Introduction: The pipeline embolization device (PED) has gained popularity in the treatment of cerebral aneurysms in selected patients, with studies evaluating its efficacy and safety showing promising results. Nonetheless, difficulty persists with deployment in tortuous vasculature, with less than ideal stent positioning, stent stretching, and poor stent/arterial wall apposition encountered in such instances. We report our experience with balloon angioplasty in reducing stent stretching, improving stent/arterial wall apposition, and aiding in stent repositioning.

Methods: A retrospective medical record, angiographic and video review of all pipeline cases done at the University of Illinois was performed, and cases where balloon angioplasty was utilized were selected. Vessel tortuosity was classified according to the published method by Lin et al 1.

Results: A total of 6 patients were identified. All had pipeline stent deployment in the cavernous/paraclinoid segment of the ICA. We found (3) type-IV, (2) type-III, and 1 type-II ICA as classified by Lin et al 1. Indications for balloon angioplasty were incomplete stent apposition in 5 cases, and poor stent position in 1 case. A balloon was successfully used in all 6 cases, improving stent/arterial wall apposition. In all cases, a Transform balloon was used over exchange wire to maintain endoluminal access. Additionally, proximal stent stretching was observed in two of the six cases, and successfully reduced with the balloon, resulting in improved positioning and apposition of the stent. Four patients have had follow-up angiogram at 6 months, none of which showed in-stent stenosis.

Conclusions: Tortuous ICA vasculature can increase the risk of stent stretching, incomplete stent/arterial wall apposition, and poor stent positioning. Balloon angioplasty is a safe and effective method to circumvent these challenges, and should be considered as a viable option in these cases.

Patient Care: Balloon angioplasty is a safe and effective method to circumvent challenges encountered during pipeline stenting. This in turn can help improve patient outcomes after this type of procedure.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the advantages of balloon angioplasty in circumventing challenges during deployment of pipeline stent in tortuous vasculature, 2) Discuss, in small groups,indications for balloon angioplasty after pipeline stent deployment, 3) Identify an effective treatment for incomplete pipeline stent apposition, and poor pipeline stent position

References: 1. Lin LM, Colby GP, Jiang B, Uwandu C, Huang J, Tamargo RJ, et al: Classification of cavernous internal carotid artery tortuosity: a predictor of procedural complexity in Pipeline embolization. J Neurointerv Surg, 2014