Introduction: Endovascular Pipeline embolization device (PED) placement for intracranial aneurysms is performed under general anesthesia (GA) in most centers for perceived improved image quality and patient safety. The objective of this work is to report the feasibility, safety and outcomes associated with PED use for intracranial aneurysm treatment under conscious sedation (CS) and local anesthetics (LA).
Methods: Between March 2012 and September 2014, 130 patients with 139 intracranial aneurysms (8 ruptured) were treated with PED at the author’s institution under CS. Procedure details and time, radiation exposure, fluoroscopy time, clinical and radiographic outcomes and complications were reviewed.
Results: A total 128 PEDs deployment under CS were performed. All patients underwent successful completion of treatment. Six cases were converted from CS to GA. The mean time between patient entered the angiosuite and the procedure started was 18 min (range, 5min-1hr10min), length of the procedure was 1hr25 min (range 30min-3hrs51min). Fluoroscopy time and radiation exposure mean value were 36.17 (SD±18.4) and 1367 mGy (SD±897), respectively. The mean amount of contrast dye administration was 211.37 mL (SD±83.5). There were 9 (7%) intraoperative complications, 5 of them with transient neurological changes.
Conclusions: In the author’s experience, conscious sedation with local anesthetics for PED placement for intracranial aneurysms is feasible and safe. Operating room, procedure, fluoroscopy times and radiation exposure is similar or less than other reports of PED placement under GA. It allows direct neurological evaluation and earlier detection and response to intraprocedural complications.
Patient Care: Most endovascular interventions, including intracranial stents, are preferentially performed under general anesthesia due to patient comfort, control of hemodynamic and respiratory profiles, and better image quality in an immobile patient. Disadvantage of general anesthesia includes risk of respiratory and hemodynamic instability during induction, inaccessibility to neurological examination during the procedure, and greater length of total procedure time, possible need for intraoperative neuromonitoring. Potential complications related to PED deployment include vessel perforation, arterial thrombosis, dissection or stenosis, vasospasm, and perforator occlusion.These complications can be heralded by neurological changes, patients under general anesthesia, might go undetected until the procedure is over and the opportunity to intervene has passed.
Learning Objectives: Realize the feasibility and safety of Pipeline embolization device placement for intracranial aneurysms under conscious sedation.
Identify the benefits of access to neurological examination during Pipeline embolization
Identify the potential complications related to Pipeline embolization device placement under conscious sedation