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

Abstract

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.

Pipeline embolization device for recurrence of previously treated aneurysms

“…Nonetheless, placement of a PED as a secondary treatment following failure of endovascular coiling has a reported efficacy of 69%-93.3%, 2,5,9,11,14,18,20,21 although many of these studies pooled initial treatments into a single cohort for evaluation. The only studies evaluating the outcome of PED placement in this specific subgroup of recurrent aneurysms in isolation (Table 3) revealed a complete obliteration of 76.7% 9 and 69.2%.…”

“…5,8,14,16,[19][20][21] While this has been described in numerous reports, 3 published studies directly evaluated the safety and efficacy of PED in this subset of recurrent aneurysms (Table 3). In achieving complete aneurysm occlusion, reported efficacy ranged from 38% to 65%, a significantly lower rate than would be expected in PED use for treatment-naïve aneurysms.…”

“…In achieving complete aneurysm occlusion, reported efficacy ranged from 38% to 65%, a significantly lower rate than would be expected in PED use for treatment-naïve aneurysms. 8,14,16 The incidence of significant adverse neurological sequelae tends to be substantially higher for previously stented aneurysms as well. Such sequelae, including transient ischemic attacks and major ischemic and hemorrhagic events, were observed in 8%-14.3% of cases.…”

Patency of the Anterior Choroidal Artery after Flow-Diversion Treatment of Internal Carotid Artery Aneurysms

“…[1][2][3][4] Flow diverters limit aneurysmal blood flow but maintain blood flow into large vessels and perforating vessels covered by the device. 5 Although many in vitro and experimental models have demonstrated long-term patency rates of branch vessels covered by the PED, the long-term patency of major branch vessels is not well-established.…”

Mid-Term Outcome Following Pipeline Embolization of Unruptured Intracranial Aneurysms

“…There is no clear protocol to delineate the duration and dosage of antiplatelet therapy to decrease the risk of in-stent thrombosis and stenosis. Very few cases of in-stent thrombosis are reported after PED insertion with the majority being less than 50% (5,8,17). One major concern about PED is the risk of aneurysm rupture in the latency period before total aneurysm occlusion (18).…”