Introduction:
Flow diversion via Pipeline Embolization Device (PED) is a novel aneurysm treatment and is indicated for large, wide-necked aneurysms of internal carotid artery from petrous to superior hypophyseal segments. Its utilization in distal carotid circulation aneurysms has not been well studied.
Methods:
We retrospectively reviewed the clinical and radiographic records of all patients who underwent endovascular treatment with PED. Those with middle cerebral artery aneurysms, anterior communicating artery aneurysms, and distal anterior cerebral artery aneurysms were included in the analyses.
Results:
Nine patients with distal anterior circulation aneurysms were treated in a single institution from 2011–2013. The mean age at surgery was 53.3 and 6 were female. Four patients (44.4%) presented with neurological deficit and 1 (11.1%) with hemorrhage. Five aneurysms were fusiform, 3 were dissecting, and 1 was saccular. Average aneurysm size was 15.1 mm and 4 were giant aneurysms. Six aneurysms arose from M1 segment, 1 from M2 segment, 1 from A1/A2 function, and 1 from distal anterior cerebral artery. PED deployment was successful in 8 patients, with coil utilized in 2 cases. Clinical follow-up was available for an average of 6.4 months (range 1.3-13 months). Eight patients had post-operative vascular imaging (5 DSA, 3 CTA): 6 aneurysms had no residual filling and 2 had partial thrombosis at dome. One PED failed to open proximally upon deployment and resulted in post-operative stroke, and another patient had in-stent thrombosis and required intra-arterial thrombolysis. No late complications occurred during follow-up. Overall, modified Rankin Score (mRS) improved in 5 patients (55.6%) after treatment, stayed the same in 3 (33.3%), and worsened in 1 (11.1%).
Conclusions:
PED can be safe and effective in the treatment of distal anterior circulation aneurysms with difficult anatomy for standard surgical or endovascular techniques. Careful patient selection and judicious use of coils are essential to avoid complications.
Patient Care:
to share our experience using PED to treat difficult MCA/ACA aneurysms.
Learning Objectives:
By the conclusion of this session, participants should be able to 1) understand the indication of using PED for treating distal carotid circulation aneurysms; 2) describe the anatomical challenge of using PED to treat distal carotid circulation aneurysms; and 3) technical aspect of avoiding complications during PED deployment, with or without coil packing.