Flow diversion requires neointimal stent overgrowth to deliver aneurysm occlusion. The existing literature on aneurysm occlusion is limited by heterogeneous follow-up, variable antiplatelet regimens, noninvasive imaging modalities, and nonstandard occlusion assessment. Using a large, single-center cohort with low attrition and standardized antiplatelet tapering, the authors evaluated outcomes after flow diversion of anterior circulation aneurysms to identify predictors of occlusion and aneurysm persistence.
Data from a prospective, IRB-approved database was analyzed for all patients with anterior circulation aneurysms treated by flow diversion with the Pipeline embolization device (PED) at the authors’ institution. Follow-up consisted of catheter cerebral angiography at 6 and 12 months postembolization. Clopidogrel was discontinued at 6 months and aspirin was reduced to 81 mg daily at 12 months. Occlusion was graded as complete, trace filling, entry remnant, or aneurysm filling. Multivariate logistic regression was performed to identify predictors of aneurysm persistence.
Follow-up catheter angiography studies were available for 445 (91%) of 491 PED procedures performed for anterior circulation aneurysms between August 2011 and August 2016. Three hundred eighty-seven patients accounted for these 445 lesions with follow-up angiography. The population was 84% female; mean age was 56 years and mean aneurysm size was 6.6 mm. Aneurysms arose from the internal carotid artery (83%), anterior cerebral artery (13%), and middle cerebral artery (4%). Morphology was saccular in 90% of the lesions, and 18% of the aneurysms has been previously treated. Overall, complete occlusion was achieved in 82% of cases at a mean follow-up of 14 months. Complete occlusion was achieved in 72%, 78%, and 87% at 6, 12, and 24 months, respectively. At 12 months, adjunctive coiling predicted occlusion (OR 0.260, p = 0.036), while male sex (OR 2.923, p = 0.032), aneurysm size (OR 3.584, p = 0.011), and incorporation of a branch vessel (OR 2.206, p = 0.035) predicted persistence. Notable variables that did not predict aneurysm occlusion were prior treatments, vessel of origin, fusiform morphology, and number of devices used.
This is the largest single-institution study showing high rates of anterior circulation aneurysm occlusion after Pipeline embolization. Predictors of persistence after flow diversion included increasing aneurysm size and incorporated branch vessel, whereas adjunctive coiling predicted occlusion.
INCLUDE WHEN CITING Published online March 30, 2018; DOI: 10.3171/2017.11.JNS171738.
M.T.B. and G.P.C. share first authorship of this work.
Disclosures A.L.C. is a consultant and proctor for Medtronic, Stryker, Microvention, and Sequent and is a consultant for InNeruroCo. G.P.C. receives research support from Medtronic and Stryker and is a consultant for Microvention. L.M.L. receives research support from Microvention and Stryker and is a consultant for Medtronic. J.H. owns stock in LONGEVITI.
AttaliJBenaissaASoizeSKadziolkaKPortefaixCPierotL: Follow-up of intracranial aneurysms treated by flow diverter: comparison of three-dimensional time-of-flight MR angiography (3D-TOF-MRA) and contrast-enhanced MR angiography (CE-MRA) sequences with digital subtraction angiography as the gold standard. J Neurointerv Surg8:81–862016
BecskeTBrinjikjiWPottsMBKallmesDFShapiroMMoranCJ: Long-term clinical and angiographic outcomes following Pipeline Embolization Device treatment of complex internal carotid artery aneurysms: five-year results of the Pipeline for Uncoilable or Failed Aneurysms trial. Neurosurgery80:40–482017
BeitzkeMLeberKADeutschmannHGattringerTPoltrumBFazekasF: Cerebrovascular complications and granuloma formation after wrapping or coating of intracranial aneurysms with cotton gauze and human fibrin adhesives: results from a single-center patient series over a 5-year period. J Neurosurg119:1009–10142013
BenderMTLinLMColbyGPLubelskiDHuangJTamargoRJ: P2Y12 hyporesponse (PRU>200) is not associated with increased thromboembolic complications in anterior circulation Pipeline. J Neurointerv Surg9:978–9812017
BrinjikjiWLanzinoGCloftHJSiddiquiAHBoccardiECekirgeS: Risk factors for ischemic complications following Pipeline Embolization Device treatment of intracranial aneurysms: results from the IntrePED Study. AJNR Am J Neuroradiol37:1673–16782016
BurkhardtJKChuaMHJWeissMDoASSWinklerEALawtonMT: Risk of aneurysm residual regrowth, recurrence, and de novo aneurysm formation after microsurgical clip occlusion based on follow-up with catheter angiography. World Neurosurg106:74–842017
ChiuAHYCheungAKWenderothJDDe VilliersLRiceHPhatourosCC: Long-term follow-up results following elective treatment of unruptured intracranial aneurysms with the Pipeline Embolization Device. AJNR Am J Neuroradiol36:1728–17342015
ColbyGPBenderMTLinLMBeatyNCaplanJMJiangB: Declining complication rates with flow diversion of anterior circulation aneurysms after introduction of the Pipeline Flex: analysis of a single-institution series of 568 cases. J Neurosurg[epub ahead of print January 12 2018. DOI: 10.3171/2017.7.JNS171289]
FischerSVajdaZAguilar PerezMSchmidEHopfNBäznerH: Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology54:369–3822012
KallmesDFBrinjikjiWCekirgeSFiorellaDHanelRAJabbourP: Safety and efficacy of the Pipeline embolization device for treatment of intracranial aneurysms: a pooled analysis of 3 large studies. J Neurosurg127:775–7802017
LinLMColbyGPKimJEHuangJTamargoRJCoonAL: Immediate and follow-up results for 44 consecutive cases of small (<10 mm) internal carotid artery aneurysms treated with the pipeline embolization device. Surg Neurol Int4:1142013
LinzeyJRGriauzdeJGuanZBentleyNGemmeteJJChaudharyN: Stent-assisted coiling of cerebrovascular aneurysms: experience at a large tertiary care center with a focus on predictors of recurrence. J Neurointerv Surg9:1081–10852017
LylykPMirandaCCerattoRFerrarioAScrivanoELunaHR: Curative endovascular reconstruction of cerebral aneurysms with the Pipeline embolization device: the Buenos Aires experience. Neurosurgery64:632–643 N62009
McAuliffeWWycocoVRiceHPhatourosCSinghTJWenderothJ: Immediate and midterm results following treatment of unruptured intracranial aneurysms with the Pipeline Embolization Device. AJNR Am J Neuroradiol33:164–1702012
MoshayediHOmofoyeOAYapEOyekunleTOSasaki-AdamsDMSolanderSY: Factors affecting the obliteration rate of intracranial aneurysms treated with a single Pipeline embolization device. World Neurosurg104:205–2122017
SaatciIYavuzKOzerCGeyikSCekirgeHS: Treatment of intracranial aneurysms using the Pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol33:1436–14462012