The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center

Abstract

OBJECT Pessimism exists regarding flow diversion for posterior circulation aneurysms because of reports of perforator territory infarcts and delayed ruptures. The authors report the results of patients who underwent Pipeline Embolization Device (PED) flow diversion using novel strategies for treatment of fusiform posterior circulation aneurysms, and compare these results with those from previously reported series. METHODS The authors conducted a retrospective review of data from consecutive patients with fusiform vertebrobasilar artery aneurysms treated with the PED. RESULTS This review resulted in the identification of 12 such patients (mean [± SD] age 55.1 ± 14.1 years). Eleven patients had symptoms; 1 had a dissecting aneurysm identified on imaging for neck pain. The average aneurysm size was 13.25 ± 4.5 mm. None of the aneurysms were ruptured or previously treated. The average clinical follow-up duration was 22.1 ± 10.7 months and radiological follow-up was 14.5 ± 11.1 months from the index PED treatment. One patient suffered a perforator stroke and had a modified Rankin Scale (mRS) score of 4 at last follow-up. Another patient had a retained stent pusher requiring retrieval via surgical cut-down but recovered to an mRS score of 0 at last follow-up. Eleven (91.7%) of 12 patients recovered to an mRS score of 0 or 1. Two patients had aneurysmal remnants at 7 and 10 months, respectively, after the index PED, which were retreated with PEDs. At last follow-up, all 12 aneurysms were occluded and PEDs were patent. The minimum follow-up duration was 12 months from the index PED treatment; no patient experienced delayed hemorrhage, stroke, or in-stent stenosis. CONCLUSIONS Flow diversion with selective adjunctive techniques is evolving to become a safer treatment option for posterior circulation aneurysms. This is the longest clinical follow-up duration reported for a single-center experience of flow-diversion treatment of these aneurysms.

Meta-analysis of treatment outcomes of posterior circulation non-saccular aneurysms by flow diverters

“…In a study of seven patients undergoing flow diversion for treatment of non-saccular posterior circulation aneurysms, Siddiqui et al demonstrated remarkably high mortality (57%) and thromboembolic complications (72%) with correspondingly low rates of favorable neurologic outcomes (29%). 22 17 However, in a subsequent study performed at the same institution, Natarajan et al used more refined selection criteria—namely, the avoidance of holobasilar aneurysms, or aneurysms with a large amount of thrombus—and reported 0% mortality, 8% thromboembolic complication rate, and 92% good neurologic outcomes 9. Indeed, in the present study, the rate of good neurologic outcome in the holobasilar aneurysm group (2/11, 13%) was lower than other locations (33–83%).…”

Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion

“…27 Eleven (90%) of 12 patients recovered to a modified Rankin Scale score of 0 or 1 after a clinical follow-up duration of 22 months, with only 1 patient experiencing a perforator territory infarction with poor clinical outcome (modified Rankin Scale Score 4). At last follow-up, the complete occlusion rate was 100%, and the PEDs were patent.…”

Pipeline for previously stented basilar trunk aneurysm: a case focusing on how the pipeline should be deployed

“…This deployment modality has an additional benefit to lower post procedural ischemia of brain stem, which was quietly frequently noted both in single-layer or multi-layers' flow-diverted cases [10]. Applying this technique, only one PED was used and the perforators were directly covered by the high-porous stent instead of a PED, so the post procedure ischemia rate might be of minimal concern; this might be the account for why our patient recovered from the procedure without any neurologic deficits.…”