a last-recorded P2Y12 reaction units value of <60 or >240 predicts thromboembolic and hemorrhagic complications up to 6 months after treatment of cerebral aneurysms with the Pipeline Embolization Device in the same patient cohort. We recorded patient and aneurysm characteristics, P2Y12 receptor antagonist administered, P2Y12 reaction units value with VerifyNow, procedural variables, and thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures at our institution during an 8-month period. Complications causing a permanent disabling neurologic deficit or death were considered major. Multivariate regression analysis was performed to identify independent predictors of thromboembolic and hemorrhagic complications. Forty-four patients underwent 48 Pipeline Embolization Device procedures at our institution during the study period. There were 11 thromboembolic and hemorrhagic complications up to 6 months after treatment in our cohort (22.9%), 5 of which were major (10.4%). A last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all (P = .002) and major (P = .03) thromboembolic and hemorrhagic complications in our cohort. Most patients (71%) required, on average, 2 adjustments to the dose or type of P2Y12 receptor antagonist to remain within the 60-240 target P2Y12 reaction units range. In our cohort, a last-recorded P2Y12 reaction units value of <60 or >240 was the only independent predictor of all and major thromboembolic and hemorrhagic complications up to 6 months after Pipeline Embolization Device procedures.

Abstract WMP25: Single-Center Experience with Dual Antiplatelet Therapy Management in Patients Treated with the Pipeline Embolization Device

Purpose: To determine the number of clopidogrel or prasugrel dose adjustments needed and final DAT regimen used to maintain patients undergoing Pipeline Embolization Device (PED) procedures within a target P2Y12 inhibition range. Methods: We recorded the number of clopidogrel or prasugrel dose adjustments, final DAT regimen and thromboembolic and hemorrhagic complications in patients undergoing PED procedures at our institution over an 8-month period. P2Y12 inhibition was measured with VerifyNow 10 and 30 days after dose adjustments (target range 80-200 P2Y12 reaction units). Patients received 325mg aspirin daily. Results: Forty-four patients underwent PED procedures at our institution during the study period, 36 female and 8 male, mean age 59 years (median 63 years, range 31-81 years). Thirteen patients did not require dose adjustments to remain within the target P2Y12 inhibition range (30%). Thirty-one patients required dose adjustments to remain within the target P2Y12 inhibition range (70%), with a mean of 2.1 dose adjustments per patient (median 2, range 1-5), and a mean time from initiation of DAT to last dose adjustment of 47.5 days (median 42 days, range 8-149 days). Four patients exceeded the target P2Y12 inhibition range after a dose adjustment (13%, 3 prasugrel, 1 clopidogrel), without complications. The table summarizes the final DAT regimen and associated major thromboembolic and hemorrhagic complications leading to death or a permanent neurological deficit in our cohort. Most major complications (80%) occurred in patients who were outside the target P2Y12 inhibition range shortly before or at the time of the complication. Conclusion: The majority of patients undergoing PED procedures in our cohort (70%) required an average of 2 clopidogrel or prasugrel dose adjustments to remain within a target P2Y12 inhibition range. Future research is needed to determine if active management of DAT may decrease the risk of major complications after PED procedures.

Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device

BackgroundThere is wide variability in the reported incidence of perioperative thromboembolic (0–14%) and hemorrhagic (0–11%) complications after Pipeline Embolization Device (PED) procedures for cerebral aneurysm treatment, which could be partly...

Early Postmarket Results After Treatment of Intracranial Aneurysms With the Pipeline Embolization Device

The pipeline embolization device (PED) is the latest technology available for intracranial aneurysm treatment. To report early postmarket results with the PED. This study was a prospective registry of patients treated with PEDs at 7 American neurosurgical centers subsequent to Food and Drug Administration approval of this device. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Follow-up data included degree of aneurysm occlusion and delayed (> 30 days after the procedure) complications. Sixty-two PED procedures were performed to treat 58 aneurysms in 56 patients. Thirty-seven of the aneurysms (64%) treated were located from the cavernous to the superior hypophyseal artery segment of the internal carotid artery; 22% were distal to that segment, and 14% were in the vertebrobasilar system. A total of 123 PEDs were deployed with an average of 2 implanted per aneurysm treated. Six devices were incompletely deployed; in these cases, rescue balloon angioplasty was required. Six periprocedural (during the procedure/within 30 days after the procedure) thromboembolic events occurred, of which 5 were in patients with vertebrobasilar aneurysms. There were 4 fatal postprocedural hemorrhages (from 2 giant basilar trunk and 2 large ophthalmic artery aneurysms). The major complication rate (permanent disability/death resulting from perioperative/delayed complication) was 8.5%. Among 19 patients with 3-month follow-up angiography, 68% (13 patients) had complete aneurysm occlusion. Two patients presented with delayed flow-limiting in-stent stenosis that was successfully treated with angioplasty. Unlike conventional coil embolization, aneurysm occlusion with PED is not immediate. Early complications include both thromboembolic and hemorrhagic events and appear to be significantly more frequent in association with treatment of vertebrobasilar aneurysms.

Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections

IntroductionThe purpose of this study was to evaluate the safety and efficacy of the recently available flow diverter “pipeline embolization device” (PED) for the treatment of intracranial aneurysms and dissections.MethodsEighty-eight consecutive patients underwent an endovascular treatment of 101 intracranial aneurysms or dissections using the PED between September 2009 and January 2011. The targeted vessels include 79 (78%) in the anterior circulation and 22 (22%) in the posterior circulation. We treated 96 aneurysms and 5 vessel dissections. Multiple devices were implanted in 67 lesions (66%).ResultsOne technical failure of the procedure was encountered. Immediate exclusion of the target lesion was not observed. Angiographic follow-up examinations were carried out in 80 patients (91%) with 90 lesions and revealed complete cure of the target lesion(s) in 47 (52%), morphological improvement in 32 lesions (36%), and no improvement in 11 lesions (12%). Six major complications were encountered: one fatal aneurysm rupture, one acute and one delayed PED thrombosis, and three hemorrhages in the dependent brain parenchyma.ConclusionOur experience reveals that the PED procedure is technically straightforward for the treatment of selected wide-necked saccular aneurysms, fusiform aneurysms, remnants of aneurysms, aneurysms with a high likelihood of failure with conventional endovascular techniques, and dissected vessels. While vessel reconstruction, performed after dissection, is achieved within days, remodeling of aneurysmal dilatations may take several months. Dual platelet inhibition is obligatory. Parenchymal bleeding into brain areas dependent on the target vessel is uncommon.