Mid-term follow-up of staged bilateral internal carotid artery aneurysm treatment with Pipeline embolization

Abstract

Background: Endovascular treatment of large complex morphology aneurysms is challenging. High recanalization rates have been reported with techniques such as stent-assisted coiling and balloon-assisted coiling. Flow diverter devices have been introduced to improve efficacy outcomes and recanalization rates. Thromboembolic complications and in-device stenosis are certainly more worrisome when treatment of bilateral internal carotid arteries has been performed. This study aimed to report our experience with mid-term imaging follow-up of staged bilateral Pipeline embolization device placement for the treatment of bilateral internal carotid artery aneurysms.

Methods: We reviewed the clinical, angiographic, and follow-up imaging data in all consecutive patients treated with bilateral internal carotid artery aneurysms who underwent elective Pipeline embolization.

Results: Six female patients were treated, harboring a total of 13 aneurysms. Of these, 60% were asymptomatic. Diplopia and headache were the most common symptoms. The most common location was the paraclinoid segment (6/13), including by cavernous segment (4/13) and ophthalmic segment (2/13). Successful delivery of the device was achieved in 12 cases. Difficult distal access precluded the deployment of the device in one case. The treatment was always staged with at least eight weeks' difference between the two procedures. All aneurysm necks were covered completely. There were no periprocedural complications. Angiographic follow-up ranged between 3 and 12 months, and computed tomography angiogram follow-up ranged between 2 and 24 months. Complete aneurysm occlusion was achieved in all cases.

Conclusion: In our series, Pipeline deployment for the treatment of bilateral internal carotid artery aneurysms in a staged fashion is safe and feasible. Mid-term imaging follow-up showed permanent occlusion of all the treated aneurysms.

Keywords: Complex intracranial aneurysms; Pipeline embolic device; endovascular treatment; flow diverter.

Figure 1.

(a) and (b) Three-dimensional and lateral digital subtraction angiography (DSA) of a complex carotid-ophthalmic aneurysm taken before treatment. (c) Lateral usubstracted catheter angiogram, lateral projection following placement of the Pipeline embolization device (PED). (d) Lateral DSA at two-month follow-up shows no evidence of aneurysm contrast filling.

Figure 2.

(a)–(c) Lateral DSA of a large dorsal paraclinoid internal carotid artery (ICA) aneurysm. Unsubtracted images showing pre- and postoperative changes of PED embolization with contrast stagnation in the sac. (d) and (e) Lateral DSA taken immediately after surgery and at six-month follow-up. Image shows contrast stagnation and complete resolution of the aneurysm, respectively.

Figure 3.

(a)–(c) Lateral DSA of symptomatic large right cavernous aneurysm. The PED was placed. However, there was proximal migration in the aneurysmal sac due to severe vessel tortuosity. A second PED was deployed with proximal stent migration. (d)–(g) Lateral and AP unsubtracted angiographic images. A third PED was placed, completing the construct and covering the neck of the aneurysm. Satisfactory contrast stagnation in the aneurysmal sac is demonstrated.

Figure 4.

Carotid ophthalmic aneurysm. (a)(b) Lateral DSA at the three-month follow-up and unsubtracted images showing severe symptomatic supraclinoid ICA stenosis due to intimal hyperplasia. (c)(d) Balloon angioplasty was performed with the Scepter XC balloon, with improvement in the caliber of the vessel at the end of the procedure. (e) and (f) Lateral DSA and unsubtracted images 12 months post procedure show only minimal narrowing and intimal hyperplasia. The patient is asymptomatic.