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Research ArticleExpedited Publication

Treatment of Intracranial Aneurysms Using the Pipeline Flow-Diverter Embolization Device: A Single-Center Experience with Long-Term Follow-Up Results

I. Saatci, K. Yavuz, C. Ozer, S. Geyik and H.S. Cekirge
American Journal of Neuroradiology September 2012, 33 (8) 1436-1446; DOI: https://doi.org/10.3174/ajnr.A3246
I. Saatci
aFrom the Neurointerventional Section, Department of Radiology, Hacettepe University Hospital, Sihhiye, Ankara, Turkey.
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K. Yavuz
aFrom the Neurointerventional Section, Department of Radiology, Hacettepe University Hospital, Sihhiye, Ankara, Turkey.
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C. Ozer
aFrom the Neurointerventional Section, Department of Radiology, Hacettepe University Hospital, Sihhiye, Ankara, Turkey.
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S. Geyik
aFrom the Neurointerventional Section, Department of Radiology, Hacettepe University Hospital, Sihhiye, Ankara, Turkey.
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H.S. Cekirge
aFrom the Neurointerventional Section, Department of Radiology, Hacettepe University Hospital, Sihhiye, Ankara, Turkey.
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Figures

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  • Fig 1.
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    Fig 1.

    Preoperative 3D angiogram (A) shows a very wide-neck large ICA aneurysm. It could be reconstructed with several overlapping devices, creating a new vessel wall within the sac as seen on the perioperative DynaCT image (B). Postoperative CT obtained the same evening (C) reveals ipsilateral frontal intraparenchymal hemorrhage. 2D (D) and 3D (E) views of 6-month control angiography demonstrate the reconstruction of the parent artery and total occlusion of the aneurysm.

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    Fig 2.

    Lateral angiogram shows a giant dissecting ICA aneurysm (A). The intraoperative view demonstrates PEDs (sizes, 4 × 202 and 4.5 × 16 mm) opening to the normal size of the parent artery at the dissected segment (arrow in A) without necessitating balloon angioplasty. Note the contrast stagnation within the sac (B). Six-month control angiography (C) shows total occlusion of the aneurysm and reconstruction of the parent artery.

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    Fig 3.

    Left vertebral angiogram (A) demonstrates the left PCA aneurysm, which presented with left thalamic infarct (not shown). Immediate postoperative view (B) shows the single PED (2.5 × 20 mm) placed in the left PCA, resulting in contrast stasis within the sac. Control angiography (C) after 6 months confirms total occlusion of the aneurysm with the PCA preserved.

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    Fig 4.

    3D image (A) and lateral angiography (B) show a left paraophthalmic bleb aneurysm in a patient who had a subarachnoid hemorrhage 3 months earlier. Lateral angiogram 6 months after placement of a single PED of 3.75 × 12 mm (C) demonstrates complete occlusion of the aneurysm.

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    Fig 5.

    Right carotid angiogram (A) demonstrates a small carotid cave aneurysm in a patient who had an anterior communicating artery aneurysm previously treated with coiling following SAH. Six-month control angiography (B) shows occlusion of the aneurysm.

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    Fig 6.

    Preoperative 2D (A and B) angiograms show the ICA aneurysm in which the anterior choroidal artery is originating from the aneurysm at the neck. A single PED is placed covering the neck, causing stagnation of the contrast within the sac (C). Six-month control angiography (D) demonstrates total occlusion of the aneurysm with the anterior choroidal artery preserved (arrow).

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    Fig 7.

    Right internal carotid oblique angiogram (A) shows a right posterior communicating artery aneurysm (the ipsilateral P1 is aplastic and not shown) in a patient in whom previous endovascular attempts and clipping had failed, with surgical wrapping performed eventually. Two years after a single PED placement, the aneurysm is remodeled in the corresponding view (B).

Tables

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    Table 1:

    Clinical presentations of the patients

    PresentationNo. of Patients%
    Incidentala2312
    Headache8343.5
    Subarachnoid hemorrhageb31c,d16.2
    Previous SAH from another aneurysm1910
    Visual findings due to mass effect28d14.7
    Othere84.2
    Total191d100
    • ↵a Incidental group includes asymptomatic patients and patients with symptoms (excluding SAH) unrelated to the aneurysms treated with a PED (ie, index aneurysms).

    • ↵b SAH from the aneurysm treated with a PED.

    • ↵c Nine of these patients, 6 of whom were in the acute stage, were treated with the Pipeline as the first treatment; 22 patients had a PED in the retreatment.

    • ↵d One of these patients had visual findings after the initial treatment and received a PED as a retreatment; this patient is cited in both groups.

    • ↵e All symptoms (eg, ataxia, paresthesia, hemi-/quadriparesis, and so forth) other than those listed above, which may be due to mass effect and/or ischemia (such as perforator injury) and so forth.

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    Table 2:

    The previous treatments in the aneurysms that had Pipeline treatment for incomplete occlusion

    Previous TreatmentNo. of Aneurysms/Patients
    Coiling with bare coils18/17
    Coiling with surface modified coils2
    Stent-assisted coiling2
    Bare stenting2
    Onyx1
    Silk flow diverter2/1
    Failed surgery5
    Surgical remnant/regrowth2
    Total34/32
    • View popup
    Table 3:

    Localizations of the aneurysms treated with PED

    LocalizationNo. of AneurysmsRatio (%)
    Petrous ICA62.4
    Cavernous ICAa2811.2
    Supraclinoid aneurysmb13453.4
    PcomA aneurysms218.4
    AchoA aneurysms2811.2
    ICA terminal bifurcation31.2
    M152
    MCA bifurcation20.8
    Basilar arteryc62.4
    Vertebral arteryd83.2
    Distal aneurysmse104
    Total251100
    • Note:—AchoA indicates anterior choroidal artery.

    • ↵a If the aneurysm involved both petrous and cavernous segments, it is included in this group, and this definition applies to 12/28 aneurysms in this group.

    • ↵b The aneurysm is included in the supraclinoid group when it involves this segment, regardless of whether it extends to more than this segment proximally (eg, to the cavernous segment). The aneurysms at the posterior communicating and anterior choroidal artery origins and the terminal bifurcation are shown separately and are not included in this group.

    • ↵c This group includes 1 superior cerebellar artery origin aneurysm and 2 aneurysms involving the vertebrobasilar junction in addition to 3 basilar trunk aneurysms.

    • ↵d Three aneurysms at the origin of PICA are included in this group.

    • ↵e This group includes all aneurysms distal to the MCA bifurcation, all anterior cerebral artery aneurysms excluding the ones located at the ICA termination, and any aneurysm distal to basilar termination (ie, posterior cerebral artery aneurysms).

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    Table 4:

    Any clinical events during/immediately after or in the follow-up period

    Adverse EventsNo. of PatientsPermanent Morbidity/Mortality
    Due to medication
        Intracranial hemorrhage21
        Aplastic anemiaa1No
        Hematuria (requiring change in medical treatment)1No
        GI bleeding (including the FU period)2No
    Associated with intervention
        Deep vein thrombosis1No
        Retroperitoneal hematomab3No
    Associated with aneurysm treatment
        Due to mass effectc41
        SAH (aneurysm rupture)1Nod
    In relation to PED
        Perioperative thromboembolic event41) Mortality (jailed PCA occlusion)
    3) Symptoms resolved totallye
        In-stent stenosisf8No
            Mild5 No intervention
            Severe3 PTAs performedg
        Ischemic event in the FU period1e
    Total27 (14.1%)e2 (1%)/1 (0.5%)
    • Note:—FU indicates follow-up; GI, gastrointestinal; PTA, percutaneous transarterial angioplasty.

    • ↵a Occurred in the patient who had resistance to clopidogrel and was on ticlopidine.

    • ↵b Included in the group of complications that are attributed to intervention, but antithrombocytic medication may also have contributed.

    • ↵c Any new symptom or increase in the findings are taken into consideration; 3 had deteriorating vision loss, of whom 2 also had visual field defects. In 2 patients, the symptoms regressed to their preoperative degree in the follow-up and caused permanent additional morbidity in 1. The remaining patient had symptoms due to mass effect on the brain stem, aggravated after the treatment, but resolved in 4 weeks' time.

    • ↵d This patient had subarachnoid hemorrhage 4 months after the treatment; imaging still showed filling of the aneurysm despite significant decrease. Initially she had had hemiparesis, but this resolved totally.

    • ↵e One patient had an ischemic attack in the postoperative 4 months after he discontinued clopidogrel without consulting his doctor. The patient was medicated with IV heparin, and clopidogrel was loaded again. The symptom of monoparesis resolved totally. The same patient woke up from the general anesthesia with monoparesis but immediately became asymptomatic after volume loading and raising the blood pressure.

    • ↵f Mild refers to any intimal thickening causing stenosis <50%. Severe refers to stenosis ≥50%.

    • ↵g In 2 patients, stenosis was discovered in the control angiography but PTA was performed because the stenosis was considered significant (>70%). The remaining patient had attacks of dysphasia which resolved after PTA, with no permanent morbidity.

    • View popup
    Table 5:

    Six-month control angiography results in regard to aneurysm sizea

    Degree of OcclusionSmallLargeGiantTotal No.%
    Total occlusion (%)136 (93.8%)56 (87.5%)27 (90%)219b91.6b–91.2c
    Still filling98320d8.4%
    Total1456430239a100
    • ↵a One patient with 1 aneurysm died after the treatment; 8 patients with 11 aneurysms (9 small and 2 large) have not yet undergone the 6-month control angiography. Therefore, a total of 12 aneurysms (4.8%) did not have control angiography.

    • ↵b Including 1 patient who had subarachnoid hemorrhage in the fourth month and was retreated with additional PEDs for her remaining aneurysm filling.

    • ↵c Represents the ratio of aneurysms that were occluded in the 6-month control without retreatment.

    • ↵d Seven were retreated. Seven of the remaining showed further thrombosis with resultant aneurysm occlusion, and 6 are pending the next control after the discontinuation of the clopidogrel.

    • View popup
    Table 6:

    Summary of previous Pipeline series in comparison with this series

    SeriesNo. of Patients/AANo of AA W Previous TX Failurea (%)No of AA Treated W Adjunctive Coilingb (%)Morbidityc and MortalityComplete Occlusion at 6-Month DSA (%)Control Angiography (%)Retx No of AA (%)Peri-Post-Operative Intracranial BleedingPerforator InfarctIn-Stent Stenosis All %/Requiring TX % PAO
    Lylyk et al 200920,d53/6323/634/63 (6%)093%100%00010%/0
    (37%)0%PAO: 0
    Szikora et al 201021,e18/191/1910/19 (53%)5.6%94.4%94.7%01/18f00
    (5.3%)5.6%5.6%PAO:5.6%
    Nelson et al 20112331/3112/3116/31 (52%)6.5%93.3%96.8%01/31g1/310
    (38.7%)0%3.2%(3.2%)PAO:0
    Fischer et al 20112488/10130/101)3/101 (3%)4%52%89%8/1014/88h02.3%/0
    (29.7%)2%7.9%4.6%PAO:2.3%
    McAuliffe et al 20123454/5716/5712/68 (18%)085.7%98.2%2/57i003.5%/0
    (28.1%)0%3.5%PAO:0
    Saatci et al 2012191/25134/25111/251 (4%)1%91.2 %95.2 %8/2513/191j1/1914.2%/1.6%
    (13.5%)0.5%3.2%1.6%0.5%PAO:0
    • Note:—AA indicates aneurysms; TX, treatment; W, with DSA; Retx retreatment.

    • ↵a Refers to the aneurysms that underwent previous endovascular or surgical treatment, including the failed treatment, incomplete treatment, and recurrences.

    • ↵b Refers to the aneurysms in which coiling was performed as an adjunctive treatment in the same session with PED placement.

    • ↵c Temporary deficits not included.

    • ↵d,e Six (d) and 9 (e) aneurysms of these series were also included in the PITA trial.

    • ↵f Refers to the rupture of a coexisting aneurysm.

    • ↵g Refers to an iatrogenic ICA rupture.

    • ↵h Includes 1 aneurysm rupture and 3 parenchymal hemorrhages.

    • ↵i Additional treatment required due to PED displacement in 2 aneurysms.

    • ↵j Includes 1 aneurysm rupture and 2 parenchymal hemorrhages.

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American Journal of Neuroradiology: 33 (8)
American Journal of Neuroradiology
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I. Saatci, K. Yavuz, C. Ozer, S. Geyik, H.S. Cekirge
Treatment of Intracranial Aneurysms Using the Pipeline Flow-Diverter Embolization Device: A Single-Center Experience with Long-Term Follow-Up Results
American Journal of Neuroradiology Sep 2012, 33 (8) 1436-1446; DOI: 10.3174/ajnr.A3246

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Treatment of Intracranial Aneurysms Using the Pipeline Flow-Diverter Embolization Device: A Single-Center Experience with Long-Term Follow-Up Results
I. Saatci, K. Yavuz, C. Ozer, S. Geyik, H.S. Cekirge
American Journal of Neuroradiology Sep 2012, 33 (8) 1436-1446; DOI: 10.3174/ajnr.A3246
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