Endovascular treatment of fusiform cerebral aneurysms with the Pipeline Embolization Device

Abstract

Object. Despite advances in surgical and endovascular techniques, fusiform aneurysms remain a therapeutic challenge. Introduction of flow-diverting stents has revolutionized the treatment of aneurysms with wide necks and of complex morphology. The authors report their experience with the endovascular treatment of fusiform aneurysms using the Pipeline Embolization Device.Methods. A retrospective review of 146 patients with cerebral aneurysms treated with the Pipeline Embolization Device between June 2011 and January 2013 was performed. Twenty-four patients were identified as having fusiform aneurysms. Twenty-four aneurysms in these 24 patients were treated. The mean patient age was 59 years. There were 9 men and 15 women. Angiographic and clinical data (including the modified Rankin Scale [mRS] score) were recorded at the time of treatment and at follow-up. The aneurysms were located in the internal carotid artery in 8 patients (33.3%), middle cerebral artery in 8 patients (33.3%), anterior cerebral artery in 1 patient (4%), and vertebrobasilar circulation in 7 patients (29%). The aneurysms were smaller than 10 mm in 3 patients, 10-25 mm in 16 patients, and larger than 25 mm in 5 patients. The mean largest dimension diameter was 18 mm.Results. Stent deployment was successful in all cases. The minor procedural morbidity was 4% (1 case). Morbidity and mortality related to aneurysm treatment were 4.2% and 4.2%, respectively. The mean mRS scores preoperatively and at clinical follow-up (median 6.0 months, mean 6.9 months) were 0.71 and 1.2, respectively (91.7% presented with an mRS score of 2 or better, and 79.2% had an mRS score of 2 or better at the 6.0-month follow-up). At clinical follow-up, 82.6% of patients were stable or had improved, 13.0% worsened, and 4.2% had died. Twentytwo (91.7%) of 24 patients had follow-up angiography available (mean follow-up time 6.3 months); 59% had excellent angiographic results (> 95% or complete occlusion), 31.8% had complete aneurysm occlusion, 27.3% had greater than 95% aneurysm occlusion, 18.2% had a moderate decrease in size (50%-95%), 4.5% had a minimal decrease in size (< 50%), 13.6% had not changed, and 4.5% had an increase in size.Conclusions. This series demonstrates that endovascular treatment of fusiform cerebral aneurysms with flow diversion was a safe and effective treatment. Procedural complications were low. Long-term morbidity and mortality rates were acceptable given the complex nature of these lesions.

Pipeline for uncoilable or failed aneurysms: 3-year follow-up results

“…It is important to emphasize that the PUFS results cannot necessarily be generalized to small aneurysms 6,18 or aneurysm in other locations for which the PED has been used, including the ICA terminus, 27 middle cerebral artery, 5,46,48 anterior cerebral artery, and posterior circulation. 1,4,7,10,14,17,[20][21][22][23]28,30,36,41 The incidence of large and giant aneurysms in these locations is relatively rare compared with that in those included in PUFS and the experience using the PED to treat such aneurysms is therefore more limited. Future prospective studies of Pipeline embolization for these indications will be required.…”

Off-label uses of the Pipeline embolization device: a review of the literature

“…Monteith and colleagues reviewed 24 cases of fusiform aneurysms treated with the PED. 52 They found the procedure-related minor morbidity and mortality rates to be 4.2% and 4.2%, respectively, and found major complications in 16.7% of their patients. At their latest follow-up, 59% of patients had ≥ 95% aneurysm occlusion.…”

Flow Diverter Therapy With the Pipeline Embolization Device Is Associated With an Elevated Rate of Delayed Fluid-Attenuated Inversion Recovery Lesions

“…In addition, multiple recent reports have touted the utility of the PED for its ability to easily treat previously challenging aneurysms with high occlusion rates and low complication rates. [2][3][4][5][6][7][8][9][10][11] Furthermore, cost-effectiveness studies have seemed to demonstrate that flow diversion may provide cost savings when compared with standard stent-assisted coil techniques and that a greater benefit is found in large or giant aneurysms. [12][13][14] Therefore, many centers have trended toward the liberal utilization of this technology in both on-and off-label applications of the device.…”