Introduction The concurrent use of the Pipeline Embolization Device (PED) with coils has been shown to be beneficial when treating complex or large aneurysms. Alternatives to coiling as an adjunctive treatment are currently limited. The FDA recently approved the Woven EndoBridge (WEB) (Microvention, Aliso Viejo, California) device as an intrasaccular flow diverter for wide neck bifurcation aneurysms (FDA). Here in we present the technical aspects of combined WEB plus PED for the treatment of intracranial aneurysms.

Methods A retrospective chart review of all patients treated via intrasaccular flow diversion at a single institution over the last 12 months was done. In total 34 aneurysms were treated via WEB intrasaccular flow diversion; however, only 7 of these aneurysms were treated with the pipeline embolization device as well. Technical aspects of each procedure were recorded.

Results In total 6 patients underwent the treatment of 7 aneurysms via combined intrasaccular and endoluminal flow diversion. All aneurysm were treated in a single setting but for one patient. This patient came in with subarachnoid hemorrhage, had a WEB placed, and subsequently was found to have recanalized their aneurysm due to WEB compaction. This prompted placement of the a Pipeline 4 weeks after initial treatment. There were no complications associated with any treatment. Post embolization MRI/A showed no new infarcts in 3/7 patients and small punctate DWI changes in 4/7 patients with good stent flow in all cases. There were no bifurcation aneurysms: 5 posterior communicating, 1 superior hypophyseal, 1 vertebrobasilar. The majority of the aneurysms required steam shaping of the Via deployment catheter in order to place the WEB orthogonally to the aneurysm dome. The radial force of the Pipeline was able to push a herniated WEB device into the aneurysm in all but one case where a balloon was employed to angioplasty the stent.

Conclusions We believe this is the first series reporting combined use of WEB and Pipeline for the treatment of intracranial aneurysms. Treatment failure rates of PED as a stand-alone treatment have been reported to be from 11.9% to 20%. Intrasaccular flow diversion with the WEB device allows for increased metal coverage at both the aneurysm neck, preventing inflow, and the aneurysm dome, protecting from rupture. For larger aneurysms the WEB device theoretically protects from a destabilizing mural thrombus. Also, in larger aneurysm were WEB devices have been shown to be less enduring, endoluminal remodeling provides a durable treatment. This series demonstrates the WEB device as a feasible and safe alternative to adjuvant coiling for achieving immediate intrasaccular flow diversion when using the PED.

Disclosures T. White: None. K. Shah: None. J. Turpin: None. J. Katz: None. H. Woo: None.