Analysis of influencing factors on post-treatment in-stent stenosis of intracranial aneurysm using Pipeline embolization device / 中华放射学杂志

Objective:To evaluate the incidence, clinical significance and influencing factors on in-stent stenosis(ISS) after treatment of intracranial aneurysms by Pipeline embolization device(PED).Methods:A retrospective analysis was conducted on the clinical data of 161 patients with intracranial aneurysms treated with PED at the Department of Interventional Radiology of the First Affiliated Hospital of Zhengzhou University from April 2015 to July 2021. PED was implanted into the parent artery through the femoral artery approach after general anesthesia. The first DSA follow-up duration time and imaging data were collected, and the patients were divided into ISS group and non-ISS group accordingly. The degree of aneurysm occlusion was evaluated by O′Kelly-Marotta(OKM) grading scale. Univariate and multivariate logistic regression analysis were applied to identify the factors related to ISS.Results:A total of 179 PED were employed in 161 patients with 168 aneurysms. Eighty-eight (52.38%) aneurysms were treated by PED only, and 80 (47.62%) aneurysms by PED combined with coiling. After a median follow-up of 6 (5, 7) months, 31(18.45%) aneurysms had ISS within the PED, of which 16(9.52%) cases were with mild stenosis (<50%), 13 (7.74%) were with moderate stenosis (50%-75%), and 2(1.19%) were with severe stenosis (>75%). All patients with ISS showed no relevant clinical symptoms. One (0.60%) patient with ISS underwent balloon angioplasty. Univariate analysis showed that the stent diameter, aneurysm location, triglyceride level, the diameter of distal parent artery, and the diameter of proximal parent artery were associated to ISS. Further multivariate logistic regression analysis showed the stent diameter (OR=0.332, 95%CI 0.191-0.578, P<0.001) and triglyceride level (OR=1.641, 95%CI 1.034-2.605, P=0.036) were independent factors of ISS. Conclusions:ISS is a common benign complication after PED treatment. The current results suggest that small stent diameter and high triglyceride level are independent factors of ISS.

Effect of Pipeline embolization device in treatment of intracranial complex aneurysms / 中国介入影像与治疗学

Objective: To observe the efficacy and safety of Pipeline embolization device (PED) in treatment of intracranial complex aneurysms. Methods: Clinical data of 11 patients with intracranial complex aneurysms treated with PED were retrospectively analyzed. Results: Twelve PED were implanted in 11 patients with 12 aneurysms. Ten patients were implanted 1 PED and 1 patient with 2 PED, 3 aneurysms were implanted PED alone, 9 aneurysms underwent PED combined with coil embolization. Cerebral angiography immediately after operation showed that contrast agent was detained in aneurysm and PED adhered well to the wall, completely covered the neck of aneurysms and the artery with aneurysm was unobstructed. One patient had a local acute cerebral infarction after operation and recovered after treatment. Postoperative follow-up time was 6-9 months, the median follow-up time was 7.5 months. The symptoms significantly relieved or disappeared, no obvious complication occurred, and the occlusion rate of aneurysm was 75.00% (9/12). According to O'kelly-Marotta (OKM) grating, there was no aneurysm in grade A, 1 of grade B, 2 of grade C and 9 of grade D. The modified Rankin scale (mRS) were 0 score in 10 patients and 1 score in 1 patient. Conclusion: Treatment of intracranial complex aneurysms with PED has good effect and safety.

Off-Label Application of Pipeline Embolization Device for Intracranial Aneurysms / 신경중재치료의학

PURPOSE: The Pipeline embolization device (PED) is approved in the USA for treating giant and large aneurysms arising from the petrous to superior hypophyseal segments of the internal carotid artery in patients older than 21 years of age. This study investigates off-label PED results in a large cohort. MATERIALS AND METHODS: Retrospective, single-center review of all patients who had off-label PED surgery. RESULTS: Sixty-two aneurysms (48 patients) underwent off-label PED treatment from 2012–2017. There were 44 females and four males (age 21 to 75 years; mean/median, 54.3/55.0 years). The most common presenting symptom was headache (47/62, 75.8%). All aneurysms were in the anterior circulation. Aneurysm size ranged from 1.4 to 25.0 mm (mean/median, 7.6/6.9 mm). Fifty-two aneurysms had post-operative imaging with total/near-complete occlusion of 84.6% (44/52). Aneurysm-based operative near-term complication rate was 9.7% while there were no permanent complications. For aneurysms and headache, 86.7% improved/resolved after embo-surgery, and were four times more likely to have a better clinical outcome (resolved or improved symptoms) after surgery (odds ratio [OR], 4.333; P=0.0325). Left-sided aneurysms had a higher occlusion rate (OR, 20; P=0.0073). Hypertension (OR, 4.2; P=0.0332) and smoking (OR, 7; P=0.0155) were more prone towards aneurysm occlusion. Patients without a family history were 14 times more likely to have favorable imaging outcome (P=0.0405). There is no difference of occlusion rates between untreated and previously treated aneurysms (P=0.6894). Overall, occlusion rate decreased by 14% with an increase of aneurysm size by 1 mm (P=0.0283). CONCLUSION: For anterior circulation aneurysms, the off-label application of PED is as effective and safe as reported for on-label intracranial aneurysms.

Preliminary experience of treating complex middle cerebral artery aneurysms with Pipeline embolization device / 中国脑血管病杂志

Objective To investigate the safety and efficacy of Pipeline embolization device (PED) for the treatment of complex middle cerebral artery aneurysms. Methods From December 2015 to June 2018, 7 patients with complex middle cerebral artery unruptured aneurysms and treated with PED at the Department of Neurosurgery, the Second Affiliated Hospital of Nanchang University were recruited. The clinical and follow-up data were analyzed. The Kamran classification was used to evaluate the immediate effect of aneurysm embolization and the changes of parent artery. At 6 months after operation, the effect of embolization was evaluated by Raymond grading; the modified Rankin scale (mRS) was used to evaluate prognosis: 0 -2 for good prognosis, 3 -6 for poor prognosis, and 6 for death. Results The 7 patients with complex middle cerebral artery aneurysms were successfully treated with one PED, including 2 patients with single PED and 5 combined with coiling. Digital subtraction angiography (DSA) were performed immediately after PED implantation. All had Kamran classification 2a at immediate angiography after embolization. The postoperative mRS score was 0 in 6 patients and 1 in 1 patient. One patient with M1 aneurysm had acute in-stent thrombosis and another one with M1 aneurysm had mini-focal occipital lobe cerebral infarction. All 7 patients were Raymond classification I during postoperative follow-up from 6 to 12 months. Among them, 6 patients had aneurysms total occlusion with patent parent artery. For the remaining one patient, the aneurysm was found slightly residual at the middle cerebral artery bifurcation but was totally occluded with parental artery patent at 12 months. There were no aneurysmal rupture, cerebral parenchymal hemorrhage, and neurological defects in the 7 patients during intraoperative and postoperative follow-up periods (6 to 18 months). Conclusions Embolization of complex cerebral artery aneurysms with PED is effective and safe, but its long-term effect still needs to be validated by longer follow-up results and large sample-sized trials.

Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Only: a Single Center Experience / 신경중재치료의학

PURPOSE: The aim of this study was to evaluate the technical feasibility and rate of mid-term occlusion in aneurysms treated solely with the Pipeline Embolization Device (PED) in a German tertiary care university hospital. MATERIALS AND METHODS: Forty-nine non-consecutive intracranial aneurysms underwent endovascular treatment using the PED exclusively between March 2011 and May 2017 at our institution. Primary endpoint was a favorable aneurysm occlusion defined as OKM C1-3 and D (O'Kelly Marotta Scale). Secondary endpoints were retreatment rate and delayed complications. Median follow-up was 200 days. RESULTS: The mean aneurysm size was 7.1 ± 5.3 mm. Forty-four aneurysms were located in the anterior circulation (90%). Ten aneurysms were ruptured (20%). Branching vessels from the sac were observed in 11 aneurysms (22%). Favorable obliteration immediately after PED placement was seen in 13/49 aneurysms (27%), of those nine aneurysms were completely occluded (18%). Angiographic and clinical follow-up was available for 45 cases (92%); 36/45 aneurysms (80%) were occluded completely and 40/45 aneurysms (89%) showed a favorable occlusion result. A branching vessel arising from the aneurysm sac was associated with incomplete occlusion (P < .05). All electively treated patients had good outcome (mRS 0). Three aneurysms (6%) required additional treatment due to aneurysm recurrence. CONCLUSION: In our series, treatment of intracranial aneurysms with the PED was associated with favorable occlusion rates and low complication rates at mid-term follow-up. The presence of branching vessels arising from the aneurysms sac was predictive for an incomplete occlusion.

Preliminary experiences of Pipeline embolization device for the treatment of complex intracranial aneurysms / 中国脑血管病杂志

Objective To preliminarly investigate the application value of Pipeline embolization device ( PED ) in the endovascular interventional treatment of complex intracranial aneurysms. Methods From July 2015 to October 2016, the clinical data of 10 consecutive patients with complex intracranial aneurysm treated with PED at the Department of Neurosurgery, Guangdong General Hospital were enrolled retrospectively. Their surgical modalities,complications,and imaging findings were analyzed. Results Of the 10 patients,7 were females and 3 were males,their age was 32-68 years ( mean age 54 ± 12 years) . There were 8 patients with internal carotid artery aneurysm,1 with middle cerebral artery aneurysm,and 1 with vertebrobasilar artery aneurysm;there were 2 patients with ruptured aneurysm and 8 with unruptured aneurysm;there were 5 patients with saccular aneurysm ( 2 with wide-necked aneu-rysm) ,3 with fusiform aneurysm,2 with dissecting aneurysm;there were 2 patients with medium aneurysm ( diameter>5-15 mm) ,2 with large aneurysm ( diameter>15-25 mm) ,6 with giant aneurysm ( diameter>25 mm) ,and there were 2 patients with recurrent aneurysm. They were all single aneurysms. Three patients were treated with PED in combination with coil embolization,and 7 patients were treated with PED implantation alone. Nine patients were treated with one PED and 1 was treated with 3 PEDs. The immediate postoperative angiography revealed that the contrast agents in the aneurysm cavities were obviously stranded. One patient died after procedure and 1 had quadriplegia after procedure,and the remaining 8 patients had no PED-related complications. The modified Rankin scale score was 0 in 8 cases,5 in 1 case,and 6 in 1 case on the first post-operative day. They were followed up for 14 to 28 months. Conclusions The different types of intracranial aneurysms treated with PED implantation is relatively safe and effective,but there are also some risks of dis-ability and death. Strictly selecting the indications and developing the individualized treatment strategies are needed.

Medium and long-term effects of Pipeline embolization device for the treatment of large and giant intracranial anterior circulation aneurysms / 中国脑血管病杂志

Objective To investigate the medium- and long-term effects and safty of Pipeline embolization device ( PED) for the treatment of large and giant intracranial anterior circulation aneurysms. Methods From December 2014 to December 2016,the data of 36 consecutive patients with large and giant aneurysm ( 36 large and giant intracranial anterior circulation aneurysms ) treated with PED in Donglei Brain Doctor Group were analyzed retrospectively. The diameter of the aneurysms was 12 -33 mm, (mean16.6±4.5mm),andthenecksizewas4-10mm(mean6.1±1.5mm).Eightaneurysmswere located in the carotid cavernous sinus segment,22 in the ophthalmic artery segment,5 in the internal carotid artery posterior communicating segment, and 1 in the M1 segment of middle cerebral artery. Seven aneurysms were only treated by PED,28 aneurysms were treated by PED in combination with coil embolization,and 1 aneurysm was treated by double PEDs. The modified Rankin scale ( mRS) score was used to evaluate the prognosis of the patients. Results (1) The clinical prognosis of the patients was followed up by telephone and outpatient department for 6-33 months. Twenty-five patients were followed up by DSA,23 aneurysms (92%) were occluded totally (Raymond gradeⅠ) and 2 (8％) were occluded near totally ( Raymond grade Ⅱ) . ( 2 ) Seven patients were treated with PED alone. Four patients were cured totally after 6 months follow-up,1 was occluded subtotally,2 were not cured;6 were cured in the last follow-up (33 months),and the other aneurysm was gradually reduced;17 of 28 patients treated with PED in combination with coils received DSA follow-up. They were followed up for 6-8 months. All the aneurysms were totally occluded ( Raymond grade Ⅰ) . 1 aneurysm was treated by 2 PEDs, DSA revealed micro-aneurysm-like development at 8 months after procedure. The aneurysms were basically occluded after 15-month follow-up. (3) MRI confirmed after operation that 10 patients had asymptomatic scattered spotted ischemic foci,4 had cerebral parenchymal hemorrhage,1 of them died,1 recovered well after treatment (mRS 1),and the other 2 were asymptomatic cerebral hemorrhage. The occupying effect of 24 cases disappeared, 8 had obvious improvement,and 3 did not have any obvious change. Conclusions The occlusion rate of the treatment of large and giant intracranial aneurysms with PED was high. The results of medium-term follow-up showed that the occlusion rate of PED in combination with coils in the treatment of aneurysms was higher than that of PED alone. The long-term follow-up results showed that the occlusion rate of patients treated with PED alone (including one or more) was gradually increased with time. The safety of the surgery needs to be further confirmed by a large sample study.

Roles of Pipeline embolization device in combination with coils in the treatment of large and giant unruptured internal carotid artery aneurysms / 中国脑血管病杂志

Objective To investigate the roles of Pipeline embolization device ( PED) in combination with coils in the treatment of large and giant unruptured internal carotid artery aneurysms. Methods From January 2014 to December 2016,51 patients with large (diameter 10-25 mm) and giant (diameter >25 mm) internal carotid artery aneurysms treated at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were analyzed retrospectively. Among them,35 were females and 16 were males, the average age was 53 ±13 years (range 15-71). They were divided into a PED group (n=31) and a PED combined with coil group (n=20) according to whether using coils for packing aneurysm cavity or not. The treatment of two groups of patients and ≥6 months of imaging follow-up effect were analyzed. The embolic rate was evaluated by Raymond grade. Results Thirty-one patients with 32 aneurysms ( mean diameter 15 ± 3 mm) in the PED group were treated with 33 PEDs,including 15 with cavernous sinus aneurysm and 17 with supraclinoid aneurysm;20 patients with 21 aneurysms ( mean diameter 17 ± 4 mm) were treated with 22 PEDs in the PED combined with coil group,including 10 cavernous sinus aneurysms and 11 supraclinoid carotid aneurysms. Six months after procedure,imaging follow-up revealed that the incidence of residual aneurysm ( Raymond grade Ⅱ-Ⅲ) in the PED group was significantly higher that that in the PED combined with coil group (9. 7% [n =3] and 0％,respectively). The incidence of thrombosis in PED combined with coil group was significantly higher than that in the PED group,there was significant difference between two groups (P<0. 05). Conclusions When using PED to treat large and giant internal carotid artery aneurysms,packing aneurysm cavity in combination with coils can reduce the incidence of residual aneurysm,but it may have a higher risk of thrombotic events. A prospective randomized controlled trial of large samples is still needed to prove it.

A Case of Ruptured Blood Blister-like Aneurysm Treated with Pipeline Embolization Device: Clinical Significance of Fetal-type Posterior Communicating Artery / 신경중재치료의학

Blood-blister like aneurysms (BBAs) are challenging lesions because of their wide fragile neck. Flow-diverting stents (FDSs), such as the Pipeline Embolization Device (PED), have been applied to treat BBAs less amenable to more established techniques of treatment. However, the use of FDSs, including the PED, in acute subarachnoid hemorrhage (SAH) still remains controversial. We report a case of aneurysm regrowth following PED application for a ruptured BBA that overlapped the origin of the dominant posterior communicating artery (PCoA), which was successfully treated after coil trapping of the origin of the fetal-type PCoA. And, we discuss the clinical significance of the fetal-type PCoA communicating with a BBA in terms of PED failure.

Short-term follow-up for unruptured wide-necked intracranial aneurysms treated with Pipeline embolization device / 中国脑血管病杂志

Objective To evaluate the short-term effect of Pipeline embolization device (PED)for the treatment of unruptured wide-necked intracranial aneurysms. Methods From October 2015 to September 2016,15 consecutive patients with unruptured wide-necked intracranial aneurysm (aneurysm neck and aneurysm body ratio ≥0. 5)treated with PED at the Department of Neurosurgery,the Second Affiliated Hospital of Nanchang University were enrolled retrospectively. Their clinical and imaging data were analyzed. Kamran scale was used to evaluate the embolization rate of aneurysms and the changes of the parent arteries. DSA examination was performed again at 6 -12 months after operation. Results Fifteen PED were implanted in 15 patients with unruptured wide-necked intracranial aneurysms,including 13ophthalmic artery aneurysms,1 posterior communicating artery aneurysm,and 1 cavernous sinus aneurysm. The technical success rate was 100% . Immediately after PED implantation,Karman rating of 15 cases were aneurysm grade 2 embolization,parent artery grade A (grade 2a). DSA examination was performed again at 6 - 12 months after operation showed that 14 patients were aneurysm grade 4,parent artery was grade A (grade 4a). One patient (ophthalmic artery aneurysm)underwent the second DSA examinations at 6 and 12 months after operation showed that the residual development of aneurysms. The aneurysm embolization was grade 3, and the parent artery was grade A (grade 3a). No branch artery occlusion was observed. Non of them had neurological deficit. The modified Rankin scale score was 0 in all 15 patients. Conclusion The use of PED in the treatment of unruptured wide-necked intracranial aneurysms has a higher occlusion rate. Its long-term effect still needs further follow-up.

Progress in study on Pipeline embolization device treatment for postoperative complications of intracranial aneurysm / 介入放射学杂志

In recent years,endovascular treatment of intracranial aneurysms has been developed rapidly.Pipeline embolization device (PED),which is a novel blood flow guiding device,can creatively reconstruct the blood flow distribution of the aneurysm-bearing artery,and it has been widely employed in clinical practice.Satisfactory curative effect has been achieved by PED for intracranial aneurysms,especially for complex intracranial aneurysms.However,because of its high metal coverage rate,the complications such as aneurysm rupture,spontaneous cerebral parenchymal hemorrhage,branch artery occlusion,etc.are not uncommonly seen in patients after receiving flow divertion treatment,and the mortality rate is higher,to which sufficient attention should be paid by clinicians.This paper aims to make a review on the research progress concerning the postoperative complications of PED in the treatment of intracranial aneurysms.

Inadvertent Complication of a Pipeline Embolization Device for Treatment with Vertebral Artery Dissecting Aneurysm : Distal Tip Fracture of Delivery Wire

Use of the Pipeline embolization device (PED) has increased based on studies about its safety and effectiveness, and new reports that describe peri- or postprocedural complications are now emerging. We report a rare periprocedural device-related complication that occurred during endovascular treatment with the pipeline embolization device for a dissecting aneurysm on the vertebral artery. A 55-year old woman was admitted due to left medullary infarction, and angiography showed a fusiform dilatation in the left vertebral artery that was suspicious for dissecting aneurysm. Endovascular treatment with PED was planned. Under general anesthesia, the procedure was performed without significant problems and a PED was deployed in an appropriate position. However, in the final step of the procedure, the distal tip of the PED delivery wire became engaged within a small branch of the posterior cerebral artery and fractured. Fortunately, imaging studies after the procedure revealed neither hemorrhagic nor ischemic stroke, and the patient recovered without neurological morbidities except initial symptoms.

Delayed Ischemic Stroke after Flow Diversion of Large Posterior Communicating Artery Aneurysm

For securing large, giant, and wide-neck aneurysms, conventional coil embolization has substantial limitations, such as incomplete occlusion, recanalization, and a high recurrence rate. To overcome these limitations, a novel paradigm was suggested and, as a result, flow-diverting device was developed. The flow-diverting device is an innovative and effective technique to allow securing of large, giant, and wide-neck aneurysms. In numerous studies, the flow-diverting device has shown better outcomes than coil embolization. However, the flow-diverting device has also some risks, including rupture of aneurysm, intracerebral hemorrhage, and ischemic stroke. In addition, with more experience, unexpected complications are also reported.5) 7) In the present case, we experienced a delayed ischemic stroke at 27 days after endovascular treatment. The patient had multiple aneurysms and, among them, we treated a large posterior communicating artery aneurysm using Pipeline™ Embolization Device. The patient was tolerable for 25 days, but then suddenly presented intermittent right hemiparesis. In the initial diffusion magnetic resonance imaging (MRI), there was no acute lesion; however, in the follow-up MRI, an acute ischemic stroke was found in the territory of anterior choroidal artery which was covered by Pipeline Embolization Device. We suspect that neo-intimal overgrowth or a tiny thrombus have led to this delayed complication. Through our case, we learned that the neurosurgeon should be aware of the possibility of delayed ischemic stroke after flow diversion, as well as, long-term close observation and follow-up angiography are necessary even in the event of no acute complications.

Uso dispositivo diversor de flujo pipeline® para tratamiento endovascular de aneurisma intracraneal distal gigante / Use pipeline® flow diversion device for endovascular treatment of giant distal intracranial aneurysm

El Dispositivo de Embolización Pipeline (PED) fue el primer dispositivo para la desviación de flujo aprobado por la FDA (Food and Drug Administration), el cual se emplea como tratamiento de aneurismas intracraneales. Se presenta el caso de un paciente femenino de 74 años de edad con diagnóstico de aneurisma sacular de la bifurcación de la arteria carótida interna derecha más placa calcificada en el origen de la arteria carótida interna derecha. Se decide terapia endovascular más colocación de PED como método terapéutico

The Pipeline Embolization Device (PED) was the first device for flow diversion approved by the FDA (Food and Drug Administration), which is used as a treatment of intracranial aneurysms. The case arises from a 74-year-old female patient with a diagnosis of a saccular aneurism in the right internal carotid artery bifurcation and a calcified plaque in the origin of the right internal carotid artery. The therapeutic method was decided to be endovascular therapy and PED placement

Persistent Aneurysm Growth Following Pipeline Embolization Device Assisted Coiling of a Fusiform Vertebral Artery Aneurysm: A Word of Caution! / 신경중재치료의학

The complex morphology of vertebrobasilar fusiform aneurysms makes them one of the most challenging lesions treated by neurointerventionists. Different management strategies in the past included parent vessel occlusion with or without extra-intracranial bypass surgery and endovascular reconstruction by conventional stents. Use of flow diversion has emerged as a promising alternative option with various studies documenting its efficacy and safety. However, there are various caveats associated with use of flow diversion in patients with fusiform vertibrobasilar aneurysms especially in patients presenting with acute subarachnoid hemorrhage (SAH). We report a rare case of persistent aneurysmal growth after coiling and placement of the Pipeline Embolization Device (PED; ev3, Irvine, California, USA) for SAH from a fusiform vertebral artery aneurysm. As consequences of aneurysm rupture can be devastating especially in patients with a prior SAH, the clinical relevance of recognizing and understanding such patterns of failure cannot be overemphasized as highlighted in the present case.

Failure of Flow Diverter Treatment of Intracranial Aneurysms Related to the Fetal-type Posterior Communicating Artery / 신경중재치료의학

PURPOSE: The pipeline embolization device (PED) is a flow diverter that has shown promise in the treatment of intracranial aneurysms. Close to one-fifth of aneurysms, however, fail to occlude after PED placement. This study aims to identify anatomical features and clinicopathologic factors that may predispose failed aneurysm occlusion with the PED. MATERIALS AND METHODS: We retrospectively reviewed all anterior circulation unruptured saccular aneurysms treated with the PED in a single-center. The primary outcome measure was angiographic occlusion. Anatomical features and potential predictors, including gender, aneurysm location, size, height, aspect ratio, neck width, prior treatment and the number of PED, were studied using binary logistic regression. RESULTS: 29 anterior circulation unruptured saccular aneurysms with a mean size of 6.99 mm treated with the PED in a single center were retrospectively studied. The overall occlusion rate was 79.3% after a mean follow-up of 9.2 months. Four aneurysms were related to the fetal-type posterior communicating artery (PComA), and all were refractory to flow diverter treatment. Female gender was significantly associated with a higher occlusion rate. We present the anatomical features and propose possible pathophysiological mechanisms of these PComA aneurysms that failed flow diverter treatment. CONCLUSION: A PComA aneurysm with persistent fetal-type circulation appears to be particularly refractory to flow diverter treatment, especially when the aneurysm incorporates a significant portion of the PComA. Our experience suggested that flow diverting stents alone may not be the ideal treatment for this subgroup of aneurysms, and alternative modalities should be considered. Female patients were found to have a significantly higher rate of treatment success.

Pipeline Embolization Device for Giant Internal Carotid Artery Aneurysms: 9-Month Follow-Up Results of Two Cases

The pipeline(TM) embolization device (PED) is a braided, tubular, bimetallic endoluminal implant used for occlusion of intracranial aneurysms through flow disruption along the aneurysm neck. The authors report on two cases of giant internal carotid artery aneurysm treated with the PED. In the first case, an aneurysm measuring 26.4 mm was observed at the C3-C4 portion of the left internal carotid artery in a 64-year-old woman who underwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at the C4-C5 portion of the right internal carotid artery in a 39-year-old woman with right ptosis and diplopia. Each giant aneurysm was treated with deployment of a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showed complete radiological occlusion of the giant intracranial aneurysm and sac shrinkage. We suggest that use of the PED can be a therapeutic option for giant intracranial aneurysms.

Microsurgical Strategies Following Failed Endovascular Treatment with the Pipeline Embolization Device: Case of a Giant Posterior Cerebral Artery Aneurysm

Treatment of giant posterior circulation aneurysms, via endovascular or microsurgical approaches, carries a high risk of morbidity and mortality. While flow-diverting stents (FDSs) represent a potent therapy for endovascular reconstruction of complex aneurysms, they are also associated with novel complications for which effective salvage techniques are lacking. We present a unique complication from failed treatment with a FDS. A 51 year-old male presented with increasing headaches secondary to a giant, fusiform aneurysm of the left posterior cerebral artery, which was largely thrombosed. Due to progressive enlargement of the aneurysm corresponding to worsening clinical symptoms, the lesion was treated with two Pipeline embolization devices (ev3, Plymouth, MN, United States). Three months after Pipeline embolization device treatment, complete posterior cerebral artery occlusion was observed at the origin of the proximal stent. Despite the lack of arterial inflow, the aneurysm dome continued to grow, resulting in obstructive hydrocephalus. Therefore microsurgical intervention was undertaken to trap and excise the aneurysm. The patient's postoperative course was complicated by multiple venous infarcts, ultimately resulting in death. Successful microsurgical obliteration of aneurysms previously treated with FDSs is extremely difficult. A combination of judicious preoperative planning and meticulous intraoperative surgical technique are requisite for effective management of these complicated cases.

Treatment for Giant Fusiform Aneurysm Located in the Cavernous Segment of the Internal Carotid Artery Using the Pipeline Embolization Device

The pipeline embolization device (PED) is a new endovascular device for treatment of complex, fusiform and wide-neck intracranial aneurysms. The main mechanism of this stent is to divert the flow in the parent artery with reduction of inflow in the aneurysm leading to thrombosis. We treated a 40-year-old woman who had left facial pain and orbit discomfort. Angiography showed a giant fusiform aneurysm located in the cavernous segment of the left internal carotid artery. A PED was successfully deployed across the aneurysm. The procedure and post-procedural course were uneventful. After 3 months, angiography showed complete obliteration of the aneurysm with good patency of the branching vessels originating from the deployed segment. The patient's symptoms improved completely without complications.