Ruptured Intracranial Aneurysms Treated with the Pipeline Embolization Device: A Systematic Review and Pooled Analysis of Individual Patient Data

Systematic evaluation of neuro-ophthalmic outcomes of the ophthalmic artery covered by flow-diverter

Carotid-ophthalmic aneurysms (COA) are complex and severe intracranial arterial lesions, and their treatment and management have always been a focus of clinical research. In recent years, the introduction of flow diverters (FD) has provided a revolutionary method for the treatment of intracranial aneurysms (IA). Although FD has achieved significant success in reducing the risk of COA rupture, the complex anatomical structure and critical function of the ophthalmic artery (OphA) mean that covering the OphA with FD may lead to adverse ophthalmic outcomes. This review aims to systematically examine the ocular complications and their mechanisms when FD covers the OphA in the treatment of COA, emphasizing the potential risks that clinicians should be aware of when applying FD treatment, to reduce complications and improve the overall prognosis of patients.

Initial Experience with the Pipeline Vantage Flow Diverter for Intracranial Aneurysms: A Systematic Review and Meta-Analysis

BACKGROUND

The Pipeline Vantage Flow diverter (Vantage) is the latest generation of Pipeline flow diverters introducing Cobalt-chronium drawn-filled tubing and 48 to 68 wires.

PURPOSE

We report the initial safety and efficacy of Vantage in treating intracranial aneurysms in the published literature.

DATA SOURCES

A systematic review and meta-analysis was conducted according to established protocols. Searches were conducted in PubMed, Scopus, Web-of-Science, and Embase databases up to December 2023. Original studies reporting treatment outcomes for intracranial aneurysms using Vantage in more than five patients were included.

STUDY SELECTION

Pooled data from 5 studies (373 patients, 418 aneurysms) were analyzed.

DATA ANALYSIS

Outcomes of interest were: technical success, occlusion rates, complication outcomes and mortality.

DATA SYNTHESIS

A technical success rate of 99.2% (95% CI: 98.29%-100%) was found. In unruptured cases, success rate was 378/383 (99.6%) versus 17/20 (85.0%) in ruptured cases (P < .01). Complete occlusion rate was 74.3% (95% CI: 67.43%-80.59%), with no significant difference between ruptured and unruptured cases (P = 0.72); median of follow up 6 months. Overall mortality rate was 1.2% (95% CI: 0.01%-3.64%), significantly higher in ruptured (18.6%; 95% CI: 5.13%-36.26%) versus unruptured cases (0.23%; 95% CI: 0%-1.36%) (P < 0.01). Hemorrhagic complications occurred at 1% (95% CI: 0%-3.36%) pooled rate. Thromboembolic complications were reported at 6.1% (95% CI: 2.60%-10.73%), decreasing to 4.35% (95% CI: 1.91%-7.54%) after excluding one outlier study.

LIMITATIONS

Only five studies, some with small number of patients, were included in this meta-analysis which may limit the generalizability of our findings. The absence of long term follow-up also limits the assessment of treatment durability.

CONCLUSIONS

In this meta-analysis, we found that Vantage initial experience is similar to previous version of the Pipeline Embolization Device in terms of safety and efficacy for treatment of intracranial aneurysms, in particular unruptured aneurysms. Further prospective and comparative studies with patient outcome data specific to aneurysm location are needed to confirm the safety and efficacy of Vantage.

Endovascular treatment of ruptured basilar artery trunk aneurysms: complications and long-term outcomes

OBJECT

Treatment of ruptured basilar artery trunk (BAT) aneurysms is challenging, and is associated with high complication and mortality rates. Herein, we analyzed the complications, long-term outcomes, and outcome predictors of endovascular treatment for ruptured BAT aneurysms.

METHODS

Between January 2011 and July 2023, 36 patients with 36 ruptured BAT aneurysms underwent endovascular treatment at our institution. The postprocedural complications and clinical and angiographic outcomes were subsequently reviewed, and the risk factors for postprocedural complications were evaluated.

RESULTS

All 36 aneurysms in 36 patients were treated successfully. The median clinical follow-up time was 47.0 (IQR: 10.5, 84.5) months. Overall, complications occurred in 10 (27.8%) patients, including 3 (8.3%) deaths. Ischemic events occurred in seven (19.4%) patients, while three (8.3%) patients had shunt-dependent hydrocephalus, of whom one (2.8%) patient had both shunt-dependent hydrocephalus and ischemic events. The cumulative survival rates at 3 and 5 years were 94.1% and 87.8%, respectively. The cumulative 3- and 5-year complication-free survival rates were 75.0% and 70.0%, respectively. Multivariate Cox regression analysis revealed that diabetes mellitus (HR:8.76, 95%CI:2.35-32.69, p=0.001), and Glasgow coma scale score ≤ 12 before the procedure (HR:5.04, 95%CI:1.40-18.12, p=0.013) were associated with overall postprocedural complications. The complete aneurysm occlusion rate was 61.5% at a median angiography follow-up time of 6.0 (IQR: 5.0, 6.0) months.

CONCLUSIONS

Endovascular treatment is a safe and feasible option for treating ruptured BAT aneurysms. The rate of favorable outcomes at the final follow-up was satisfactory. However, postprocedural complications, particularly ischemic events, should be carefully considered.

Pipeline Embolization device for the treatment of unruptured intracranial saccular aneurysms: a systematic review and meta-analysis of long-term outcomes

INTRODUCTION

The pipeline embolization device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well-established, its efficacy for saccular aneurysms remains controversial. We aimed to assess the long-term outcomes of PED treatment for unruptured intracranial saccular aneurysms.

METHODS

Systematic review and meta-analysis were conducted following PRISMA guidelines. Studies with at least one year of follow-up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic aneurysm occlusion at long-term follow-up (≥ 12 months), and the secondary outcome was long-term complications. We conducted a meta-regression analysis to explore potential sources of heterogeneity across studies.

RESULTS

Eleven studies of 797 patients with 963 aneurysms were included. Long-term angiographic occlusion rate was 85% (95% CI, 77-91%; p < 0.01), symptomatic ischemic stroke rate was 1% (95% CI, 0-3%; p < 0.01), rupture rate was 1% (95% CI, 0-2%; p = 0.02), and intracranial hemorrhage (ICH) rate was 0.2% (95% CI, 0-1%; p = 0.11). Meta-regression analysis revealed a non-significant decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, delayed aneurysmal rupture, and ICH.

CONCLUSION

PED demonstrates high long-term occlusion and low complication rates, suggesting it is a safe and effective treatment option for saccular aneurysms. Additionally, newer devices exhibit reduced thrombogenic profiles and safety with decreasing trends in ICH, ischemic stroke, and delayed aneurysmal rupture.

Outcome study of the Pipeline Vantage Embolization Device (second version) in unruptured (and ruptured) aneurysms (PEDVU(R) study)

BACKGROUND

The Pipeline Vantage Embolization Device (PEDV) is the fourth-generation pipeline flow diverter for intracranial aneurysm treatment. There are no outcome studies for the second PEDV version. We aimed to evaluate safety and efficacy outcomes. Primary and secondary objectives were to determine outcomes for unruptured and ruptured cohorts, respectively.

METHODS

In this multicenter retrospective and prospective study, we analyzed outcome data from eight centers using core laboratory assessments. We determined 30-day and ≥3-month mortality and morbidity rates, and 6- and 18-month radiographic aneurysm occlusion rates for procedures performed during the period July 2021-March 2023.

RESULTS

We included 121 consecutive patients with 131 aneurysms. The adequate occlusion rate for the unruptured cohort at short-term and medium-term follow up, and also for the ruptured cohort at short-term follow up, was >90%. Two aneurysms (1.5%) underwent retreatment. When mortality attributed to a palliative case in the unruptured cohort, or subarachnoid hemorrhage in the ruptured cohort, was excluded then the overall major adverse event rate in respective cohorts was 7.5% and 23.5%, with 0% mortality rates for each. When all event causes were included on an intention-to-treat basis, the major adverse event rates in respective cohorts were 8.3% and 40.9%, with 0.9% and 22.7% mortality rates.

CONCLUSIONS

For unruptured aneurysm treatment, the second PEDV version appears to have a superior efficacy and similar safety profile to previous-generation PEDs. These are acceptable outcomes in this pragmatic and non-industry-sponsored study. Analysis of ruptured aneurysm outcomes is limited by cohort size. Further prospective studies, particularly for ruptured aneurysms, are needed.

Treatment of intracranial aneurysms with pipeline embolization device: a single-center experience

Background

Endovascular therapy is the primary treatment modality for intracranial aneurysms (IA). The objective of this study was to assess the effectiveness and safety of a pipeline embolization device (PED) for the treatment of IA.

Methods

This retrospective study was conducted at a single center. Data were collected for all patients who underwent PED treatment at the Fourth Affiliated Hospital of Xinjiang Medical University between December 2018 and January 2022. Clinical characteristics, aneurysm-related characteristics, treatment details, and clinical and imaging outcomes were collected and analyzed.

Results

A total of 60 consecutive patients with 60 IAs were treated with a PED. The mean age of the participants was 61.8 years, with 53% being female. The average size of the aneurysms was 14.7 mm, with 54 located in the anterior circulation and six in the posterior circulation. The median last follow-up time was 13.0 months (range, 11-24 months). All patients underwent final digital subtraction angiography (DSA) for angiographic follow-up, and 50 aneurysms (83.3%) were completely occluded. The overall complication rate was 3.3%, and there were no reported mortalities. Among the 12 cases of ruptured aneurysms, all of which underwent adjunctive coil embolization, the complete occlusion rate was 91.7% with a complication rate of 16.6% [ischemic complication and modified Rankin scale (mRS) deteriorated]. In the 6 cases of posterior circulation aneurysms (2 in the basilar artery), 5 cases achieved complete occlusion and 1 case achieved near-complete occlusion, with no reported complications or mortality.

Conclusions

The use of PEDs appears to be an effective treatment option for IA, demonstrating high occlusion rates and low complication rates. While the application of PEDs for the treatment of ruptured aneurysms did not increase the risk of secondary aneurysm rupture, caution is still warranted due to a higher complication rate. In the treatment of aneurysms of the vertebrobasilar artery using PEDs, this study achieved favorable efficacy outcomes without complications nor patient mortality. However, further studies are needed to validate these findings.

Treatment of a ruptured blister aneurysm of the left internal carotid artery with telescoping Pipeline Flex embolization devices with Shield Technology

Ruptured blister aneurysms have significant rates of morbidity and mortality, but evidence of positive results with use of flow-diverting stents such as the Pipeline embolization device (PED) is growing. The authors describe the staged endovascular treatment of a ruptured left internal carotid artery blister aneurysm in a patient with a Hunt and Hess grade IV subarachnoid hemorrhage. PED placement was done via the common femoral artery using a triaxial delivery system. The telescoping stent technique performed over 48-72 hours achieved sufficient coverage of the aneurysm neck while limiting treatment time during the acute presentation and allowing interim dual antiplatelet treatment. A staged approach allows the targeting of a second PED placement in patients whose aneurysm continues to fill on the first follow-up angiogram. The authors have not experienced increased thromboembolic complications with this approach. Complete occlusion was achieved by postbleed day 8. The video can be found here: https://stream.cadmore.media/r10.3171/2022.7.FOCVID2264.

Outcomes after Flow Diverter Treatment in Subarachnoid Hemorrhage: A Meta-Analysis and Development of a Clinical Prediction Model (OUTFLOW)

Background: patients with a subarachnoid hemorrhage (SAH) might need a flow diverter (FD) placement for complex acutely ruptured intracranial aneurysms (IAs). We conducted a meta-analysis and developed a prediction model to estimate the favorable clinical outcome after the FD treatment in acutely ruptured IAs. Methods: a systematic literature search was performed from 2010 to January 2021 in PubMed and Embase databases. Studies with more than five patients treated with FDs within fifteen days were included. In total, 1157 studies were identified. The primary outcome measure was the favorable clinical outcome (mRS 0–2). Secondary outcome measures were complete occlusion rates, aneurysm rebleeding, permanent neurologic deficit caused by procedure-related complications, and all-cause mortality. A prediction model was constructed using individual patient-level data. Results: 26 retrospective studies with 357 patients and 368 aneurysms were included. The pooled rates of the favorable clinical outcome, mortality, and complete aneurysm occlusion were 73.7% (95% CI 64.7–81.0), 17.1% (95% CI 13.3–21.8), and 85.6% (95% CI 80.4–89.6), respectively. Rebleeding occurred in 3% of aneurysms (11/368). The c-statistic of the final model was 0.83 (95% CI 0.76–0.89). All the studies provided a very low quality of evidence. Conclusions: FD treatment can be considered for complex ruptured IAs. Despite high complication rates, the pooled clinical outcomes seem favorable. The prediction model needs to be validated by larger prospective studies before clinical application.

Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study

Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling.

Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed.

Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050).

Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.