Learning from failure: persistence of aneurysms following pipeline embolization

Maksim Shapiro Departments of Radiology, Bernard and Irene Schwartz Neurointerventional Radiology Section,
Neurology, and

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Tibor Becske Department of Neurology, Rochester General Hospital, Rochester Regional Health System, Rochester, New York

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Peter K. Nelson Departments of Radiology, Bernard and Irene Schwartz Neurointerventional Radiology Section,
Neurosurgery, NYU School of Medicine, New York; and

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OBJECTIVE

A detailed analysis was performed of anterior circulation aneurysms treated with a Pipeline Embolization Device (PED) that did not progress to complete occlusion by 1-year follow-up. Angiography was performed with the purpose of identifying specific factors potentially responsible for these failed outcomes.

METHODS

From among the first 100 patients with anterior circulation aneurysms, 92 underwent 1-year follow-up angiography and were individually studied through review of their pre- and postembolization studies.

RESULTS

Nineteen aneurysms (21%) remained unoccluded at 12 months. Independent predictors of treatment failure, identified by logistic regression analysis, were found to be fusiform aneurysm morphology, decreasing dome-to-neck ratio, and the presence of a preexisting laser-cut stent. Further examination of individual cases identified several common mechanisms—device malapposition, inadequate coverage of the aneurysm neck with persistent exchange across the device, and the incorporation of a branch vessel into the aneurysm fundus—potentially contributing to failed treatment in these settings.

CONCLUSIONS

Attention to specific features of the aneurysm and device construct can frequently identify cases predisposed to treatment failure and suggest strategies to maximize favorable outcomes.

ABBREVIATIONS

ICA = internal carotid artery; MPED = minimally porous endoluminal device; PCoA = posterior communicating artery; PED = Pipeline Embolization Device; PRU = platelet reactivity unit; PUFS = Pipeline for Uncoilable or Failed Aneurysms; ROC = receiver operating characteristic.
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  • 1

    Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, et al.: Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 267:858868, 2013

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  • 2

    Bing F, Darsaut TE, Salazkin I, Makoyeva A, Gevry G, Raymond J: Stents and flow diverters in the treatment of aneurysms: device deformation in vivo may alter porosity and impact efficacy. Neuroradiology 55:8592, 2013

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  • 3

    Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF: Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke 44:442447, 2013

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  • 4

    Chapot R, Mosimann P, Stauder M, Nordneyer H, Velasco A: Patency of a side branch as a factor to explain failure of flow diverters. ABC-WIN 2013 Val d'Isere, France, ABC-WIN, 2013. (Abstract)

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    Ebrahimi N, Claus B, Lee CY, Biondi A, Benndorf G: Stent conformity in curved vascular models with simulated aneurysm necks using flat-panel CT: an in vitro study. AJNR Am J Neuroradiol 28:823829, 2007

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    Fiorella D, Lylyk P, Szikora I, Kelly ME, Albuquerque FC, McDougall CG, et al.: Curative cerebrovascular reconstruction with the Pipeline embolization device: the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg 1:5665, 2009

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  • 7

    Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafé A, Cekirge S, et al.: International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36:108115, 2015

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  • 8

    Makoyeva A, Bing F, Darsaut TE, Salazkin I, Raymond J: The varying porosity of braided self-expanding stents and flow diverters: an experimental study. AJNR Am J Neuroradiol 34:596602, 2013

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  • 9

    Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D: The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 32:3440, 2011

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  • 10

    Puffer RC, Kallmes DF, Cloft HJ, Lanzino G: Patency of the ophthalmic artery after flow diversion treatment of paraclinoid aneurysms. J Neurosurg 116:892896, 2012

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  • 11

    Raz E, Shapiro M, Becske T, Zumofen DW, Tanweer O, Potts MB, et al.: Anterior choroidal artery patency and clinical follow-up after coverage with the Pipeline embolization device. AJNR Am J Neuroradiol 36:937942, 2015

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  • 12

    Shapiro M, Becske T, Riina HA, Raz E, Zumofen D, Jafar JJ, et al.: Toward an endovascular internal carotid artery classification system. AJNR Am J Neuroradiol 35:230236, 2014

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  • 13

    Shapiro M, Raz E, Becske T, Nelson PK: Building multidevice pipeline constructs of favorable metal coverage: a practical guide. AJNR Am J Neuroradiol 35:15561561, 2014

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  • 14

    Shapiro M, Raz E, Becske T, Nelson PK: Variable porosity of the Pipeline embolization device in straight and curved vessels: a guide for optimal deployment strategy. AJNR Am J Neuroradiol 35:727733, 2014

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  • 15

    Vedantam A, Rao VY, Shaltoni HM, Mawad ME: Incidence and clinical implications of carotid branch occlusion following treatment of internal carotid artery aneurysms with the pipeline embolization device. Neurosurgery 76:173178, 2015

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  • 16

    Wang K, Huang Q, Hong B, Li Z, Fang X, Liu J: Correlation of aneurysm occlusion with actual metal coverage at neck after implantation of flow-diverting stent in rabbit models. Neuroradiology 54:607613, 2012

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  • 17

    Wang K, Yuan S: Actual metal coverage at the neck is critical for flow-diverting stents in treating intracranial aneurysms. AJNR Am J Neuroradiol 34:E31E32, 2013

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