Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms

N. Adeeb; C.J. Griessenauer; A.A. Dmytriw; H. Shallwani; R. Gupta; P.M. Foreman; H. Shakir; J. Moore; N. Limbucci; S. Mangiafico; A. Kumar; C. Michelozzi; Y. Zhang; V.M. Pereira; C.C. Matouk; M.R. Harrigan; A.H. Siddiqui; E.I. Levy; L. Renieri; T.R. Marotta; C. Cognard; C.S. Ogilvy; A.J. Thomas

doi:10.3174/ajnr.A5696

Abstract

BACKGROUND AND PURPOSE: Flow diversion with the Pipeline Embolization Device is increasingly used for endovascular treatment of intracranial aneurysms due to high reported obliteration rates and low associated morbidity. While obliteration of covered branches in the anterior circulation is generally asymptomatic, this has not been studied within the posterior circulation. The aim of this study was to evaluate the association between branch coverage and occlusion, as well as associated ischemic events in a cohort of patients with posterior circulation aneurysms treated with the Pipeline Embolization Device.

MATERIALS AND METHODS: A retrospective review of prospectively maintained databases at 8 academic institutions from 2009 to 2016 was performed to identify patients with posterior circulation aneurysms treated with the Pipeline Embolization Device. Branch coverage following placement was evaluated, including the posterior inferior cerebellar artery, anterior inferior cerebellar artery, superior cerebellar artery, and posterior cerebral artery. If the Pipeline Embolization Device crossed the ostia of the contralateral vertebral artery, its long-term patency was assessed as well.

RESULTS: A cohort of 129 consecutive patients underwent treatment of 131 posterior circulation aneurysms with the Pipeline Embolization Device. Adjunctive coiling was used in 40 (31.0%) procedures. One or more branches were covered in 103 (79.8%) procedures. At a median follow-up of 11 months, 11% were occluded, most frequently the vertebral artery (34.8%). Branch obliteration was most common among asymptomatic aneurysms (P < .001). Ischemic complications occurred in 29 (22.5%) procedures. On multivariable analysis, there was no significant difference in ischemic complications in cases in which a branch was covered (P = .24) or occluded (P = .16).

CONCLUSIONS: There was a low occlusion incidence in end arteries following branch coverage at last follow-up. The incidence was higher in the posterior cerebral artery and vertebral artery where collateral supply is high. Branch occlusion was not associated with a significant increase in ischemic complications.

ABBREVIATIONS:

PCA: posterior cerebral artery
PED: Pipeline Embolization Device
VA: vertebral artery

Footnotes

Disclosures: Christophe Cognard—UNRELATED: Consultancy: Stryker, Medtronic, MicroVention. Elad I. Levy—UNRELATED: Board Membership: Acute Ischemic Stroke Clinical Advisory Board (Stryker), Advisory Board (NeXtGen Biologics), Advisory Board (MEDX), Advisory Board (Cognition Medical); Consultancy: Pulsar Vascular; Expert Testimony: Medical Malpractice, Comments: renders medical/legal opinion as an expert witness; Payment for Lectures Including Service on Speakers Bureaus: Medtronic, Abbott Vascular, Comments: honorarium for training and lectures (Medtronic), carotid training sessions for physicians (Abbott Vascular); Stock/Stock Options: Intratech Medical Ltd, NeXtGen Biologics, Neuravi/now Codman Neuro (Johnson & Johnson), sold April 2017. Thomas R. Marotta—UNRELATED: Consultancy: proctor for PED Medtronic; Patents (Planned, Pending or Issued): no money for eCLIPS/Evasc; Stock/Stock Options: eCLIPS/Evasc. Ajith J. Thomas—UNRELATED: Expert Testimony: CRICO, Comments: cerebrovascular disorders; OTHER RELATIONSHIPS: I am on the Data Safety Monitoring Board of the SCENT trial, a flow-diverter trial.* Adnan H. Siddiqui—UNRELATED: Consultancy: Amnis Therapeutics, Boston Scientific, Canon Medical Systems USA, Cerebrotech Medical Systems, Cerenovus, Claret Medical, Corindus Vascular Robotics, EndoStream Medical, Guidepoint Global consulting, Imperative Care, Integra, MicroVention, Penumbra, Rapid Medical, Rebound Therapeutics Corp, Silk Road Medical, StimMed, Stryker, Three Rivers Medical Center, VasSol, W.L. Gore & Associates, Medtronic; Stock/Stock Options: Amnis Therapeutics, Apama Medical, Blinktbi, Buffalo Technology partners, Cardinal Health, Cerebrotech Medical Systems, Claret Medical, Cognition Medical, EndoStream Medical, Imperative Care, International Medical Distribution Partners, Rebound Therapeutics Corp, Silk Road Medical, StimMed, Synchron, Three Rivers Medical, Viseon Spine; Other: Cerenovus LARGE trial and ARISE II trial, MicroVention FRED Trial and CONFIDENCE study, MUSC POSITIVE trial, Penumbra Separator 3D trial, COMPASS trial, INVEST trial, Comments: National Principal Investigator/Steering Committees. *Money paid to the institution.