Long-term outcomes and dynamic changes of in-stent stenosis after Pipeline embolization device treatment of intracranial aneurysms

Abstract

BackgroundFlow diverters have revolutionized the treatment of intracranial aneurysms. However, the delayed complications associated with flow diverter use are unknown.ObjectiveTo evaluate the incidence, severity, clinical outcomes, risk factors, and dynamic changes associated with in-stent stenosis (ISS) after treatment with a Pipeline embolization device (PED).MethodsPatients who underwent PED treatment between 2015 and 2020 were enrolled. The angiographic, clinical, and follow-up data of 459 patients were independently reviewed by four neuroradiologists to identify ISS. Binary logistic regression was conducted to determine ISS risk factors, and an ISS–time curve was established to demonstrate dynamic changes in ISS after PED implantation.ResultsOf the 459 treated patients, 69 (15.0%) developed ISS. At follow-up, nine patients (2.0%) with ISS demonstrated reversal, while 18 (3.9%) developed parental artery occlusion. A total of 380 patients (82.8%) achieved complete aneurysm occlusion (O’Kelly–Marotta grade D). Patients with posterior-circulation aneurysm (OR=2.895, 95% CI (1.732 to 4.838; P<0.001) or balloon angioplasty (OR=1.992, 95% CI 1.162 to 3.414; P=0.037) were more likely to develop ISS. Patients aged >54 years (OR=0.464, 95% CI 0.274 to 0.785; P=0.006) or with a body mass index of >28 kg/m2(OR=0.427, 95% CI 0.184 to 0.991; P=0.026) had a lower ISS risk. Intimal hyperplasia initiated by PED placement peaked within 1 year after the procedure, rarely progressed after 12 months, and tended to reverse within 24 months.ConclusionsISS is a common, benign, and self-limiting complication of PED implantation in the Chinese population.

Safety and efficacy analysis of the off-label use of pipeline embolization devices for intracranial aneurysms: a propensity score matching study

“…Previous studies have suggested that posterior circulation aneurysms may have a higher complication rate ( 22 , 23 ). However, no serious ischemic events occurred in the 16 cases of posterior circulation aneurysms included in the present study, possibly because of the strict administration of antiplatelet therapy before and after surgery.…”

“…ISS is a common outcome after stent implantation. According to a recent study, PED-induced intimal hyperplasia reaches its pinnacle within 1 year and resolves within 2 years ( 22 ). Chalouhi et al reported that during an average follow-up period of 6.7 months, 15.8% ( n = 22) of patients developed stenosis within the stent, with 11 patients developing mild stenosis and 11 developing moderate-to-severe stenosis (>50%).…”

“…Strictures that develop within stents after implantation have been identified as benign anatomical changes that result from intravascular intimal hyperplasia. Patients with such stenoses generally remain asymptomatic and may exhibit a degree of improvement in imaging over a certain follow-up period ( 10 , 22 ). Therefore, excessive clinical intervention to manage this condition may be unnecessary.…”

In-stent stenosis after stenting the PulseRider for a middle cerebral artery aneurysm: A case report

“…ISS is a relatively well-known complication of coronary artery disease treatment, with an incidence of 10%-50% [3] . Furthermore, ISS is a frequently delayed complication after endovascular treatment with a flow diverter, occurring in 15%-39% of patients receiving flow diverter stenting [4] . However, little is known about the mechanism underlying ISS formation.…”

“…Recent reports have suggested that ISS leads to complete blood vessel occlusion, although it rarely causes serious symptoms y [4] . Gui et al.…”