Use of Coils in Conjunction With the Pipeline Embolization Device for Treatment of Intracranial Aneurysms

Lin, Ning; Brouillard, Adam M.; Krishna, Chandan; Mokin, Maxim; Natarajan, Sabareesh K.; Sonig, Ashish; Snyder, Kenneth V.; Levy, Elad I.; Siddiqui, Adnan H.

doi:10.1227/neu.0000000000000579

Cited by 109 publications

(73 citation statements)

References 24 publications

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“…Certain authors have advocated coil embolization as a method of improving occlusion rates and minimizing the potential for catastrophic aneurysm rupture following the use of flow-diverting stents. 23,25,26 Others have argued that the addition of coil embolization to the procedure yields no significant added advantage in regard to treatment efficacy. 21 However, our single-center results, which have been previously presented, did identify a statistically significant increase in the need for retreatment with a strategy of PED alone versus PED/coil.…”

Section: Discussionmentioning

confidence: 99%

“…1,2,4,13,15,16,[18][19][20][21] The addition of coil embolization to flow diversion, while prevalent in daily use, has not been subjected to a large systematic analysis. [7][8][9][10][11]16,[21][22][23][24] The earliest case report hypothesized that coils within the aneurysm sac can augment the degree of flow diversion with the goal of improved occlusion of the aneurysm. 1 Others believe that adjunctive coil embolization does little to improve the already high occlusion rates obtained by using the Pipeline Embolization Device (PED; Covidien, Irvine, California) alone.…”

mentioning

confidence: 99%

“…In a recent series published by Lin et al, 23 75 patients treated with the PED alone were compared with 29 patients treated with the PED and adjunctive coil embolization. There was no statistically significant difference in the complication rates between the 2 groups (10.3% with PED/coil versus 8.0% with PED alone, P ϭ .7).…”

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confidence: 99%

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Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry

Park

Kilburg

Taussky

et al. 2016

AJNR Am J Neuroradiol

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SUMMARY: Flow diversion to treat cerebral aneurysms has revolutionized neurointerventional surgery. Because the addition of coils potentially increases the time and complexity of endovascular procedures, we sought to determine whether adjunctive coil use is associated with an increase in complications. Patients in the International Retrospective Study of Pipeline Embolization Device registry were divided into those treated with the Pipeline Embolization Device alone (n ϭ 689 patients; n ϭ 797 aneurysms; mean aneurysm size, 10.3 Ϯ 7.6 mm) versus those treated with the Pipeline Embolization Device and concurrent coil embolization (n ϭ 104 patients; n ϭ 109 aneurysms; mean aneurysm size, 13.6 Ϯ 7.8 mm). Patient demographics and aneurysm characteristics were examined. Rates of neurologic morbidity and mortality were compared between groups. The Pipeline Embolization Device with versus without coiling required a significantly longer procedure time (135.8 Ϯ 63.9 versus 96.7 Ϯ 46.2 min; P Ͻ .0001) and resulted in higher neurological morbidity (12.5% versus 7.8%; P ϭ .13). These data suggest that either strategy represents an acceptable risk profile in the treatment of complex cerebral aneurysms and warrants further investigation.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

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Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry

Park

Kilburg

Taussky

et al. 2016

AJNR Am J Neuroradiol

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“…7 Typically, braided flow diverters such as the PED foreshorten significantly during and often even after deployment. Because fusiform aneurysms are larger than the largest diameter of these devices and involve long segments of affected vessels, the tendency to foreshorten is increased.…”

Section: Adjunctive Coilingmentioning

confidence: 99%

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

Natarajan

Lin

Sonig

et al. 2016

JNS

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102

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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.

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“…Coils are often used as an adjunct to enhance embolization of giant aneurysms with PED; they may additionally function as a scaffold or to provide support for the PED to prevent migration/foreshortening. 22 We have also had experience using self-expanding stents to augment the wall apposition and outward radial force of flow diverters at either end in cases of giant aneurysms, which may also prevent migration. 20,30 As one of the causes discussed is a short landing zone, we recommend generous neck coverage proximally and distally as a way to prevent foreshortening.…”

Section: Preventionmentioning

confidence: 99%

Prolapse of the Pipeline embolization device in aneurysms: incidence, management, and outcomes

Srinivasan¹,

Carlson

Mokin

et al. 2017

Neurosurgical Focus

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OBJECTIVEThe Pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, the PED has its own unique technical challenges, including the occurrence of device foreshortening or migration leading to prolapse into the aneurysm. The authors sought to determine the incidence of this phenomenon, the rescue strategies, and outcomes.METHODSFour institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with PEDs. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases involving device prolapse into the aneurysm.RESULTSA total of 413 intracranial aneurysms were treated with PEDs during the study period, by 5 neurointerventionalists. Large and giant aneurysms (≥ 2 cm) accounted for 32 of these aneurysms. Among these 32 PEDs, prolapse into the aneurysm occurred in 3 patients, with 1 of these PEDs successfully rescued and the other 2 left in situ. No patients suffered any severe complications. The 2 patients in whom the PEDs were left in situ remained on antiplatelet therapy.CONCLUSIONSThe PED may foreshorten or migrate during or after deployment, leading to prolapse into the aneurysm. This phenomenon appears to be associated with large and giant aneurysms, vessel tortuosity, short landing zones, and use of balloon angioplasty. Future study and follow-up is needed to further evaluate this phenomenon, but some of the observations and techniques described in this paper may help to prevent or salvage prolapsed devices.

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Use of Coils in Conjunction With the Pipeline Embolization Device for Treatment of Intracranial Aneurysms

Abstract: PED+coils may be a safe and effective treatment for aneurysms with high risk of rupture (or rerupture) and complex anatomy. Coiling in conjunction with PED placement provided a higher aneurysm occlusion rate and reduced the need for retreatment.

Cited by 109 publications

References 24 publications

Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry

Pipeline Embolization Device with or without Adjunctive Coil Embolization: Analysis of Complications from the IntrePED Registry

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

Prolapse of the Pipeline embolization device in aneurysms: incidence, management, and outcomes

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