Predictive factors of incomplete aneurysm occlusion after endovascular treatment with the Pipeline embolization device

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OBJECTIVE

The Pipeline embolization device (PED) is a routine choice for the endovascular treatment of select intracranial aneurysms. Its success is based on the high rates of aneurysm occlusion, followed by near-zero recanalization probability once occlusion has occurred. Therefore, identification of patient factors predictive of incomplete occlusion on the last angiographic follow-up is critical to its success.

METHODS

A multicenter retrospective cohort analysis was conducted on consecutive patients treated with a PED for unruptured aneurysms in 3 academic institutions in the US. Patients with angiographic follow-up were selected to identify the factors associated with incomplete occlusion.

RESULTS

Among all 3 participating institutions a total of 523 PED placement procedures were identified. There were 284 procedures for 316 aneurysms, which had radiographic follow-up and were included in this analysis (median age 58 years; female-to-male ratio 4.2:1). Complete occlusion (100% occlusion) was noted in 76.6% of aneurysms, whereas incomplete occlusion (≤ 99% occlusion) at last follow-up was identified in 23.4%. After accounting for factor collinearity and confounding, multivariable analysis identified older age (> 70 years; OR 4.46, 95% CI 2.30–8.65, p < 0.001); higher maximal diameter (≥ 15 mm; OR 3.29, 95% CI 1.43–7.55, p = 0.005); and fusiform morphology (OR 2.89, 95% CI 1.06–7.85, p = 0.038) to be independently associated with higher rates of incomplete occlusion at last follow-up. Thromboembolic complications were noted in 1.4% and hemorrhagic complications were found in 0.7% of procedures.

CONCLUSIONS

Incomplete aneurysm occlusion following placement of a PED was independently associated with age > 70 years, aneurysm diameter ≥ 15 mm, and fusiform morphology. Such predictive factors can be used to guide individualized treatment selection and counseling in patients undergoing cerebrovascular neurosurgery.

ABBREVIATIONS IQR = interquartile range; mRS = modified Rankin Scale; PED = Pipeline embolization device; POD = postoperative day.

Article Information

Correspondence Ajith J. Thomas: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. athomas6@bidmc.harvard.edu.

INCLUDE WHEN CITING Published online April 26, 2019; DOI: 10.3171/2019.1.JNS183226.

Disclosures Dr. Kan is a consultant for Stryker Neurovascular and Medtronic Covidien. Drs. Maragkos and Ascanio are recipients of research financial support from Medtronic Inc., Cerebrovascular Group. Dr. Thomas is on the data safety monitoring board of Stryker; funds are paid to his institution.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Age-related variation in the rate of complete occlusion following intracranial aneurysm treatment with the PED. In the horizontal axis, patients have been split into age groups (≤ 40 years, 41–50, 51–60, 61–70, and > 70 years). In the vertical axis are the percentages of incomplete occlusion for each age group.

  • View in gallery

    Size-related variation in the rate of complete occlusion following intracranial aneurysm treatment with the PED. In the horizontal axis, aneurysms have been split into groups of increasing size (maximum diameter ≤ 5.0 mm, 5.1–10.0, 10.1–15.0, 15.1–20.0, and > 20.0 mm). In the vertical axis are the percentages of incomplete occlusion for each aneurysm size group.

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