Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results

Abstract

Background and purpose: Flow-diverting devices now offer a new treatment alternative for cerebral aneurysms. We present the results of a large single-center series of patients treated with the PED, including long-term follow-up.

Materials and methods: Between November 2008 and September 2011, sidewall aneurysms with a wide neck (≥4 mm) or unfavorable dome-neck ratio (≤1.5); large/giant, fusiform, dissecting, blister-like, and recurrent sidewall aneurysms; aneurysms at difficult angles; and aneurysms in which a branch was originating directly from the sac were treated with the PED. Patients were premedicated with dual antiplatelet medications. Data, including demographics, aneurysm features, clinical presentation, complications, results, and follow-up information, for up to 2 years are presented.

Results: Two hundred fifty-one aneurysms in 191 patients were treated. Of these, 96 (38.3%) were large or giant (≥10 mm). In 34/251 (13.5%), PEDs were used for retreatment. Adjunctive coiling was performed in 11 aneurysms (2.1%). The mean number of devices per aneurysm was 1.3. One aneurysm ruptured in the fourth month posttreatment (0.5%), and symptomatic in-construct stenosis was detected in 1 patient (0.5%) treated with percutaneous transarterial angioplasty. Any event rate was 27/191 (14.1%), with a permanent morbidity of 1% and mortality of 0.5%. Control angiography was available in 182 (95.3%) patients with 239 (95.2%) aneurysms. In 121 aneurysms (48.2%), 1- to 2-year control angiography was available. The aneurysm occlusion rate was 91.2% in 6 months, increasing to 94.6%.

Conclusions: Use of the PED is safe, efficacious, and durable in cerebral aneurysm treatment, with low morbidity-mortality and high occlusion rates as confirmed with mid- to long-term control angiography.

Fig 1.

Preoperative 3D angiogram (A) shows a very wide-neck large ICA aneurysm. It could be reconstructed with several overlapping devices, creating a new vessel wall within the sac as seen on the perioperative DynaCT image (B). Postoperative CT obtained the same evening (C) reveals ipsilateral frontal intraparenchymal hemorrhage. 2D (D) and 3D (E) views of 6-month control angiography demonstrate the reconstruction of the parent artery and total occlusion of the aneurysm.

Fig 2.

Lateral angiogram shows a giant dissecting ICA aneurysm (A). The intraoperative view demonstrates PEDs (sizes, 4 × 20² and 4.5 × 16 mm) opening to the normal size of the parent artery at the dissected segment (arrow in A) without necessitating balloon angioplasty. Note the contrast stagnation within the sac (B). Six-month control angiography (C) shows total occlusion of the aneurysm and reconstruction of the parent artery.

Fig 3.

Left vertebral angiogram (A) demonstrates the left PCA aneurysm, which presented with left thalamic infarct (not shown). Immediate postoperative view (B) shows the single PED (2.5 × 20 mm) placed in the left PCA, resulting in contrast stasis within the sac. Control angiography (C) after 6 months confirms total occlusion of the aneurysm with the PCA preserved.

Fig 4.

3D image (A) and lateral angiography (B) show a left paraophthalmic bleb aneurysm in a patient who had a subarachnoid hemorrhage 3 months earlier. Lateral angiogram 6 months after placement of a single PED of 3.75 × 12 mm (C) demonstrates complete occlusion of the aneurysm.

Fig 5.

Right carotid angiogram (A) demonstrates a small carotid cave aneurysm in a patient who had an anterior communicating artery aneurysm previously treated with coiling following SAH. Six-month control angiography (B) shows occlusion of the aneurysm.

Fig 6.

Preoperative 2D (A and B) angiograms show the ICA aneurysm in which the anterior choroidal artery is originating from the aneurysm at the neck. A single PED is placed covering the neck, causing stagnation of the contrast within the sac (C). Six-month control angiography (D) demonstrates total occlusion of the aneurysm with the anterior choroidal artery preserved (arrow).

Fig 7.

Right internal carotid oblique angiogram (A) shows a right posterior communicating artery aneurysm (the ipsilateral P1 is aplastic and not shown) in a patient in whom previous endovascular attempts and clipping had failed, with surgical wrapping performed eventually. Two years after a single PED placement, the aneurysm is remodeled in the corresponding view (B).