Parent vessel occlusion after Pipeline embolization of cerebral aneurysms of the anterior circulation

Restricted access

OBJECTIVE

The Pipeline Embolization Device (PED) is now a well-established option for the treatment of giant or complex aneurysms, especially those arising from the anterior circulation. Considering the purpose of such treatment is to maintain patency of the parent vessel, postembolization occlusion of the parent artery can be regarded as an untoward outcome. Antiplatelet therapy in the posttreatment period is therefore required to minimize such events. Here, the authors present a series of patients with anterior circulation aneurysms treated with the PED who subsequently experienced parent vessel occlusion (PVO).

METHODS

The authors performed a retrospective review of all anterior circulation aneurysms consecutively treated at a single institution with the PED through 2014, identifying those with PVO on follow-up imaging. Aneurysm size and location, number of PEDs used, and follow-up digital subtraction angiography results were recorded. When available, pre- and postembolization platelet function testing results were also recorded.

RESULTS

Among 256 patients with anterior circulation aneurysms treated with the PED, the authors identified 8 who developed PVO after embolization. The mean aneurysm size in this cohort was 22.3 mm, and the number of PEDs used per case ranged from 2 to 10. Six patients were found to have asymptomatic PVO discovered incidentally on routine follow-up imaging between 6 months and 3 years postembolization, 3 of whom had documented “delayed” PVO with prior postembolization angiograms confirming aneurysm occlusion and a patent parent vessel at an earlier time. Two additional patients experienced symptomatic PVO, one of which was associated with early discontinuation of antiplatelet therapy.

CONCLUSIONS

In this large series of anterior circulation aneurysms, the authors report a low incidence of symptomatic PVO, complicating premature discontinuation of postembolization antiplatelet or anticoagulation therapy. Beyond the subacute period, asymptomatic PVO was more common, particularly among complex fusiform or very large–necked aneurysms, highlighting an important phenomenon with the use of PED for the treatment of anterior circulation aneurysms, and suggesting that extended periods of antiplatelet coverage may be required in select complex aneurysms.

ABBREVIATIONS ICA = internal carotid artery; MCA = middle cerebral artery; MPED = minimally porous endoluminal device; PED = Pipeline Embolization Device; PRU = platelet reactivity units; PVO = parent vessel occlusion.

Article Information

Correspondence Matthew B. Potts, Departments of Neurological Surgery and Radiology, Division of Cerebrovascular/Neurointerventional Surgery, Northwestern University Feinberg School of Medicine, 676 N St. Clair St., Ste. 2210, Chicago, IL 60611. email: mpotts@nm.org.

INCLUDE WHEN CITING Published online January 6, 2017; DOI: 10.3171/2016.9.JNS152638.

Disclosures Drs. Shapiro, Becske, and Nelson report that they are consultants for Medtronic.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 1. Case example of a 72-year-old male presenting with headache and visual complaints who was found to have a large right paraophthalmic ICA aneurysm (A and B). The neck of the aneurysm measured 17.6 mm with a dome of 9.2 mm. The patient underwent Pipeline embolization using 2 telescoping PEDs. He remained neurologically stable on completion of the procedure. Several hours later, the patient developed right hemiplegia and aphasia. An emergency cerebral angiogram was obtained, which demonstrated occlusion of the left ICA just past the ophthalmic artery (E). Mechanical thrombectomy and thrombolysis was performed to recanalize his left ICA but the patient developed a left frontal infarct. A: Preembolization digital subtraction (DS) angiogram of the left ICA in the lateral projection, showing a giant paraophthalmic segment aneurysm. B: 3D rotational angiography of the left ICA further characterizing the aneurysm's broad neck. C and D: Immediate postembolization angiograms of the left ICA in native (C) and unsubtracted (D) views showing the Pipeline construct and contrast stagnation within the aneurysm sac. E: Postembolization DS angiogram obtained after the patient developed right hemiplegia, showing occlusion of the left ICA just above the ophthalmic artery. F: Right ICA DS angiogram showing inadequate cross-filling through the anterior communicating artery. G: Postthrombectomy/thrombolysis DS angiogram of the left ICA showing restored flow through the ICA. Note the significantly reduced filling of the aneurysm compared with the immediate postembolization DS angiogram (*). H: Noncontrast head CT scan obtained 3 days after the patient's embolization and parent vessel occlusion, demonstrating cortical and subcortical infarction within the left frontal lobe.

  • View in gallery

    Case 2. Case example of a 70-year-old female presenting with cranial nerve III and VI palsies of the right eye who was found to have a giant right cavernous ICA aneurysm. The neck of the aneurysm measured 12 mm with a dome of 32 mm. The patient underwent Pipeline embolization using 4 telescoping PEDs. Due to vessel stenosis within the proximal ICA, balloon dilation was performed during embolization. A: Preembolization DS angiogram of the right ICA in a left anterior oblique projection showing a giant cavernous segment ICA aneurysm. The region of ICA stenosis proximal to the aneurysm can be seen. B and C: Immediate postembolization angiogram of the right ICA in native (B) and subtracted (C) views showing stagnation of contrast within the aneurysm sac. D: Six-month follow-up DS angiogram of the right ICA showing complete occlusion of the aneurysm with only minimal intimal hyperplasia within the Pipeline construct. E: One-year follow-up DS angiogram of the right common carotid artery (CCA) showing complete occlusion of the proximal right ICA. F and G: Five-year follow-up DS angiogram of the right CCA (F) and left ICA (G) showing persistent complete occlusion of the right ICA with collateral filling of the right hemisphere through the anterior communicating artery.

  • View in gallery

    Case 6. Case example of a 30-year-old female presenting with headache and left facial pain who was found to have a giant left petrous ICA aneurysm with a 36-mm neck and 21-mm dome. Pipeline embolization with 10 telescoping PEDs was performed. A: Preembolization DS angiogram showing a large left petrous ICA aneurysm. B: Immediate postembolization control DS angiogram showing contrast stagnation within the aneurysm dome. C and D: Six-month (not shown) and 1-year (C, unsubtracted; and D, subtracted) follow-up DS angiograms both show complete aneurysm occlusion with only minimal intimal hyperplasia within the Pipeline construct. E: Three-year follow-up DS angiogram of the left CCA showing complete occlusion of the left ICA with persistent complete aneurysm occlusion. F–H: Three-year follow-up DS angiogram of the right ICA (F), left vertebral artery (G), and left external carotid artery (H) showing collateral filling of the left hemisphere through the anterior communicating artery (F), posterior communicating arteries (G), and the left ophthalmic artery via multiple branches of the left external carotid artery (H).

References

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 6 6 6
Full Text Views 290 290 8
PDF Downloads 228 228 3
EPUB Downloads 0 0 0

PubMed

Google Scholar