Experience With the Pipeline Embolization Device for Posterior Circulations Aneurysms: A Multicenter Cohort Study

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>BACKGROUND</jats:title> <jats:p>The Pipeline Embolization Device (PED; Medtronic) has been used off-label for the treatment of challenging posterior circulation aneurysms. Data on this modality are primarily limited to small retrospective single-center series.</jats:p> </jats:sec> <jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>To assess safety and efficacy of this treatment by establishing an international, multicenter collaboration.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Consecutive posterior circulation aneurysms treated with the PED from 2012 to 2019 across 11 neurovascular centers were retrospectively reviewed. Baseline demographics, aneurysm and treatment characteristics, complications, occlusion status, and functional outcome were assessed.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>There were 149 posterior circulation aneurysms treated with PED in 146 patients. A total of 24 (16.4%) patients presented with subarachnoid hemorrhage. Most aneurysms were dissecting/blister (36.2%) in morphology, followed by saccular (35.6%) and fusiform (28.2%). The most common locations were the vertebral (51.7%) and basilar arteries (22.8%). Complete or near-complete occlusion (&amp;gt;90%) was achieved in 90.9% of aneurysms at a median follow-up of 12 mo. Dissecting/blister aneurysms were most likely to occlude (P = .06). Symptomatic neurologic complications occurred in 9.4% of aneurysms, associated with larger size, ruptured presentation, presentations with brain stem compression, cranial nerve palsy, or stroke. Favorable functional outcome (modified Rankin Score 0-2) was achieved in 86.2% of patients. There were 6 fatalities of which 4 occurred in aneurysmal subarachnoid hemorrhage patients.</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSION</jats:title> <jats:p>This multicenter study shows that PED for the treatment of posterior circulation is preferentially used for the treatment of fusiform and dissecting/blister aneurysm morphologies. Despite the challenges presented by these less-common morphologies, flow diversion may be performed with a neurologic complication rate of about 10% and favorable long-term aneurysm occlusion rates.</jats:p> </jats:sec>

Endovascular Treatment of Large or Giant Basilar Artery Aneurysms Using the Pipeline Embolization Device: Complications and Outcomes

“…The PED is another treatment option in patients with complex posterior circulation aneurysms. Use of the PED can achieve better outcomes than surgical or other endovascular techniques ( 6 , 7 ). To our knowledge, our study is the largest one to date that has examined PED treatment of large or giant BA aneurysms.…”

“…The mean time to complete occlusion overall confirmed by the first imaging was 10.0 ± 1.1 months (range, 4. [5][6][7][8][9][10][11][12][13][14][15][16][17][18]. The mean time to complete occlusion confirmed by the first imaging was significantly longer in fusiform aneurysms than saccular aneurysms (12.1 ± 3.9 months vs. 7.1 ± 3.5 months; p = 0.036).…”

“…In the treatment of large or giant aneurysms, Pipeline embolization device (PED; Medtronic, Minneapolis, MN, USA) treatment has a much higher success rate than other endovascular techniques. In addition, the PED enables treatment of fusiform or complex aneurysms that were previously considered untreatable (6,7). As experience with flow diverters (FDs) has increased, off-label use of the PED for treatment of posterior circulation aneurysms has become more common (7)(8)(9); however, safety and efficacy data for PED treatment of large or giant BA aneurysms are lacking.…”

Anterior Circulation Fusiform Aneurysms Have a Lower Occlusion Rate After Pipeline Embolization Device Treatment Than Posterior Circulation Fusiform Aneurysms: A Multicenter Cohort Study

“…In a study by Griessenauer et al of 131 PC aneurysms with a median follow-up time of 9 months, the occlusion rate of 53 fusiform aneurysms was 59.7% ( 19 ). In a recent study by Griessenauer et al in 149 PC aneurysms, including 42 fusiform aneurysms, with a median follow-up time of 12 months, the occlusion rate was 91.3% ( 20 ). Bhogal and colleagues reported 56 PC non-saccular aneurysms, including 24 fusiform aneurysms, with 75% aneurysm occlusion at the last follow-up of 25.2 months ( 21 ).…”

Vertebral artery dissection and associated ruptured intracranial pseudoaneurysm successfully treated with coil assisted flow diversion

“…[ 7 8 9 ] There is a growing body of literature highlighting the successful treatment of dolichoectasia, fusiform aneurysms, and intracranial dissections with FD. [ 10 11 12 13 14 15 16 17 18 19 ] However, significant debate remains in relation to their application in the setting of subarachnoid hemorrhage (SAH). [ 12 20 21 ] FD stents require at least 6 months of dual-antiplatelet therapy (DAPT) to allow for endothelialization, which has limited their utility in the setting of acute hemorrhage.…”