Pipeline embolization device for recurrence of previously treated aneurysms

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The utilization of the Pipeline embolization device (PED) has increased significantly since its inception and original approval for use in large, broad-necked aneurysms of the internal carotid artery. While microsurgical clipping and advances in endovascular techniques have improved overall efficacy in achieving complete occlusion, recurrences still occur, and the best modality for retreatment remains controversial. Despite its efficacy in this setting, the role of PED utilization in the setting of recurrent aneurysms has not yet been well defined. This study was designed to assess the safety and efficacy of PED in the recurrence of previously treated aneurysms.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors reviewed a total of 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following prior treatment with another modality. The PEDs were used to treat aneurysm recurrence or residual following endovascular coiling in 7 cases, flow diversion in 2, and microsurgical clipping in 4. The mean time between initial treatment and retreatment with a PED was 28.1 months, 12 months, and 88.7 months, respectively. Clinical outcomes, including complications and modified Rankin Scale (mRS) scores, and angiographic evidence of complete occlusion were tabulated for each treatment group.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>All PEDs were successfully placed without periprocedural complications. The rate of complete occlusion was 80% at 6 months after PED placement and 100% at 12 months in these patients who underwent PED placement following failed endovascular coiling; there were no adverse clinical sequelae at a mean follow-up of 26.1 months. In the 2 cases in which PEDs were placed for treatment of residual aneurysms following prior flow diversion, 1 patient demonstrated asymptomatic vessel occlusion at 6 months, and the other exhibited complete aneurysm occlusion at 12 months. In patients with aneurysm recurrence following prior microsurgical clipping, the rate of complete occlusion was 100% at 6 and 12 months, with no adverse sequelae noted at a mean clinical follow-up of 27.7 months.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The treatment of recurrent aneurysms with the PED following previous endovascular coiling, flow diversion, or microsurgical clipping is associated with a high rate of complete occlusion and minimal morbidity.</jats:p></jats:sec>

Pipeline Embolization for Salvage Treatment of Previously Stented Residual and Recurrent Cerebral Aneurysms

“…Fischer et al[7] reported a patient with large dissecting MCA aneurysm initially treated with coaxial Enterprise and Solitaire stents and subsequently treated with 2 PED who developed severe headaches postprocedurally and was found to have aneurysm thrombosis on DSA and scattered MCA territory diffusion restriction on MRI. Asymptomatic parent vessel occlusion has been observed on routine follow-up DSA in the present series and by others [19], although it is unclear whether this is related to the stent construct, proximal dissection, or otherwise. Reports abound of ischemic symptoms following the cessation of dual antiplatelet therapy, whether at 6 weeks after procedure [7], 18 months [18], or 4 years, as in our case.…”

“…One of these patients (33%) died secondary to in-stent thrombosis after clopidogrel was stopped 13 months after retreatment. Dornbos et al[19] reported 2 retreatments of previously flow-diverted aneurysms with residual filling. One case (50%) developed asymptomatic ICA occlusion at 6-month digital subtraction angiography (DSA), while complete aneurysm occlusion was achieved in the other case at 17 months (50%).…”

Factors affecting recurrence and management of recurrent cerebral aneurysms after initial coiling

“…Currently, flow diversion as an option for recurrent aneurysms following prior coil embolization has been shown to be an effective approach in small series. [29][30][31][32] In 2017, Dornbos et al 29 reported 13 cases in which patients underwent secondary placement of a PED for aneurysm recurrence following endovascular coiling in seven cases, Fow diversion in two, and microsurgical clipping in four. They found that the rate of complete occlusion was 80% at six months after PED placement and 100% at 12 months in patients undergoing failed endovascular coiling.…”

Management of recurrent aneurysms after endovascular coiling: A Fujita experience

“…In this scenario, a second EC is an option in the management with most of the recurrences. With the advances in the endovascular technique, many recurrent aneurysms have been managed effectively with stenting/stent-assisted[141516] coiling as well as pipeline embolization[17] devices, but this expertise may not be available in all centers and not all aneurysms are suitable for this type of intervention by virtue of its unfavorable anatomical configuration, namely, wider neck and mass effect. Moreover, stent-assisted coiling has been shown to be associated with more complications[18] as well as recurrences[1920] in view of the dual antiplatelets therapy required for long-term patency.…”