In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Pipeline Embolization Device for Difficult-to-Treat, Extra-Cranial Carotid Dissections with High-Grade Stenosis: Report of 2 Cases and Review of the Literature

    Final Number:
    296

    Authors:
    Branden John Cord MD, MS, PhD, BA; Jacky Yeung MD; Ryan Matthew Hebert MD; Charles Christian Matouk BSc MD

    Study Design:
    Other

    Subject Category:
    Ischemic Stroke

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: Flow-diverting stents (FDS) are braided, self-expanding stents designed for the treatment of intra-cranial aneurysms. Their unique properties may also make them well suited for treating extra-cranial carotid artery dissections with high-grade stenosis. Here we report our experience treating two patients with the Pipeline Embolization Device (PED) in addition to a literature review focused on indications, clinical results, and complications.

    Methods: Two patients with symptomatic, medically refractory, extra-cranial carotid artery dissections underwent treatment with overlapping PEDs. A PUBMED search identified four articles reporting treatment of extra-cranial carotid dissections with FDS. Our analysis is restricted to those with high-grade stenosis.

    Results: Case 1) 58yM on Plavix for stroke presents with new thromboembolic strokes downstream of a L ICA chronic dissection with high-grade stenosis and pseudoaneurysm formation. The dissection and pseudoaneurysm were successfully treated in a two-stage procedure with overlapping PEDs and a proximal TCS. Case 2) 59yM presents with spontaneous left petrous-carotid dissection with severe stenosis, and recurrent thromboembolic strokes despite maximal medical therapy. The dissection was successfully treated with overlapping PEDs. A proximal TCS was used to repair an iatrogenic carotid dissection. At 6-month follow-up, both patients are without recurrent events. Review of the literature reveals 13 additional patients with 14 high-cervical carotid dissections and high-grade stenosis successfully treated with PEDs. Complications included iatrogenic dissection, delayed in-stent-thrombosis, and PED collapse.

    Conclusions: FDS treatment of extra-cranial carotid artery dissections with high-grade stenosis demonstrates high technical success and good intermediate results. TCS are stiff, large-system stents not well suited for the angulation of the high-cervical ICA. Classical intracranial stents are only available up to 4.5-mm in size and therefore may be too small for this ICA segment. PEDs are extremely navigable and available in a 5.0-mm size (expanding up to 5.25-mm). Their low porosity decreases thromboembolic risk by trapping friable debris and promotes thrombosis of pseudoaneurysms.

    Patient Care: Our two cases of symptomatic, medically refractory extra-cranial carotid artery dissections with associated high-grade stenosis treated with PEDs add to a growing body of literature describing the indications, outcomes, and complications associated with off-label use of flow diverting stents which will serve to guide physicians in making appropriate patient specific treatment decisions.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) compare and contrast the characteristics of traditional carotid stents, classical intracranial stents, and flow-diverting stents; 2) describe the relative indications and efficacy for treatment of carotid artery dissection with a flow-diverter stent; 3) discuss the complications associated with flow-diverter stenting in the context of extra-cranial carotid dissections

    References: 1. Cohen JE, Gomori JM, Rajz G, Itshayek E, Eichel R, Leker RR (2015) Urgent off-label use of the pipeline flow diverter stent in selected ischemic cerebrovascular conditions: thrombotic segments and tortuous arteries. J Neurointerv Surg 7(9):671-5 2. Brzezicki G, Rivet DJ, Reavey-Cantwell J (2015) Pipeline Embolization Device for treatment of high cervical and skull base carotid artery dissections: clinical case series. J Neurointerv Surg 0:1-7. 3. Vega RA, Brzezicki G, Reavey-Cantwell JF (2015) Delayed collapse of a Pipeline Embolization Device. Operative Neurosurgery 0(0):1-6. 4. Cohen JE, Gomori JM, Ben-Hur T, Moscovici S, Itschayek E (2012) The use of telescoped flow diverters as an endovascular bypass in the management of symptomatic chronic carotid occlusion. J Clin Neurosci 19(7):1026-8

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy