Failure of Flow Diverter Treatment of Intracranial Aneurysms Related to the Fetal-type Posterior Communicating Artery

Abstract

Purpose: The pipeline embolization device (PED) is a flow diverter that has shown promise in the treatment of intracranial aneurysms. Close to one-fifth of aneurysms, however, fail to occlude after PED placement. This study aims to identify anatomical features and clinicopathologic factors that may predispose failed aneurysm occlusion with the PED.

Materials and methods: We retrospectively reviewed all anterior circulation unruptured saccular aneurysms treated with the PED in a single-center. The primary outcome measure was angiographic occlusion. Anatomical features and potential predictors, including gender, aneurysm location, size, height, aspect ratio, neck width, prior treatment and the number of PED, were studied using binary logistic regression.

Results: 29 anterior circulation unruptured saccular aneurysms with a mean size of 6.99 mm treated with the PED in a single center were retrospectively studied. The overall occlusion rate was 79.3% after a mean follow-up of 9.2 months. Four aneurysms were related to the fetal-type posterior communicating artery (PComA), and all were refractory to flow diverter treatment. Female gender was significantly associated with a higher occlusion rate. We present the anatomical features and propose possible pathophysiological mechanisms of these PComA aneurysms that failed flow diverter treatment.

Conclusion: A PComA aneurysm with persistent fetal-type circulation appears to be particularly refractory to flow diverter treatment, especially when the aneurysm incorporates a significant portion of the PComA. Our experience suggested that flow diverting stents alone may not be the ideal treatment for this subgroup of aneurysms, and alternative modalities should be considered. Female patients were found to have a significantly higher rate of treatment success.

Keywords: Fetal circulation; Flow diverters; Intracranial aneurysm; Outcome; Pipeline embolization device.

Fig. 1. Patient 1. (A) Pre-treatment digital subtraction angiography showing the fetal-type posterior communicating artery circulation (long arrow) and aneurysm (arrow); (B) curve reformation of the post-treatment CTA showed that the right PComA IA was receiving persistent supply from the fetal PComA (arrow).

Fig. 2. Patient 2.(A) Pre-treatment computer tomography angiography showing the right posterior communicating artery (PComA) aneurysm remnant (long arrow), which was previously treated with four GDC coils, and the atrophic right P1 segment (arrowhead) associated with fetal-type; (B) control DSA showing persistent supply to the aneurysm despite coverage with PED (black arrow).

Fig. 3. Patient 3. (A) Pre-treatment magnetic resonance angiography showing the left-sided aneurysm (long arrow), and the atrophic right P1 segment (arrow head) associated with fetal-type circulation; (B) pre-treatment digital subtraction angiography showing that the aneurysm received supply from both the internal carotid artery and the fetal posterior communicating artery; (C) digital subtraction angiography performed six months after the placement of one pipeline device showing persistent contrast filling of the slightly enlarged aneurysm with evidence of coil compaction.