Introduction: The Pipeline Embolization Device (PED) provides effective, durable and safe endovascular reconstruction of large and giant intracranial aneurysms. However, 80% of aneurysms are <10 mm. Treatment of small aneurysms (<10 mm) with flow diverters may be advantageous over endosaccular modalities with inherent risks of procedural rupture during aneurysm access or coil placement. We present periprocedural outcomes and early angiographic follow-up for 44 consecutive cases of internal carotid artery (ICA) aneurysms <10 mm treated with the PED.
Methods: We retrospectively reviewed a prospective, single-center aneurysm database to identify all patients with small (<10mm) ICA aneurysms who underwent PED treatment. Patient demographics, aneurysm characteristics, procedural details, complications, and technical and clinical outcomes were analyzed.
Results: Forty-four cases were performed in 41 patients (age range 31-78 years). PED was successfully implanted in 42 cases. Mean post-procedure hospital stay was 1.7 ± 0.3 days and 98% of patients were discharged home. Major complication occurred in one patient (2.3%), who died of early SAH. Transient neurological deficit, delayed ICH (asymptomatic), and delayed groin infection occurred in one patient each. Follow-up rate was 85.7% (42 aneurysms in 33 patients) with a mean follow-up of 3.9 ± 0.4 months. By 6 months post-PED implantation, angiographic success (complete or near complete aneurysm occlusion) was observed in 78.6%. Figure 1 and Figure 2 are representative cases demonstrating complete and near complete angiographic occlusion, respectively, on follow-up. Mild, asymptomatic, non-flow limiting in-stent stenosis was observed in 5.7% (2/35 cases). All 33 patients with follow-up remained at neurological baseline.
Conclusions: Small (<10mm) ICA aneurysm treatment with PED implantation is safe and carries a high angiographic success rate.
Patient Care: This research fills a knowledge gap on the indications of flow-diverters by focusing on small aneurysms alone. Results from this focused cohort series demonstrate that compared to PED implantation for large and giant aneurysms, use in small ICA aneurysms may be achieved with a lower complication rate and earlier angiographic success. Early angiographic success represents the potential for complete parent vessel reconstruction sooner than 6 months as previously suggested and as such, a decrease in the rupture risk of an aneurysm with a shorter waiting period. Such information can be reassuring for patients by decreasing the stress and anxiety associated with waiting for aneurysm occlusion.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Discuss the validity and safety of flow diversion as an alternative endovascular treatment for small ICA aneurysms, 2) Understand the advantage of early angiographic success (sooner than 6 months) with flow diversion in small aneurysms.