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  • Tourniquet Parent Artery Occlusion after Flow Diversion

    Final Number:
    282

    Authors:
    Visish M. Srinivasan MD; Maxim Mokin MD PhD; Edward A.M. Duckworth MD MS; Stephen Chen MD; Ajit S. Puri MD; Peter Kan MD, MPH, FRCSC

    Study Design:
    Other

    Subject Category:
    Aneurysm/Subarachnoid Hemorrhage

    Meeting: AANS/CNS Cerebrovascular Section 2017 Annual Meeting

    Introduction: The Pipeline Embolization Device (PED) is increasingly used for both on- and off-label purposes for treatment of intracranial aneurysms. The device gradually slows flow of blood into the aneurysm, but the high metal coverage of PED promotes endothelialization of the device. Occasionally, this leads to in-stent stenosis that is clinically well-tolerated. We present a multi-institutional Pipeline series that includes 4 cases of gradual, asymptomatic tourniquet occlusion within the PED and parent vessel.

    Methods: Institutional databases at each participating center were searched for patients treated with the Pipeline Embolization Device (ev3, Irvine, CA). We selected patients that had at least 50% stenosis or occlusion, and reviewed all relevant clinical and radiographic data.

    Results: A total of 326 cases performed by 5 neurointerventionalists across 4 institutions were reviewed. Among these, there were 4 cases of complete occlusion and 2 cases of 50% stenosis, for an occlusion rate of 1.2%. All patients were clinically asymptomatic.

    Conclusions: A gradual, tourniquet-like occlusion can occur following placement of PED, leading to vessel occlusion. This has been clinically well-tolerated by patients in our series due to the formation of pial collaterals as the stenosis progresses, likely due to ischemic preconditioning. Small parent vessel, preexisting stenosis, fusiform pathology, overlapping devices, and suboptimal antiplatelet therapy seem to be predisposing factors. Further experience and follow-up with these patients will allow us to characterize risk factors and optimize post-procedural therapy for these patients.

    Patient Care: By identifying the common complications and this newly described phenomenon associated with Pipeline, we may glean a better understanding of this phenomenon and tailor patient care appropriately. This initial description should prompt further investsigation.

    Learning Objectives: 1) Be able to identify the common applications for Pipeline 2) Be able to describe the common complications with Pipeline 3) Be able to distinguish between acute thrombosis and tourniquet occlusion

    References: 1. Bahl VK, Narang R: Elective stenting in small coronary arteries: lessons learnt from recent trials. Indian Heart J 53:275-281, 2001 2. Chalouhi N, Polifka A, Daou B, Kung D, Barros G, Tjoumakaris S, et al: In-Pipeline Stenosis: Incidence, Predictors, and Clinical Outcomes. Neurosurgery 77:875-879; discussion 879, 2015 3. Cohen JE, Gomori JM, Moscovici S, Leker RR, Itshayek E: Delayed complications after flow-diverter stenting: reactive in-stent stenosis and creeping stents. J Clin Neurosci 21:1116-1122, 2014 4. Dai D, Ding YH, Kelly M, Kadirvel R, Kallmes D: Histopathological findings following pipeline embolization in a human cerebral aneurysm at the basilar tip. Interv Neuroradiol 22:153-157, 2016 5. Daou B, Starke RM, Chalouhi N, Barros G, Tjoumakaris S, Rosenwasser RH, et al: P2Y12 Reaction Units: Effect on Hemorrhagic and Thromboembolic Complications in Patients With Cerebral Aneurysms Treated With the Pipeline Embolization Device. Neurosurgery 78:27-33, 2016 6. Daou B, Valle-Giler EP, Chalouhi N, Starke RM, Tjoumakaris S, Hasan D, et al: Patency of the posterior communicating artery following treatment with the Pipeline Embolization Device. J Neurosurg:1-6, 2016 7. Delgado Almandoz JE, Crandall BM, Scholz JM, Fease JL, Anderson RE, Kadkhodayan Y, et al: Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the Pipeline Embolization Device. J Neurointerv Surg 5 Suppl 3:iii3-10, 2013 8. Guedon A, Clarencon F, Di Maria F, Rosso C, Biondi A, Gabrieli J, et al: Very late ischemic complications in flow-diverter stents: a retrospective analysis of a single-center series. J Neurosurg:1-7, 2016 9. John S, Bain MD, Hui FK, Hussain MS, Masaryk TJ, Rasmussen PA, et al: Long-term Follow-up of In-stent Stenosis After Pipeline Flow Diversion Treatment of Intracranial Aneurysms. Neurosurgery 78:862-867, 2016 10. Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafe A, Cekirge S, et al: International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36:108-115, 2015 11. Lin N, Lanzino G, Lopes DK, Arthur AS, Ogilvy CS, Ecker RD, et al: Treatment of Distal Anterior Circulation Aneurysms With the Pipeline Embolization Device: A US Multicenter Experience. Neurosurgery 79:14-22, 2016 12. Murthy SB, Shah S, Venkatasubba Rao CP, Bershad EM, Suarez JI: Treatment of unruptured intracranial aneurysms with the pipeline embolization device. J Clin Neurosci 21:6-11, 2014 13. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D: The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 32:34-40, 2011 14. Puffer RC, Kallmes DF, Cloft HJ, Lanzino G: Patency of the ophthalmic artery after flow diversion treatment of paraclinoid aneurysms. J Neurosurg 116:892-896, 2012 15. Rangel-Castilla L, Munich SA, Jaleel N, Cress MC, Krishna C, Sonig A, et al: Patency of anterior circulation branch vessels after Pipeline embolization: longer-term results from 82 aneurysm cases. J Neurosurg:1-6, 2016 16. Vedantam A, Rao VY, Shaltoni HM, Mawad ME: Incidence and clinical implications of carotid branch occlusion following treatment of internal carotid artery aneurysms with the pipeline embolization device. Neurosurgery 76:173-178; discussion 178, 2015 17. Wajnberg E, Silva TS, Johnson AK, Lopes DK: Progressive deconstruction: a novel aneurysm treatment using the pipeline embolization device for competitive flow diversion: case report. Neurosurgery 10 Suppl 1:E161-166; discussion E166, 2014

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