Purpose To examine clinical and angiographic outcomes in a cohort of consecutive patients with recurrent intracranial aneurysms treated with the Pipeline Embolization Device (PED) at a referral center.
Methods We conducted a retrospective review of all patients with recurrent intracranial aneurysms treated with the PED in our center center between December 13th, 2011 and March 29th, 2017. Baseline patient and aneurysm characteristics, intra-operative, peri-operative and delayed complications were recorded. Aneurysm volumes in initial and follow-up angiographic studies were calculated using AngioCalc. Clinical outcomes were categorized using the modified Rankin Scale (mRS).
Results 50 patients underwent 53 PED procedures to treat 56 recurrent intracranial aneurysms during the study period. 36 patients were women (72%) and 14 men (28%). Mean age was 58 years (range 29–77 years). 23 patients were active smokers (46%) and 26 had a prior history of subarachnoid hemorrhage (52%). 46 patients were premedicated with aspirin/clopidogrel (92%), 3 with aspirin/prasugrel (6%) and 1 with warfarin/clopidogrel (2%). All patients underwent pre-procedure VerifyNow testing. 46 aneurysms were recurrent after simple coiling (82%), 5 after PED embolization (9%, 1 after PED/coiling), 3 after stent-assisted coiling (5%), 1 after Onyx HD500 embolization (2%) and 1 after surgical clipping (2%). 4 aneurysms were symptomatic from mass effect (7%) and 1 was acutely ruptured (2%). 3 aneurysms were fusiform (5%) and 1 blister (2%). 39 aneurysms were located in the internal carotid artery (70%), 8 in the middle cerebral artery (14%), 5 in the anterior cerebral artery (9%), 3 in the posterior inferior cerebellar artery (5%) and 1 in the basilar tip (2%). 30 aneurysms had a vessel arising from the aneurysm dome/neck (54%), 14 of which were the posterior communicating artery (47%). Mean aneurysm size was 6.2 mm (1.5–26.2 mm), mean neck was 3.9 mm (0.5–9.3 mm), mean dome-to-neck ratio was 1.6 (0.6–11.5). 24 aneurysms were wide-neck (≥4 mm, 43%). Mean number of PEDs deployed per aneurysm was 0.9. Adjunctive coiling was performed in 7 aneurysms (12.5%, mean 4.7 coils deployed). 28 aneurysms were treated with PED Flex (50%). There were 4 intra-operative (7.5%), 15 peri-operative (28%) and 3 delayed (5.7%) complications. 1 peri-operative complication, an ipsilateral intracerebral hemorrhage on post-operative day 4 in a patient with P2Y12 reception over-inhibition at the time of the hemorrhage, resulted in the patient’s death (1.9%). No other treatment-related complication led to a disabling neurological deficit or death (mRS ≥3). Treatment-related mortality was 2%. There were no post-operative aneurysm ruptures. Angiographic follow-up was available in 47 aneurysms (86%, 8 follow-ups currently pending), with a mean time to last angiographic follow-up of 20 months. At last follow-up, 36 aneurysms were completely occluded (77%), 2 aneurysms had near-completed occlusion (4%, mean 97.3% vol reduction), and 9 aneurysms had incomplete occlusion (19%, mean 68.7% vol reduction). No aneurysms required retreatment.
Conclusion The PED is a safe and effective treatment for recurrent intracranial aneurysms, with high long-term complete aneurysm occlusion rates, low re-treatment rates, and a low rate of major treatment-related complications.
Disclosures J. Delgado Almandoz: 2; C; Medtronic Neurovascular, Accriva Diagnostics. Y. Kayan: 2; C; Medtronic Neurovascular. J. Fease: None. K. Uittenbogaard: None. J. Scholz: None. A. Milner: None. K. Nelson: None. A. Wallace: None. M. Mulder: None.
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