The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center

Sabareesh K. Natarajan Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo;
Department of Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo;

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Ning Lin Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo;
Department of Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo;
Department of Neurosurgery, Weill Cornell Medical College, New York City, New York;

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Ashish Sonig Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo;
Department of Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo;

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Ansaar T. Rai Department of Radiology, West Virginia University, Morgantown, West Virginia;

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Jeffrey S. Carpenter Department of Radiology, West Virginia University, Morgantown, West Virginia;

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Elad I. Levy Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo;
Department of Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo;
Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;
Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo; and

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Adnan H. Siddiqui Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo;
Department of Neurosurgery, Gates Vascular Institute/Kaleida Health, Buffalo;
Department of Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York;
Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo; and
Jacobs Institute, Buffalo, New York

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OBJECT

Pessimism exists regarding flow diversion for posterior circulation aneurysms because of reports of perforator territory infarcts and delayed ruptures. The authors report the results of patients who underwent Pipeline Embolization Device (PED) flow diversion using novel strategies for treatment of fusiform posterior circulation aneurysms, and compare these results with those from previously reported series.

METHODS

The authors conducted a retrospective review of data from consecutive patients with fusiform vertebrobasilar artery aneurysms treated with the PED.

RESULTS

This review resulted in the identification of 12 such patients (mean [± SD] age 55.1 ± 14.1 years). Eleven patients had symptoms; 1 had a dissecting aneurysm identified on imaging for neck pain. The average aneurysm size was 13.25 ± 4.5 mm. None of the aneurysms were ruptured or previously treated. The average clinical follow-up duration was 22.1 ± 10.7 months and radiological follow-up was 14.5 ± 11.1 months from the index PED treatment. One patient suffered a perforator stroke and had a modified Rankin Scale (mRS) score of 4 at last follow-up. Another patient had a retained stent pusher requiring retrieval via surgical cut-down but recovered to an mRS score of 0 at last follow-up. Eleven (91.7%) of 12 patients recovered to an mRS score of 0 or 1. Two patients had aneurysmal remnants at 7 and 10 months, respectively, after the index PED, which were retreated with PEDs. At last follow-up, all 12 aneurysms were occluded and PEDs were patent. The minimum follow-up duration was 12 months from the index PED treatment; no patient experienced delayed hemorrhage, stroke, or in-stent stenosis.

CONCLUSIONS

Flow diversion with selective adjunctive techniques is evolving to become a safer treatment option for posterior circulation aneurysms. This is the longest clinical follow-up duration reported for a single-center experience of flow-diversion treatment of these aneurysms.

ABBREVIATIONS

AICA = anterior inferior cerebellar artery; BA = basilar artery; CTA = CT angiography; DSA = digital subtraction angiography; MRA = MR angiography; mRS = modified Rankin scale; PCA = posterior cerebral artery; PED = Pipeline Embolization Device; PICA = posterior inferior cerebellar artery; PRU = P2Y12 reactivity unit; VA = vertebral artery; VB = vertebrobasilar; VBJ = VB junction.
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