The Pipeline: Less is More, Slower is Better, and Smaller is Possible
Background and Purpose:Despite experience gained with the Pipeline Embolization Device (PED), the following remain unclear: the significance of intra-procedural aneurysm occlusion after PED placement, if PED’s should be used for treatment of smaller aneurysms, and whether multiple PED’s are needed to achieve occlusion.
Methods: Between October 2009 and December 2015, 299 patients, with 342 aneurysms distributed at the internal carotid artery and posterior circulation underwent PED embolization by a single team. Data was collected prospectively and analyzed retrospectively. A new metric assessing flow into the aneurysm following PED placement was created: the Post Stenting Flow Scale (PSFs). It ranges from 0 (no residual flow) to 3 (no significant change in flow). Clinical complications, as well as aneurysm occlusion rates and their predictors, were calculated.
Results: The overall peri-procedural clinical complication rate was 18/299 (6%) including 2.7% mortality. All mortality occurred in the giant and fusiform groups. Predictors of clinical complication were aneurysm location (posterior vs. anterior circulation) and the use of multiple PED’s. Clinical complications were more common in fusiform and giant aneurysms 15/168 (9%) than in other aneurysms 3/131 (2.2%). PSFs of 0 was a predictor of vascular complications. Occlusion rate was 77%. PSFs was its only significant predictor.
Conclusions: Using a single PED for aneurysm embolization is enough. Rapid and total occlusion of the aneurysm following PED deployment is an ominous sign and warrants clinical attention. Expanding the use of PED’s to treat smaller aneurysms located at the internal carotid artery appears to be a valid strategy.
Chalouhi N, Tjoumakaris S, Phillips JL, et al. A single pipeline embolization device is sufficient for treatment of intracranial aneurysms. AJNR.2014, 35:1562-6
Lin N, Brouillard AM, Krishna C, et al. Use of coils in conjunction with the pipeline embolization device for treatment of intracranial aneurysms. Neurosurgery. 2015, 76:142-9
Kallmes DF, Hanel R, Lopes D, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR. 2015, 36:108-15
Briganti F, Leone G, Marseglia M, et al. Endovascular treatment of cerebral aneurysms using flow-diverter devices: A systematic review. NeuroradiolJ. 2015, 28:365-75
Nelson PK, Lylyk P, Szikora I, et al. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR. 2011, 32:34-40
Lylyk P, Miranda C, Ceratto R, et al. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery. 2009, 64:632-42
Fischer S, Vajda Z, Aguilar Perez M, et al. Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2012, 54:369-82
McAuliffe W, Wenderoth JD. Immediate and midterm results following treatment of recently ruptured intracranial aneurysms with the pipeline embolization device. AJNR. 2012, 33:487-493
Nossek E, Chalif DJ, Chakraborty S, et al. Concurrent use of the Pipeline Embolization Device and coils for intracranial aneurysms: technique, safety, and efficacy. J Neurosurg. 2015, 122:904-11
Moshayedi H, Omofoye OA, Yap E, et al. Factors affecting the obliteration rate of intracranial aneurysms treated with a single Pipeline Embolization Device. World Neurosurg. 2017, 104:205-212
Yu SC, Kwok CK, Cheng PW, et al. Intracranial aneurysms: midterm outcome of pipeline embolization device--a prospective study in 143 patients with 178 aneurysms. Radiology. 2012, 265:893-901
McLaughlin N, McArthur DL, Martin NA. Use of stent assisted coil embolization for the treatment of wide-necked aneurysm: a systematic review. Surg Neurol Int. 2013, 4:43
Shapiro M, Becske T, Sahlein D, et al. Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. AJNR. 2012, 33:159-63
Fiorella D, Albuquerque FC, Woo H, et al. Neuroform stent assisted aneurysm treatment: evolving treatment strategies, complications and results of long term follow-up. J Neurointerv Surg. 2010, 2:16-22
Piotin M, Blanc R, Spelle L, et al. Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke. 2010, 41:110-5
Chalouhi N, Starke RM, Yang S, et al. Extending the indications of flow diversion to small, unruptured, saccular aneurysms of the anterior circulation. Stroke. 2014, 45:54-8
Geyik S, Yavuz K, Yurttutan N, et al. Stent-assisted coiling in endovascular treatment of 500 consecutive cerebral aneurysms with long-term follow-up. AJNR. 2013, 34:2157-62.
Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004, 364:331-7
Flow Diversion in Intracranial Aneurysm Treatment (FIAT). clinicaltrials.gov. http://clinicaltrials.gov/ct2/show/nct01349582. Accessed November 12, 2017
LARGE Aneurysm Randomized Trial: Flow Diversion Versus Traditional Endovascular Coiling Therapy. Clinicaltrials.gov. http://clinicaltrials.gov/ct2/show/NCT01349582. Accessed November 12, 2017
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