Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device

Abstract

Background and purpose: Aneurysm treatment by intrasaccular packing has been associated with a relatively high rate of recurrence. The use of mesh tubes has recently gained traction as an alternative therapy. This article summarizes the midterm results of using an endoluminal sleeve, the PED, in the treatment of aneurysms.

Materials and methods: A total of 19 wide-neck aneurysms were treated in 18 patients: 10 by implantation of PEDs alone and 9 by a combination of PED and coils. Angiographic and clinical results were recorded immediately and at 6 months following treatment.

Results: Immediate angiographic occlusion was achieved in 4 and flow reduction, in another 15 aneurysms. Angiography at 6 months demonstrated complete occlusion in 17 and partial filling in 1 of 18 patients. There was no difference between coil-packed and unpacked aneurysms. Of 28 side branches covered by > or =1 device, the ophthalmic artery was absent immediately in 1 and at 6 months in another 2 cases. One patient experienced abrupt in-stent thrombosis resulting in a transient neurologic deficit, and 1 patient died due to rupture of a coexisting aneurysm. All giant aneurysms treated with PED alone were demonstrated by follow-up cross-sectional imaging to have involuted by 6 months.

Conclusions: Treatment of large, wide-neck, or otherwise untreatable aneurysms with functional reconstruction of the parent artery may be achieved with relative safety using dedicated flow-modifying devices with or without adjunctive use of intrasaccular coil packing.

Fig 1.

Giant cavernous carotid aneurysm, with the patient presenting with third and sixth nerve palsy due to mass effect (patient 16, On-line Table and Tables 1 and 2), treated with flow modification. A, DSA, right ICA injection, oblique posteroanterior view before treatment demonstrates a giant partially thrombosed aneurysm (arrow). B, DSA, right ICA injection, oblique posteroanterior view, immediately following implantation of 3 coaxial PEDs across the neck of the aneurysm, demonstrates significantly reduced flow (arrow). C, Fluoroscopic image demonstrates the implanted PEDs (arrow) and delayed contrast stasis (broken arrow) within the aneurysm. D, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm and reconstruction of the parent artery. E, T2-weighted axial MR image of the same patient before treatment demonstrates the giant ICA aneurysm (arrow) with associated significant mass effect. F, Follow-up MR image at 12 months demonstrates collapse of the aneurysm and resolution of the mass effect.

Fig 2.

Giant infrasupraclinoid aneurysm of the right ICA. The patient presented with loss of vision due to mass effect (patient 13, On-line Table and Tables 1 and 2) and was treated with flow modification with transient thrombosis of the parent artery. A, DSA, right ICA injection, demonstrates bilobulated giant aneurysm (arrows). B, DSA, same view, following implantation of 2 coaxial PEDs, demonstrates partial in-stent thrombosis (arrow). C, DSA, same view, following tirofiban thrombolysis, demonstrates recanalization of the ICA (arrow) and significantly reduced flow within the aneurysm (broken arrow). D, Complete thrombosis of the ICA 2 days later. E, DSA, right vertebral artery injection, demonstrates good collateral circulation toward the right carotid system. No further action was taken at this time. F, Six-month follow-up angiogram demonstrates residual filling of the inferior portion of the aneurysm only (arrow).

Fig 3.

Giant dissecting aneurysm of the basilar trunk in a 16-year-old boy presenting with mass effect and sudden onset of hemiparesis (On-line Table and Tables 1 and 2, patient 18.). A, T1-weighted sagittal MR image demonstrates a basilar trunk aneurysm with mass effect (arrow). B, DSA, left vertebral artery injection, posteroanterior view, demonstrates the aneurysm (arrow). Small arrows demonstrate the origin of both duplicated SCAs; broken arrow demonstrates the origin of the left AICA. C, Fluoroscopic image following the procedure. Large arrows demonstrate the distal (white) and proximal (black) edges of the 5 coaxial PEDs that were used to reconstruct the lumen of the BA. Small arrows demonstrate the SCAs, and the broken arrow demonstrates the AICA, which are both covered by the flow-modifying devices. D, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm and reconstruction of the BA. Small arrows represent the duplicated SCAs, and the broken arrow demonstrates the left AICA. All of them are patent. E, T1-weighted MR image 7 months after treatment demonstrates collapse of the aneurysm and resolution of the mass effect. Signal intensity void due to metal artifacts is seen in the treated section of the BA.

Fig 4.

Results of aneurysm treatment by a combination of flow modification and additional coil packing. A and B, Nine-millimeter-diameter paraophthalmic aneurysm (arrow, B) treated with flow modification and coil packing (patient 3, On-line Table and Tables 1 and 2). C, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm with reconstruction of the parent artery. Arrows demonstrate subtraction artifacts and nonsubtracted view of the coil mass (23.3% volumetric packing attenuation); broken arrow demonstrates a single PED within the ICA.

Fig 5.

Results of aneurysm treatment with flow modification only. A and B, Aneurysm with size and location similar to the one on Fig 4 (10-mm diameter paraophthalmic ICA aneurysm; arrow, B) treated with flow modification only (patient 11, On-line Table and Tables 1 and 2). C, Six-month follow-up angiogram demonstrates complete occlusion of the aneurysm and reconstruction of the parent artery (arrow). D, Arrow represents 3 coaxial PEDs implanted for parent artery reconstruction. No coils were used.