Pipeline embolization of posterior circulation aneurysms: a multicenter study of 131 aneurysms

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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS BA = basilar artery; DSA = digital subtraction angiography; ISUIA = International Study of Unruptured Intracranial Aneurysms; mRS = modified Rankin Scale; PCA = posterior cerebral artery; PCoA = posterior communicating artery; PED = Pipeline embolization device; PICA = posterior inferior cerebellar artery; SAH = subarachnoid hemorrhage; VA = vertebral artery.

Article Information

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

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.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Artist’s renderings of posterior circulation aneurysm morphology: dissecting (A), fusiform (B), and saccular (C). Copyright Christoph Griessenauer. Published with permission. Figure is available in color online only.

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