1
|
Chinnadurai A, Salih M, Taussky P, Ogilvy C. Safety and Outcomes of the Off-Label Treatment of Intracranial Aneurysms with Pipeline Embolization Device: A Systematic Review and Meta-analysis. World Neurosurg 2024; 185:e786-e799. [PMID: 38432507 DOI: 10.1016/j.wneu.2024.02.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Off-label use of pipeline embolization devices (PEDs) has been increasingly used for endovascular treatment of intracranial aneurysms. Numerous articles have highlighted the safety and effectiveness of PED placement from independent centers for both on- and off-label indications. There remains a paucity of information that considers overall safety and efficacy of off-label PED placement across the existing literature. Our objective is to systematically review the safety and occlusion outcomes of PED off-label use in intracranial aneurysm embolization. METHODS A systematic search of PubMed and Embase was performed to identify studies on off-label use of PED. The selected studies provided relevant information, including study characteristics, patient demographics, clinical outcomes, peri-procedural complications, and long-term outcomes, which were subjected to meta-analysis. RESULTS Twelve studies met the inclusion and exclusion criteria. There were 747 patients and 791 aneurysms included for analysis. Among the patient, 69.2% were female, with an age range of 16 to 80 years. The overall incidence rates for ischemic and hemorrhagic complications were 7% (95% CI: 4%-10%) and 2% (95% CI: 0%-4%), respectively. The mortality rate was 1% (95% CI: 0%-4%). The occlusion rates of aneurysm at initial follow up and 1 year follow-up were 82% (95% CI: 72%-91%) and 81% (95%CI: 75%-86%), respectively. Meta-regression analysis indicated no correlation between occlusion rate and factors such as age, sex, aneurysm size, location, morphology, rupture, or history of treatment. CONCLUSIONS Despite variations in results observed in single-center studies, this meta-analysis provides evidence supporting the safety and efficacy of PED off-label use.
Collapse
Affiliation(s)
- Anu Chinnadurai
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Mira Salih
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA
| | - Christopher Ogilvy
- Neurosurgical Service, Harvard Medical School, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts, USA.
| |
Collapse
|
2
|
Chen C, Ling C, Yang Y, Wang G, Li X, Huang T, Wu Z, Tai C, Wang H. Comparison Between the Efficacy of a Flow Diverter and Interventional Trapping with Bypass in the Treatment of Unruptured Large- or Giant-Sized ICA Aneurysms. World Neurosurg 2023; 178:e382-e393. [PMID: 37482085 DOI: 10.1016/j.wneu.2023.07.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/15/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVE Management of large- or giant-sized internal carotid artery aneurysms (LICAAs) remains challenging. Whether a flow diverter device (FDD) or interventional trapping with extracranial-intracranial bypass (ITB) is better, remains unclear. METHODS We conducted a multicenter retrospective analysis of unruptured LICAA patients treated with FDD or ITB at 3 medical centers. Both the effectiveness and safety results of FDD and ITB were compared. RESULTS In total, 101 aneurysms in 95 patients treated with FDDs and 36 aneurysms in 36 patients managed with ITBs were included (September 2014-June 2021). There was no significant difference between the groups in the complete obliteration rate 1 year after surgery (P = 0.101). There were 2 relapse cases (2.0%) and 4 retreated cases (4.0%) in the FDD group and 1 relapse case (2.8%) and 2 retreated cases (5.6%) in the ITB group. Neither the relapse rates nor retreat rates between groups were significantly different. The neurological morbidity rates were 4.0% (4/101) and 2.8% (1/36) in the FDD group and ITB group, respectively, and were not significantly different. There was 1 mortality case in each group, and the mortality rates were not significantly different (P = 0.443). Both the perioperative and overall (perioperative plus long-term) complication rates in the FDD group were significantly lower than those in the ITB group (P = 0.033, P = 0.039). CONCLUSIONS FDD had comparable surgical efficacy and a significantly lower postoperative complication rate to traditional ITB. FDD might be preferable to ITB as a treatment modality for LICAA.
Collapse
Affiliation(s)
- Chuan Chen
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Cong Ling
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yang Yang
- Department of Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Gang Wang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Xifeng Li
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Tengchao Huang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Zhimin Wu
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Chuyang Tai
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Hui Wang
- Department of Neurosurgery, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, PR China.
| |
Collapse
|
3
|
Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clin Neurol Neurosurg 2021; 212:107063. [PMID: 34864490 DOI: 10.1016/j.clineuro.2021.107063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis. METHODS Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis. RESULTS In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%). CONCLUSION Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.
Collapse
|
4
|
Li W, Zhu W, Liu J, Yang X. Imbalanced flow changes of distal arteries: An important factor in process of delayed ipsilateral parenchymal hemorrhage after flow diversion in patients with cerebral aneurysms. Interv Neuroradiol 2021; 27:788-797. [PMID: 33823618 DOI: 10.1177/15910199211009120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Hemodynamic forces may play a role in symptomatic delayed ipsilateral parenchymal hemorrhage (DIPH) of intracranial aneurysm (IA) after flow diverter placement. We aimed to investigate the hemodynamic risk factors in the postsurgical DIPH process. METHODS Six patients with internal carotid artery (ICA) aneurysm developed to DIPH and 12 patients without DIPH (1:2 matched controls) after flow diverter were included between January 2015 to January 2019. Postsurgical hemodynamics of distal arteries (terminal ICA, middle cerebral artery (MCA), anterior cerebral artery (ACA)) were investigated using computational fluid dynamics, as well as the hemodynamic alteration between pre- and post-treatment. The DIPH related and unrelated distal arteries (either MCA or ACA) were discriminated and compared. Definition of imbalance index is the difference in increased velocity post-flow diverter between MCA and ACA and was used to evaluate the blood flow distribution of distal arteries. RESULTS The mean and maximum flow velocities in the terminal ICA increased significantly after treatment in both groups. In DIPH group, the increase rate of mean velocity in the DIPH-related artery was significantly higher than that in DIPH-unrelated artery after the treatment (20.98 ± 15.38% vs -6.40 ± 7.74%; p = 0.028). Between the DIPH and control group, the baseline characteristics were well matched. However, a higher imbalance index of mean velocity was found in DIPH group (27.38 ± 13.03% vs 10.85 ± 14.12%; p = 0.031). CONCLUSION The mean velocity of DIPH related artery increased more, and the imbalance in increased blood flow distribution of distal arteries might play an important role in DIPH after flow diverter of IAs.
Collapse
Affiliation(s)
- Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
5
|
Guédon A, Thépenier C, Shotar E, Gabrieli J, Mathon B, Premat K, Lenck S, Degos V, Sourour N, Clarençon F. Predictive score for complete occlusion of intracranial aneurysms treated by flow-diverter stents using machine learning. J Neurointerv Surg 2020; 13:341-346. [PMID: 33219150 DOI: 10.1136/neurintsurg-2020-016748] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/26/2020] [Accepted: 11/03/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Complete occlusion of an intracranial aneurysm (IA) after the deployment of a flow-diverter stent is currently unpredictable. The aim of this study was to develop a predictive occlusion score based on pretreatment clinical and angiographic criteria. METHODS Consecutive patients with ≥6 months follow-up were included from 2008 to 2019 and retrospectively analyzed. Each IA was evaluated using the Raymond-Roy occlusion classification (RROC) and dichotomized as occluded (A) or residual (B/C); 80% of patients were randomly assigned to the training sample. Feature selection and binary outcome prediction relied on logistic regression and threshold maximizing class separation selected by a CART tree algorithm. The feature selection was addressed by a genetic algorithm selected from the 30 pretreatment available variables. RESULTS The study included 146 patients with 154 IAs. Feature selection yielded a combination of six variables with a good cross-validated accuracy on the test sample, a combination we labeled DIANES score (IA diameter, indication, parent artery diameter ratio, neck ratio, side-branch artery, and sex). A score of more than -6 maximized the ability to predict RROC=A with sensitivity of 87% (95% CI 79% to 95%) and specificity of 82% (95% CI 64% to 96%) in the training sample. Accuracy was 86% (95% CI 79% to 94%). In the test sample, sensitivity and specificity were 89% (95% CI 77% to 98%) and 60% (95% CI 33% to 86%), respectively. Accuracy was 81% (95% CI 69% to 91%). CONCLUSION A score was developed as a grading scale for prediction of the final occlusion status of IAs treated with a flow-diverter stent.
Collapse
Affiliation(s)
- Alexis Guédon
- Biosurgical Research Lab (Carpentier Foundation), European Georges-Pompidou Hospital, INSERM UMR_S 1140, University of Paris, Paris, France.,Department of Anatomy, University of Paris, Paris, France
| | - Cédric Thépenier
- French Armed Forces Biomedical Research Institute (IRBA), Brétigny-sur-Orge, France.,Department of Experimental Neuropathology, Institut Pasteur, Paris, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Joseph Gabrieli
- Department of Neuroradiology, University of Padova Faculty of Medicine and Surgery, Padova, Veneto, Italy
| | - Bertrand Mathon
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, Île-de-France, France
| | - Kévin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Sorbonne University, Paris, Île-de-France, France
| | - Stéphanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Vincent Degos
- Sorbonne University, Paris, Île-de-France, France.,Department of Neuro-anesthesiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Nader Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, AP-HP, Paris, France .,Sorbonne University, Paris, Île-de-France, France
| |
Collapse
|
6
|
Shin DS, Carroll CP, Elghareeb M, Hoh BL, Kim BT. The Evolution of Flow-Diverting Stents for Cerebral Aneurysms; Historical Review, Modern Application, Complications, and Future Direction. J Korean Neurosurg Soc 2020; 63:137-152. [PMID: 32120455 PMCID: PMC7054118 DOI: 10.3340/jkns.2020.0034] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
In spite of the developing endovascular era, large (15–25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.
Collapse
Affiliation(s)
- Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Christopher P Carroll
- Department of Brain & Spine Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA.,Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | | | - Brian L Hoh
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| |
Collapse
|
7
|
Nariai Y, Kawamura Y, Takigawa T, Hyodo A, Suzuki K. Pipeline embolization for an iatrogenic intracranial internal carotid artery pseudoaneurysm after transsphenoidal pituitary tumor surgery: Case report and review of the literature. Interv Neuroradiol 2019; 26:74-82. [PMID: 31505983 DOI: 10.1177/1591019919874943] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Intracranial pseudoaneurysms are uncommon and among the most difficult lesions to treat with surgery or endovascular means without parent artery sacrifice. Here, we report on a patient who underwent successful treatment using a flow-diverting stent for an iatrogenic intracranial internal carotid artery pseudoaneurysm following a vessel injury after endoscopic pituitary tumor resection via the transsphenoidal approach. A 62-year-old man with a Rathke's cleft cyst presenting with bitemporal hemianopia and progressive decline of left visual acuity underwent endoscopic transsphenoidal pituitary tumor resection. During dura incision, brisk arterial bleeding was encountered from the right internal carotid artery. Immediate packing was performed, and hemostasis was achieved. Three days after the vessel injury, an angiography revealed a pseudoaneurysm (2.9 × 2.1 mm) at the cavernous segment of the right internal carotid artery, which showed enlargement on follow-up magnetic resonance imaging at six days postoperatively. Pipeline embolization was performed nine days after the vessel injury. Angiography performed one month after Pipeline embolization revealed significant stagnation but not complete occlusion of blood flow inside the pseudoaneurysm cavity. Dual antiplatelet therapy was replaced with single antiplatelet therapy. Follow-up angiograms three months after Pipeline embolization confirmed complete obliteration of the pseudoaneurysm and successful endoluminal reconstruction of the damaged vessel. Despite the possibility of short-term bleeding and the need for dual antiplatelet therapy administration for a certain period, the use of flow-diverting stents is a feasible vessel-sparing option in the management of intracranial internal carotid artery pseudoaneurysms resulting from transsphenoidal surgery injuries if intraoperative hemodynamic stability can be achieved with effective packing.
Collapse
Affiliation(s)
- Yasuhiko Nariai
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yosuke Kawamura
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Akio Hyodo
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Kensuke Suzuki
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| |
Collapse
|
8
|
Atallah E, Saad H, Mouchtouris N, Bekelis K, Walker J, Chalouhi N, Tjoumakaris S, Smith M, Rosenwasser RH, Zarzour H, Herial N, Feghali J, Gooch MR, Missios S, Sweid A, Jabbour P. Pipeline for Distal Cerebral Circulation Aneurysms. Neurosurgery 2019; 85:E477-E484. [DOI: 10.1093/neuros/nyz038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 01/27/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms.
OBJECTIVE
To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes.
METHODS
Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning.
RESULTS
A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up.
CONCLUSION
Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.
Collapse
Affiliation(s)
- Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neurosciences Institute, Little Rock, Arkansas
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kimon Bekelis
- Department of Neurological Surgery, Good Samaritan Hospital Medical Center, West Islip, New York
| | - Jackson Walker
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Michelle Smith
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - James Feghali
- Department of Neurosurgery, American University of Beirut, Beirut, Lebanon
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Symeon Missios
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
9
|
Iosif C, Biondi A. Braided stents and their impact in intracranial aneurysm treatment for distal locations: from flow diverters to low profile stents. Expert Rev Med Devices 2019; 16:237-251. [DOI: 10.1080/17434440.2019.1575725] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Christina Iosif
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
- Department of Interventional Neuroradiology, Erasmus University Hospital, Brussels, Belgium
- Associate Professor in Radiology, European University of Cyprus, Nicosia, Cyprus
| | - Alessandra Biondi
- Department of Neuroradiology and Endovascular Treatment, Jean-Minjoz University Hospital, Besancon, France
| |
Collapse
|
10
|
Al Kasab S, Guerrero WR, Nakagawa D, Samaniego EA, Ortega-Gutierrez S, Hasan D. Safety and Efficacy of the Pipeline Embolization Device Use in the Outside Circle of Willis Located Intracranial Aneurysms: A Single-Center Experience. INTERVENTIONAL NEUROLOGY 2019; 8:83-91. [PMID: 32508889 DOI: 10.1159/000495074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 11/02/2018] [Indexed: 11/19/2022]
Abstract
Background The use of Pipeline Embolization Device (PED) is approved by the US Food and Drug Administration (FDA) to treat aneurysms located between the petrous and superior hypophyseal segments of the internal carotid artery. The purpose of this study is to evaluate the feasibility and efficacy of treating aneurysms outside the FDA approved anatomical locations. Furthermore, we analyze the safety of our antiplatelet protocol. Methods Data on all patients treated with PED at our center from March 2015 to December 2017 were reviewed. Only patients with aneurysms treated with PED as off label use were included. Procedural complications and long-term functional outcome measured by modified Rankin Scale (mRS) were recorded. Tirofiban maintenance infusion was administered intravenously after PED deployment. None of the patients had platelet function testing. Results A total of 36 patients harboring 36 aneurysms were included in the study. Mean age was 58.2 years ±14.6. Nineteen were women (52.8%) and most aneurysms were unruptured (80.6%). There were no intraoperative complications. Five patients experienced postoperative complications - 4 ischemic strokes and one groin hematoma. None led to any significant disability at follow-up. Thirty-one patients (86.1%) achieved an mRS of 0-2 at follow-up. A Raymond-Roy classification of 1 was achieved in 78.9% of patients. Conclusion The use of PED to treat aneurysms located outside the circle of Willis is feasible and effective. Our novel antiplatelet protocol did not require platelet function assay testing and did not lead to a higher rate of thrombo-embolic events compared to what has been previously reported.
Collapse
Affiliation(s)
- Sami Al Kasab
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Waldo R Guerrero
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Daichi Nakagawa
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.,Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| |
Collapse
|
11
|
Zhang Y, Ma C, Liang S, Yan P, Liang F, Guo F, Jiang C. Morphologic Feature Elongation Can Predict Occlusion Status Following Pipeline Embolization of Intracranial Aneurysms. World Neurosurg 2018; 119:e934-e940. [DOI: 10.1016/j.wneu.2018.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/02/2018] [Accepted: 08/03/2018] [Indexed: 11/30/2022]
|
12
|
Outcomes After Off-Label Use of the Pipeline Embolization Device for Intracranial Aneurysms: A Multicenter Cohort Study. World Neurosurg 2018; 115:e200-e205. [DOI: 10.1016/j.wneu.2018.04.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 11/19/2022]
|
13
|
Volker M, Anastasios M, Jan B, Nuran A, Thomas L, Franziska D, Pantelis S, De-Hua C, Christoph K. Treatment of Intracranial Aneurysms with the Pipeline Embolization Device Only: a Single Center Experience. Neurointervention 2018. [PMID: 29535896 PMCID: PMC5847888 DOI: 10.5469/neuroint.2018.13.1.32] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The aim of this study was to evaluate the technical feasibility and rate of mid-term occlusion in aneurysms treated solely with the Pipeline Embolization Device (PED) in a German tertiary care university hospital. Materials and Methods Forty-nine non-consecutive intracranial aneurysms underwent endovascular treatment using the PED exclusively between March 2011 and May 2017 at our institution. Primary endpoint was a favorable aneurysm occlusion defined as OKM C1-3 and D (O'Kelly Marotta Scale). Secondary endpoints were retreatment rate and delayed complications. Median follow-up was 200 days. Results The mean aneurysm size was 7.1 ± 5.3 mm. Forty-four aneurysms were located in the anterior circulation (90%). Ten aneurysms were ruptured (20%). Branching vessels from the sac were observed in 11 aneurysms (22%). Favorable obliteration immediately after PED placement was seen in 13/49 aneurysms (27%), of those nine aneurysms were completely occluded (18%). Angiographic and clinical follow-up was available for 45 cases (92%); 36/45 aneurysms (80%) were occluded completely and 40/45 aneurysms (89%) showed a favorable occlusion result. A branching vessel arising from the aneurysm sac was associated with incomplete occlusion (P < .05). All electively treated patients had good outcome (mRS 0). Three aneurysms (6%) required additional treatment due to aneurysm recurrence. Conclusion In our series, treatment of intracranial aneurysms with the PED was associated with favorable occlusion rates and low complication rates at mid-term follow-up. The presence of branching vessels arising from the aneurysms sac was predictive for an incomplete occlusion.
Collapse
Affiliation(s)
- Maus Volker
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Mpotsaris Anastasios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Borggrefe Jan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Abdullayev Nuran
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Liebig Thomas
- Department of Neuroradiology, Charité, Berlin, Germany
| | - Dorn Franziska
- Department of Neuroradiology, University Hospital Munich (LMU), Munich, Germany
| | - Stavrinou Pantelis
- Department of Neurosurgery, University Hospital Cologne, Cologne, Germany
| | - Chang De-Hua
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Kabbasch Christoph
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
14
|
Amenta PS, Medel R, Dumont AS. Editorial. FIAT, flow diverters, and establishing the role of new technology. J Neurosurg 2017; 127:449-453. [DOI: 10.3171/2016.5.jns161096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
15
|
Patel PD, Chalouhi N, Atallah E, Tjoumakaris S, Hasan D, Zarzour H, Rosenwasser R, Jabbour P. Off-label uses of the Pipeline embolization device: a review of the literature. Neurosurg Focus 2017; 42:E4. [DOI: 10.3171/2017.3.focus1742] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Pipeline embolization device (PED) is the most widely used flow diverter in endovascular neurosurgery. In 2011, the device received FDA approval for the treatment of large and giant aneurysms in the internal carotid artery extending from the petrous to the superior hypophyseal segments. However, as popularity of the device grew and neurosurgeons gained more experience, its use has extended to several other indications. Some of these off-label uses include previously treated aneurysms, acutely ruptured aneurysms, small aneurysms, distal circulation aneurysms, posterior circulation aneurysms, fusiform aneurysms, dissecting aneurysms, pseudoaneurysms, and even carotid-cavernous fistulas. The authors present a literature review of the safety and efficacy of the PED in these off-label uses.
Collapse
Affiliation(s)
- Purvee D. Patel
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
- 2Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; and
| | - Nohra Chalouhi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Elias Atallah
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Stavropoula Tjoumakaris
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - David Hasan
- 3Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hekmat Zarzour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Robert Rosenwasser
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Pascal Jabbour
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Martínez-Galdámez M, Lamin SM, Lagios KG, Liebig T, Ciceri EF, Chapot R, Stockx L, Chavda S, Kabbasch C, Farago G, Nordmeyer H, Boulanger T, Piano M, Boccardi EP. Periprocedural outcomes and early safety with the use of the Pipeline Flex Embolization Device with Shield Technology for unruptured intracranial aneurysms: preliminary results from a prospective clinical study. J Neurointerv Surg 2017; 9:772-776. [PMID: 28223428 PMCID: PMC5583676 DOI: 10.1136/neurintsurg-2016-012896] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/03/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE The Pipeline Embolization Device (PED) has become a routine first-line option for treatment of intracranial aneurysms (IAs). We assessed the early safety and technical success of a new version of PED, Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield), which has the same design and configuration but has been modified to include a surface synthetic biocompatible polymer. MATERIALS AND METHODS The Pipeline Flex Embolization Device with Shield Technology (PFLEX) study is a prospective, single-arm, multicenter study for the treatment of unruptured IAs using Pipeline Shield. The primary study endpoints included the occurrence of major stroke in the territory supplied by the treated artery or neurologic death at 1 year post-procedure. Secondary endpoints included the rate of Pipeline Shield-related or procedure-related serious or non-serious adverse events. Analyses were conducted to evaluate early safety findings in the 30-day post-procedure period as well as technical procedural success outcomes. RESULTS Fifty patients with 50 unruptured target IAs were enrolled. Mean aneurysm diameter was 8.82±6.15 mm. Thirty-eight aneurysms (76%) were small (<10 mm). Device deployment was technically successful with 98% of devices. Complete wall apposition was achieved immediately post-procedure in 48 cases (96%). No major strokes or neurologic deaths were reported in the 30-day post-procedure period. CONCLUSIONS The results of this first experience with the new Pipeline Flex corroborate the early safety of the device. Mid-term and long-term follow-up examinations will provide data on safety outcomes at the 6-month and 1-year follow-up periods. CLINICAL TRIAL REGISTRATION NCT02390037.
Collapse
Affiliation(s)
- Mario Martínez-Galdámez
- Department of Interventional Neuroradiology/Endovascular Neurosurgery, Fundación Jiménez-Díaz, Madrid, Spain
| | | | - Konstantinos G Lagios
- Department of Interventional Neuroradiology, Hellenic Air Force Hospital, Goudi, Greece
| | - Thomas Liebig
- Department of Neuroradiology, Institut für Neuroradiologie, Charite, Berlin, Germany
| | - Elisa F Ciceri
- Department of Interventional Neuroradiology, Foundation Neurological Institution 'C Besta', Milan, Italy.,Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Rene Chapot
- Department of Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Luc Stockx
- Department of Neuroradiology, Ziekenhuizen Oost-Limburg, Genk, Belgium
| | | | - Christoph Kabbasch
- Department of Neuroradiology, Institut für Neuroradiologie, Charite, Berlin, Germany
| | - Giuseppe Farago
- Department of Interventional Neuroradiology, Foundation Neurological Institution 'C Besta', Milan, Italy
| | - Hannes Nordmeyer
- Department of Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany
| | - Thierry Boulanger
- Department of Neuroradiology, Ziekenhuizen Oost-Limburg, Genk, Belgium
| | - Mariangela Piano
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
| | - Edoardo P Boccardi
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Milan, Italy
| |
Collapse
|
17
|
Feng MT, Wen WL, Feng ZZ, Fang YB, Liu JM, Huang QH. Endovascular Embolization of Intracranial Aneurysms: To Use Stent(s) or Not? Systematic Review and Meta-analysis. World Neurosurg 2016; 93:271-8. [DOI: 10.1016/j.wneu.2016.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/03/2016] [Accepted: 06/06/2016] [Indexed: 11/27/2022]
|