Flow diversion for posterior circulation aneurysms performed using the Pipeline embolization device (PED) constitutes an increasingly common off-label use for otherwise untreatable aneurysms. The safety and efficacy of this treatment modality has not been assessed in a multicenter study.
A retrospective review of prospectively maintained databases at 8 academic institutions was performed for the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement.
A total of 129 consecutive patients underwent 129 procedures to treat 131 aneurysms; 29 dissecting, 53 fusiform, and 49 saccular lesions were included. At a median follow-up of 11 months, complete and near-complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms, whereas minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than did clopidogrel nonresponders. The majority of dissecting aneurysms were treated in the immediate or acute phase following subarachnoid hemorrhage, a circumstance that contributed to the highest mortality rate in those aneurysms.
In the largest series to date, fusiform aneurysms were found to have the lowest occlusion rate and the highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had a low complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel nonresponders.
Correspondence Ajith J. Thomas: Beth Israel Deaconess Medical Center, Harvard University, Boston, MA. email@example.com.
INCLUDE WHEN CITING Published online May 4, 2018; DOI: 10.3171/2017.9.JNS171376.
Disclosures Dr. Cognard is a consultant for Medtronic, Stryker, and MicroVention. Dr. Levy has direct stock ownership in Intratech Medical, Ltd., NeXtGen Biologics, and Neuravi (sold the latter in April 2017). He is a consultant for Pulsar Vascular. He is receiving an honorarium for training and lectures for Covidien, and he serves on the advisory board for Abbott Vascular, Stryker, NeXtGen Biologics, MEDX, and Cognition Medical. Dr. Pereira is a consultant for Stryker, Medtronic, Balt, and Phenox. Dr. Siddiqui is a consultant for Covidien as well as for the following companies: Amnis Therapeutics, Ltd.; Cerebrotech Medical Systems, Inc.; CereVasc, LLC; Claret Medical, Inc.; Codman; Corindus, Inc.; GuidePoint Global Consulting; Medtronic; MicroVention; Neuravi; Penumbra; Pulsar Vascular; Rapid Medical; Rebound Therapeutics Corp.; Silk Road Medical; Stryker; The Stroke Project, Inc.; Three Rivers Medical, Inc.; and W.L. Gore & Associates. He has direct stock ownership in the following companies: Buffalo Technology Partners, Inc.; Cardinal Health; International Medical Distribution Partners; Medina Medical Systems; Neuro Technology Investors; StimMed; and Valor Medical. He is on the Advisory Board of the Intersocietal Accreditation Commission. He is Principal Investigator (PI)/National Steering Committee for 3D Separator Trial, COMPASS Trial, and INVEST Trial (Penumbra); PI/National Steering Committee for SWIFT PRIME and SWIFT DIRECT Trials (Medtronic); PI/National Steering Committee for FRED Trial and CONFIDENCE Study (MicroVention); and PI/National Steering Committee for LARGE Trial (Codman & Shurtleff). Dr. Thomas is on the Data Safety Monitoring Board of the SCENT flow diverter trial.
BhogalPPérezMAGanslandtOBäznerHHenkesHFischerS: Treatment of posterior circulation non-saccular aneurysms with flow diverters: a single-center experience and review of 56 patients. J Neurointervent Surg9:471–4812017
Delgado AlmandozJECrandallBMScholzJMFeaseJLAndersonREKadkhodayanY: Last-recorded P2Y12 reaction units value is strongly associated with thromboembolic and hemorrhagic complications occurring up to 6 months after treatment in patients with cerebral aneurysms treated with the pipeline embolization device. AJNR Am J Neuroradiol35:128–1352014
GuptaRMooreJMGriessenauerCJAdeebNPatelASYounR: Assessment of dual-antiplatelet regimen for Pipeline Embolization Device placement: a survey of major academic neurovascular centers in the United States. World Neurosurg96:285–2922016
MolyneuxAKerrRStrattonISandercockPClarkeMShrimptonJ: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet360:1267–12742002
MunichSATanLAKeigherKMChenMMoftakharRLopesDK: The Pipeline Embolization Device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution. J Neurosurg121:1077–10842014
NatarajanSKLinNSonigARaiATCarpenterJSLevyEI: The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center. J Neurosurg125:111–1192016
RaychevRTateshimaSVinuelaFSayreJJahanRGonzalezN: Predictors of thrombotic complications and mass effect exacerbation after pipeline embolization: The significance of adenosine diphosphate inhibition, fluoroscopy time, and aneurysm size. Interv Neuroradiol22:34–412016