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  • Pipeline embolization of ruptured, previously coiled posterior communicating artery aneurysms: case series and considerations for management

    Final Number:

    Jared Blaine Cooper MD; John Varmaa Wainwright MD; Christian Andrew Bowers MD; Chirag D. Gandhi MD, FACS; Justin G. Santarelli MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Coiled aneurysms have a high recurrence rate, ranging from 13-49%. Posterior communicating artery aneurysms have been shown to have a particularly high rate of recurrence after coiling with prior studies reporting recurrence in up to 37% of cases. In general, only 15% of aneurysms are completely occluded at time of initial coiling, and the presence of residual aneurysm is associated with a higher risk of post-treatment rupture in previously unruptured aneurysms. Previously ruptured aneurysms have an even higher rate of rupture when incompletely coiled, which is a critical factor when evaluating treatment strategies for intracranial aneurysms. The Pipeline Embolization Device (PED) has been effectively used to treat recurrent, previously coiled aneurysms. We assessed the efficacy and safety of the PED in the treatment of primarily coiled, ruptured aneurysms, with a focus on aneurysms of the posterior communicating artery.

    Methods: We performed a retrospective analysis of 19 patients who underwent PED treatment of a recurrent, previously coiled, ruptured aneurysm. The most recent cerebral angiogram was reviewed to assess efficacy with regards to recurrence and retreatment rates after PED placement. Safety was evaluated by assessing complications, morbidity, and mortality.

    Results: The average patient age at time of initial rupture was 56 years. Of the 19 aneurysms that recurred, 13 (68%) were Posterior Communicating Artery (PCoA) aneurysms. Of those patients who have received follow-up angiograms (53%) to date, aneurysm obliteration rate is 100%. There were no PED procedural complications or treatment related morbidity or mortalities.

    Conclusions: PED as a second-line treatment is a safe and effective modality for achieving aneurysm occlusion in recurrent, primarily coiled, ruptured PCoA aneurysms. We propose that a staged coil-to-PED approach be considered for management of ruptured PCoA aneurysms to achieve aneurysmal obliteration.

    Patient Care: We believe that a staged coil-PED approach for ruptured posterior communicating artery aneurysms offers patients a safe and effective means of achieving aneurysm obliteration. Additionally, we propose that this management strategy will lessen long-term patient cost and potential morbidity by reducing the amount of invasive follow-up procedures.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) describe the likelihood of aneurysm recurrence following primary coil embolization, 2) identify the risks of aneurysm recurrence, particularly after initial rupture, 3) recognize the utility of pipeline embolization for secondary management of recurrent, previously ruptured aneurysms, and 4) describe the potential application of a staged coil-PED treatment strategy for management of ruptured posterior communicating artery aneurysms

    References: 1. Munich SA, Cress MC, Rangel-Castilla L, et al. Neck remnants and the risk of aneurysm rupture after endovascular treatment with coiling or stent-assisted coiling: much ado about nothing? Neurosurgery. 2018; 0: 1-10. 2. Daou B, Tarke RM, Chalouhi N, et al. The use of the pipeline embolization device in the management of recurrent previously coiled cerebral aneurysms. Neurosurgery. 2015; 77: 692-697. 3. Raymond J, Guilbert F, Georganos SA, et al. Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke. 2003; 34(6): 1398-1403. 4. Ferns SP, Sprengers ME, van Rooij WJ, et al. Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates. Stroke. 2009;40(8):e523-e529.

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