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Research ArticleNeurointervention

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 and A.J. Thomas
American Journal of Neuroradiology June 2018, DOI: https://doi.org/10.3174/ajnr.A5696
N. Adeeb
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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C.J. Griessenauer
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
bDepartment of Neurosurgery (C.J.G.), Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
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A.A. Dmytriw
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
cDepartment of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
dDivision of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
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H. Shallwani
eDepartment of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
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R. Gupta
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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P.M. Foreman
fDepartment of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
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H. Shakir
eDepartment of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
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J. Moore
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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N. Limbucci
gDepartment of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
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S. Mangiafico
gDepartment of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
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A. Kumar
dDivision of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
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C. Michelozzi
hDepartment of Diagnostic and Therapeutic Neuroradiology (C.M., C.C.), Toulouse University Hospital, Toulouse, France
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Y. Zhang
cDepartment of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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V.M. Pereira
cDepartment of Medical Imaging (A.A.D., Y.Z., V.M.P.), Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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C.C. Matouk
iDepartment of Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, Connecticut.
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M.R. Harrigan
fDepartment of Neurosurgery (P.M.F., M.R.H.), University of Alabama at Birmingham, Birmingham, Alabama
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A.H. Siddiqui
eDepartment of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
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E.I. Levy
eDepartment of Neurosurgery (H. Shallwani, H. Shakir, A.H.S., E.I.L.), State University of New York at Buffalo, Buffalo, New York
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L. Renieri
gDepartment of Interventional Neuroradiology (N.L., S.M., L.R.), University of Florence, Florence, Italy
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T.R. Marotta
dDivision of Diagnostic and Therapeutic Neuroradiology (A.A.D., A.K., T.R.M.), St. Michael's Hospital, Toronto, Ontario, Canada
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C. Cognard
hDepartment of Diagnostic and Therapeutic Neuroradiology (C.M., C.C.), Toulouse University Hospital, Toulouse, France
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C.S. Ogilvy
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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A.J. Thomas
aFrom the Beth Israel Deaconess Medical Center (N.A., C.J.G., A.A.D., R.G., J.M., C.S.O., A.J.T.), Harvard Medical School, Boston, Massachusetts
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    Fig 1.

    Digital subtraction angiography shows a basilar tip saccular aneurysm before treatment with the Pipeline Embolization Device (A). The PED was placed spanning the lower part of the basilar truck into the left posterior cerebral artery. On 4-month follow-up (B), DSA shows complete aneurysm occlusion, along with complete occlusion of the right PCA. The anterior inferior cerebral arteries and superior cerebellar arteries remained patent. The patient remained neurologically intact.

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    Fig 2.

    Digital subtraction angiography shows 2 basilar trunk saccular aneurysms before treatment with the Pipeline Embolization Device (A). The PED was placed spanning the AICA bilaterally. On follow-up DSA (B), there was complete occlusion of the left AICA. The patient had a symptomatic left-sided pontine stroke that remained symptomatic at 10-month follow-up (C).

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    Table 1:

    Baseline characteristics

    ParameterNo.
    No. of procedures129
    No. of aneurysms131
    No. of branches covered228
    Sex
        Female82 (63.6%)
        Male47 (36.4%)
    Median age (range) (yr)58 (29–82)
    Smokinga40 (33.3%)
    Multiple aneurysms32 (24.8%)
    Presenting symptoms
        Asymptomatic28 (21.7%)
        Headache/dizziness30 (23.3%)
        Neurologic deficit71 (55%)
    Subarachnoid hemorrhage
        Immediate (<24 hr)18 (14.0%)
        Acute (>24 hr and <2 wk)7 (5.4%)
        Remote (>2 wk)14 (10.9%)
    Pretreatment mRS
        0–2101 (78.3%)
        3–528 (21.7%)
    Aneurysm shape
        Saccular49 (37.4%)
        Fusiform53 (40.5%)
        Dissecting29 (22.1%)
    Aneurysm location
        Vertebral artery46 (35.1%)
        PICA10 (7.6%)
        Vertebrobasilar artery18 (13.6%)
        Basilar artery45 (34.5%)
        SCA4 (3.1%)
        PCA8 (6.1%)
    Aneurysm measurements (median) (range) (mm)
        Maximal diameter12 (2–73)
        Neck size (for saccular aneurysms)5.35 (2–15)
    Daughter sac26 (19.8%)
    Prior treatment
        Endovascular14 (10.7%)
        Surgery2 (1.5%)
        Both1 (0.8%)
    Platelet function test77 (59.7%)
    Clopidogrel nonresponders14 (18.2%)
    Treatment of nonresponders
        Continue clopidogrel8 (57.1%)
        Switch to ticagrelor5 (35.8%)
        Other1 (7.1%)
    • Note:—SCA indicates superior cerebellar artery.

    • ↵a Data are missing for 9 procedures.

    • View popup
    Table 2:

    Outcome measures

    ParameterNo.
    No. of Pipelines deployed (median) (range)1 (1–14)
    Adjunctive coiling40 (31%)
    Procedures with covered branches103 (79.8%)
    No. of covered branches (median) (range)2 (0–6)
    Last angiographic follow-up (median) (range) (mo)a11 (1–72)
    Follow-up aneurysm occlusion ratea
        Complete (100%)85 (66.4%)
        Near-complete (90%–99%)15 (11.7%)
        Partial (<90%)28 (21.9%)
    Retreatment
        Endovascular11 (8.4%)
    Outcome of covered branchesb228
        Occluded (overall)25 (11%)
        VA23
            Occluded8 (34.8%)
        PICA49
            Occluded4 (8.2%)
        AICA78
            Occluded6 (7.7%)
        SCA61
            Occluded3 (4.9%)
        PCA17
            Occluded4 (23.5%)
    Last clinical follow-up (median) (range) (mo)c8 (0.3–72)
    Posttreatment mRSc
        0–299 (79.2%)
        3–512 (9.6%)
        6 (Death)14 (11.2%)
    Follow-up mRSc
        Improved43 (34.4%)
        No change54 (43.2%)
        Worsened28 (22.4%)
    Ischemic complications29 (22.5%)
        Timing
            Intraprocedural2 (1.6%)
            Postprocedural27 (20.9%)
        Location
            Brain stem13 (10.1%)
            Cerebellum13 (10.1%)
            PCA territory10 (7.8%)
        Symptomatic17 (13.2%)
            Temporary6 (4.7%)
            Permanent11 (8.5%)
    Territory of ischemic complications
        Same as covered branch21 (72.4%)
        Different8 (27.6%)
    • Note:—SCA indicates superior cerebellar artery.

    • ↵a Data were missing on 3 aneurysms.

    • ↵b Each covered branch was considered separately.

    • ↵c Data were missing on 4 procedures.

    • View popup
    Table 3:

    Predictors of branch occlusion following coverage

    ParameterBranch Occlusion (No.) (%)P Value
    Not Occluded (n = 203)Occluded (n = 25)
    Sex
        Female108 (87.1%)16 (12.9%).3
        Male95 (91.3%)9 (8.7%)
    Median age (range) (yr)59.5 (29–82)61 (42–78).56
    Smokinga
        Yes53 (82.8%)11 (17.2%).1
        No137 (90.7%)14 (9.3%)
    Presenting symptoms
        Asymptomatic32 (72.7%)12 (27.3%)<.001
        Headache/dizziness38 (88.4%)5 (11.5%)
        Neurologic deficit133 (94.3%)8 (5.7%)
    Subarachnoid hemorrhage
        No141 (87.6%)20 (12.4%).36
        Acute (<24 hr)25 (96.2%)1 (3.8%)
        Immediate (<2 wk)11 (100%)0%
        Remote (>2 wk)26 (86.7%)4 (13.3%)
    Pretreatment mRS
        0–2160 (87.4%)23 (12.6%).12
        3–543 (95.6%)2 (4.4%)
    Aneurysm shape
        Saccular74 (84.1%)14 (15.9%).18
        Fusiform89 (91.8%)8 (8.2%)
        Dissecting38 (92.7%)3 (7.3%)
    Aneurysm measurements
        Maximal diameter
            <7 mm32 (84.2%)6 (15.8%).23
            7–12 mm50 (84.7%)9 (15.3%)
            13–24 mm52 (89.7%)6 (10.3%)
            >24 mm69 (94.5%)4 (5.5%)
    Daughter sac
        Yes45 (90%)5 (10%).8
        No158 (88.8%)20 (11.2%)
    Intra-aneurysmal thrombus
        Yes68 (94.4%)4 (5.6%).08
        No135 (86.5%)21 (13.5%)
    Prior treatment
        No174 (88.3%)23 (11.7%).8
        Endovascular25 (92.6%)2 (7.4%)
        Surgery3 (100%)0%
        Both1 (100%)0%
    Platelet function testing
        Yes128 (85.3%)22 (14.7%).01
        No75 (96.2%)3 (3.8%)
    Clopidogrel respondersb
        Yes110 (86.6%)17 (13.4%).3
        No18 (78.3%)5 (21.7%)
    Adjunctive coiling
        Yes75 (88.2%)10 (11.8%).77
        No128 (89.5%)15 (10.5%)
    No. of Pipelines deployed (median) (range)1 (1–14)1 (1–4).33
    Length of procedure (median) (range) (min)110 (22–410)114 (32–271).8
    Branch
        VA15 (65.2%)8 (34.8%).001
        PICA45 (91.8%)4 (8.2%)
        AICA72 (92.3%)6 (7.7%)
        SCA58 (95.1%)3 (4.9%)
        PCA13 (76.5%)4 (23.5%)
    No. of covered branches in same procedure
        137 (97.4%)1 (2.6%).07
        ≥2166 (87.4%)24 (12.6%)
    • Note:—SCA indicates superior cerebellar artery.

    • ↵a Data are missing for 13 branches.

    • ↵b Among patients with platelet function testing.

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Cite this article
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
Risk of Branch Occlusion and Ischemic Complications with the Pipeline Embolization Device in the Treatment of Posterior Circulation Aneurysms
American Journal of Neuroradiology Jun 2018, DOI: 10.3174/ajnr.A5696

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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
American Journal of Neuroradiology Jun 2018, DOI: 10.3174/ajnr.A5696
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