Introduction Flow diversion with the Pipeline Embolization Device (PED) provides a dramatic new tool for the treatment of intracranial aneurysms, though its use has been marked by technical nuances and challenges, particularly related to the delivery system. The Pipeline Flex provides a new delivery system, allowing more precise deployment. Here we report the use of the new PED Flex system in a child with a giant, symptomatic intracranial aneurysm.
Materials and methods A 7 year-old boy with right eye vision loss was discovered to have a giant aneurysm of the right internal carotid artery (ICA) extending from the cavernous segment to the carotid terminus (Figure 1). The aneurysm was fusiform and measured 3.5 cm. He was treated with aspirin and clopidogrel and doses were adjusted based on VerifyNow assays. A 3D model of the aneurysm and parent vessel was created, and several Pipeline configurations were rehearsed prior to the procedure. A 6 French Shuttle Sheath (Cook) was used as the guide catheter. A multi-PED construct was created across the aneurysm, using a total of six devices (Figure 1). All devices were deployed without difficulty, and occasional device distortions were easily corrected with resheathing and redeployment. After the construct was complete, partial coil embolization of the aneurysm was performed.
Results The patient awoke without new symptoms, but did have some vision loss of the contralateral eye over the ensuing three months related to aneurysmal thrombosis and inflammation. He was treated with multiple courses of steroids and his vision improved in the contralateral eye. Platelet inhibition was monitored and required frequent clopidogrel dose adjustments. Follow up angiography was performed at 6 months, and will be presented.
Conclusion Flow diversion is a powerful tool for the treatment of large and giant aneurysms, and may also be used in children. This case demonstrates the utility of the PED Flex in creating a complex, multi-device construct in a 7-year-old child with a giant aneurysm, and provides a number of useful observations: a 6 French sheath may be used in a 7-year-old child if needed; the Pipeline Flex offers additional precision in deployment; rehearsal of comple procedures using a 3D model can be very useful; and clopidogrel dosing in children is often a moving target, and requires frequent laboratory monitoring of platelet inhibition and dose adjustment.
Disclosures M. Froehler: None.
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