Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device

Abstract

Background and purpose: The Pipeline Embolization Device was reported to be safe and effective in the treatment of sidewall aneurysms, preserving the patency of the vessels covered by the construct. However, to date, the safety and efficacy of this device in treating bifurcation aneurysms remains unknown. We report our preliminary experience with the use of the Pipeline Embolization Device in the management of MCA aneurysms located at the bifurcations, including mid- and long-term follow-up data.

Materials and methods: Wide-neck MCA aneurysms, which give rise to a bifurcating or distal branch in which other endovascular techniques are thought to be unfeasible or more risky, were included. Data including demographics, aneurysm features, antiplatelet therapy, complications, and angiographic follow-up results for up to 30 months were recorded.

Results: Twenty-five aneurysms located at the MCA bifurcation (n = 21) or distal (n = 4) were treated. Of these, 22 were small and 3 were large. A single device was used in all but 2. No deaths occurred in the series. All patients had at least 1 control angiographic study, 21 of which were DSA (3-30 months), which showed that 12 of the rising branches were patent whereas 6 were filling in reduced caliber and 3 were occluded asymptomatically. According to the last angiographic follow-up, complete occlusion was revealed in 21 of 25 aneurysms (84%).

Conclusions: The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky.

Fig 1.

Occlusion process of right MCA bifurcation aneurysm. A and B, Preoperative 3D reconstruction and DSA images show the early bifurcating branch originating from the aneurysm sac. C and D, Six-month control angiogram and 3D image demonstrate the “remodeled artery.” E and F, Eighteen-month control angiogram and 3D image show the complete occlusion of the aneurysm with the bifurcating branch filling in reduced caliber.

Fig 2.

Occlusion stages of left MCA bifurcation aneurysm. A, DSA image shows the aneurysm giving rise to superior trunk. B, Fluoroscopic image shows the deployment of the PED in the inferior trunk. C and D, Early and late phases of 6-month control angiogram demonstrate the reduced and delayed filling of the aneurysm sac with the significant stagnation. Bifurcating branch is also filling belated in reduced caliber. E and F, Early and late phases of 6-month control angiogram (lateral view) show reduced filling of the superior trunk with retrograde filling of the distal branches through pial collaterals. G, One-year control angiogram demonstrates the remodeled superior trunk. The superior trunk and its branches are still filling in reduced caliber. H, Eighteen-month control angiogram shows complete occlusion of the aneurysm, with the superior trunk coming to its original size. I, Thirty-month control angiogram shows the stable occlusion of the aneurysm with the patency of the bifurcating branch (note the carotid cave aneurysm in A, treated with PED as well).

Fig 3.

Recanalized left MCA bifurcation aneurysm. A, Preoperative angiogram shows recanalization of the aneurysm previously treated by use of balloon-assisted coiling. Inferior trunk is emanating from the neck. B, Nonsubtracted image shows the PED placed within the superior trunk. C, Six-month control angiogram shows the remodeled inferior trunk (arrowhead). The “healing zone” appears as the “interruption” between the remodeled artery and bifurcation (arrow).