The Pipeline Embolization Device for the treatment of posterior circulation fusiform aneurysms: lessons learned at a single institution

Clinical article

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  • Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
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Object

Vertebrobasilar fusiform aneurysms (VFAs) are rare lesions characterized by abnormal dilation and tortuosity of the vertebral and/or basilar arteries. Untreated, these aneurysms have a tendency to progress, often resulting in neurological symptoms or rupture leading to subarachnoid hemorrhage. The microsurgical treatment of these lesions can be difficult due to their location and the circumferential involvement of the arteries. These features make microsurgical treatment prone to high morbidity. The Pipeline Embolization Device (PED) has gained popularity for the treatment of aneurysms of the internal carotid artery. Its use in the posterior circulation has been limited, likely due to a fear of perforating artery occlusion.

Methods

The authors retrospectively reviewed their database of patients treated with the PED and identified 12 patients who had VFAs. The clinical features, complications, and outcomes of these patients were analyzed.

Results

At an average follow-up of 11 months, the mean modified Rankin Scale score was 1.9. Complete aneurysm occlusion was seen in 90% of the patients with radiographic follow-up. Three patients suffered new neurological deficits postoperatively. One of these patients died, while the remaining 2 demonstrated significant clinical improvement at follow-up.

Conclusions

With attention to the anatomy of perforating arteries, staged contralateral vertebral artery sacrifice, and adequate platelet inhibition, PED may be an effective treatment option—alone or in a hybrid construct with stents of less coverage for VFAs—with an acceptable complication rate.

Abbreviations used in this paper:

AICA = anterior inferior cerebellar artery; DSA = digital subtraction angiography; MRA = MR angiography; mRS = modified Rankin Scale; PED = Pipeline Embolization Device; PRU = P2Y12 reaction unit; SAH = subarachnoid hemorrhage; VFA = vertebrobasilar fusiform aneurysm.

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