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Predicting Persistent Aneurysm Filling After Pipeline Embolization Device Treatment in Patients with Intracranial Aneurysm: Development and External Validation of a Nomogram Model

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Abstract

The pipeline embolization device (PED) is an effective endovascular treatment modality for intracranial aneurysm (IA), but nearly one-fifth of IAs treated with a PED remain persistently filling at 1-year angiography follow-up. Developing a nomogram to predict persistent aneurysm filling after PED treatment can help neurointerventionalists identify aneurysms with incomplete occlusion and change their treatment strategies. This retrospective study included patients with IA treated with a PED from three institutions between April 2016 and April 2022, assigned to a derivation or validation cohort. Multivariate logistic regression analysis was used to identify predictors and develop a nomogram to predict persistent aneurysm filling after PED treatment in the derivation cohort. Predictive accuracy and clinical benefits of the nomogram were assessed using area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA). In total, 1006 patients with IA were included, 786 in the derivation cohort and 220 in the validation cohort. Over mean follow-up time 18.36 ± 8.58 months, 142 (14.1%) patients developed persistent aneurysm filling after PED treatment, 110 (14.0%) in the derivation cohort and 32 (14.5%) in the validation cohort. In multivariate logistic regression analysis, we developed a nomogram incorporating five predictors: aneurysms located in the basilar artery, dissecting aneurysms, maximum diameter, aneurysms with incorporated branches, and PED plus coiling. AUCs of the nomogram were 0.810 (95% confidence interval [CI], 0.765–0.856) in the derivation cohort and 0.840 (95% CI, 0.754–0.925) in the validation cohort. Calibration curve and DCA analysis demonstrated the utility and clinical application value of this nomogram. This nomogram provides individualized prediction of persistent aneurysm filling after PED treatment for patients with IA, representing a practical approach to effectiveness evaluation. This tool can help neurointerventionalists to identify aneurysms with incomplete occlusion and change their treatment strategy.

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Data Availability

Anonymized data not published in this article are available from the corresponding author on reasonable request.

References

  1. Hanel RA, Cortez GM, Lopes DK, Nelson PK, Siddiqui AH, Jabbour P, Mendes Pereira V, István IS, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer CM, Hellinger FR, Given C, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS, Kallmes DF. Prospective study on embolization of intracranial aneurysms with the pipeline device (PREMIER study): 3-year results with the application of a flow diverter specific occlusion classification. J Neurointerv Surg. 2023;15(3):248–54.

    Article  PubMed  Google Scholar 

  2. Kadirvel R, Ding Y-H, Dai D, Rezek I, Lewis DA, Kallmes DF. Cellular mechanisms of aneurysm occlusion after treatment with a flow diverter. Radiology. 2014;270(2):394–9.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Kan P, Siddiqui AH, Veznedaroglu E, Liebman KM, Binning MJ, Dumont TM, Ogilvy CS, Gaughen JR, Mocco J, Velat GJ, Ringer AJ, Welch BG, Horowitz MB, Snyder KV, Hopkins LN, Levy EI. Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device: a U.S. multicenter experience. Neurosurgery 2012;71(6).

  4. Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafé A, Cekirge S, Fiorella D, Jabbour P, Levy E, McDougall C, Siddiqui A, Szikora I, Woo H, Albuquerque F, Bozorgchami H, Dashti SR, Delgado Almandoz JE, Kelly ME, Turner R, Woodward BK, Brinjikji W, Lanzino G, Lylyk P. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol. 2015;36(1):108–15.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, Moran CJ, Woo HH, Lopes DK, Berez AL, Cher DJ, Siddiqui AH, Levy EI, Albuquerque FC, Fiorella DJ, Berentei Z, Marosfoi M, Cekirge SH, Nelson PK. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267(3):858–68.

    Article  PubMed  Google Scholar 

  6. Hanel RA, Kallmes DF, Lopes DK, Nelson PK, Siddiqui A, Jabbour P, Pereira VM, Szikora István I, Zaidat OO, Bettegowda C, Colby GP, Mokin M, Schirmer C, Hellinger FR, Given Ii C, Krings T, Taussky P, Toth G, Fraser JF, Chen M, Priest R, Kan P, Fiorella D, Frei D, Aagaard-Kienitz B, Diaz O, Malek AM, Cawley CM, Puri AS. Prospective study on embolization of intracranial aneurysms with the pipeline device: the PREMIER study 1 year results. J Neurointerv Surg. 2020;12(1):62–6.

    Article  PubMed  Google Scholar 

  7. Luo B, Kang H, Zhang H, Li T, Liu J, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X. Pipeline embolization device for intracranial aneurysms in a large Chinese cohort: factors related to aneurysm occlusion. Ther Adv Neurol Disord. 2020;13:1756286420967828.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Jabbour P, Chalouhi N, Tjoumakaris S, Gonzalez LF, Dumont AS, Randazzo C, Starke RM, Hasan D, Chitale R, Singhal S, Moukarzel LA, Rosenwasser R. The pipeline embolization device: learning curve and predictors of complications and aneurysm obliteration. Neurosurgery 2013;73(1).

  9. Gupta R, Ogilvy CS, Moore JM, Griessenauer CJ, Enriquez-Marulanda A, Leadon M, Adeeb N, Ascanio L, Maragkos GA, Jain A, Schmalz PGR, Alturki AY, Kicielinski K, Schirmer CM, Thomas AJ. Proposal of a follow-up imaging strategy following pipeline flow diversion treatment of intracranial aneurysms. J Neurosurg. 2018;131(1):32–9.

    Article  PubMed  Google Scholar 

  10. Adeeb N, Moore JM, Wirtz M, Griessenauer CJ, Foreman PM, Shallwani H, Gupta R, Dmytriw AA, Motiei-Langroudi R, Alturki A, Harrigan MR, Siddiqui AH, Levy EI, Thomas AJ, Ogilvy CS. Predictors of incomplete occlusion following pipeline embolization of intracranial aneurysms: is it less effective in older patients? AJNR Am J Neuroradiol. 2017;38(12):2295–300.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Maragkos GA, Ascanio LC, Salem MM, Gopakumar S, Gomez-Paz S, Enriquez-Marulanda A, Jain A, Schirmer CM, Foreman PM, Griessenauer CJ, Kan P, Ogilvy CS, Thomas AJ. Predictive factors of incomplete aneurysm occlusion after endovascular treatment with the pipeline embolization device. J Neurosurg. 2019;132(5):1598–605.

    Article  PubMed  Google Scholar 

  12. Bender MT, Colby GP, Lin L-M, Jiang B, Westbroek EM, Xu R, Campos JK, Huang J, Tamargo RJ, Coon AL. Predictors of cerebral aneurysm persistence and occlusion after flow diversion: a single-institution series of 445 cases with angiographic follow-up. J Neurosurg. 2018;130(1):259–67.

    PubMed  Google Scholar 

  13. Shapiro M, Becske T, Nelson PK. Learning from failure: persistence of aneurysms following pipeline embolization. J Neurosurg. 2017;126(2):578–85.

    Article  PubMed  Google Scholar 

  14. Daou B, Atallah E, Chalouhi N, Starke RM, Oliver J, Montano M, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Aneurysms with persistent filling after failed treatment with the pipeline embolization device. J Neurosurg. 2018;130(4):1376–82.

    Article  PubMed  Google Scholar 

  15. Rouchaud A, Ramana C, Brinjikji W, Ding YH, Dai D, Gunderson T, Cebral J, Kallmes DF, Kadirvel R. Wall apposition is a key factor for aneurysm occlusion after flow diversion: a histologic evaluation in 41 rabbits. AJNR Am J Neuroradiol. 2016;37(11):2087–91.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. O’Kelly CJ, Krings T, Fiorella D, Marotta TR. A novel grading scale for the angiographic assessment of intracranial aneurysms treated using flow diverting stents. Interv Neuroradiol. 2010;16(2):133–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Cler SJ, Lauzier DC, Chatterjee AR, Osbun JW, Moran CJ, Kansagra AP. Time line of occlusion for intracranial aneurysms treated with the pipeline embolization device. World Neurosurg. 2022;166:e750–7.

    Article  PubMed  Google Scholar 

  18. Kang H, Zhou Y, Luo B, Lv N, Zhang H, Li T, Song D, Zhao Y, Guan S, Maimaitili A, Wang Y, Feng W, Wang Y, Wan J, Mao G, Shi H, Yang X, Liu J. Pipeline embolization device for intracranial aneurysms in a large Chinese cohort: complication risk factor analysis. Neurotherapeutics. 2021;18(2):1198–206.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Hodis S, Ding Y-H, Dai D, Lingineni R, Mut F, Cebral J, Kallmes D, Kadirvel R. Relationship between aneurysm occlusion and flow diverting device oversizing in a rabbit model. J Neurointerv Surg. 2016;8(1):94–8.

    Article  PubMed  Google Scholar 

  20. Hanel RA, Monteiro A, Nelson PK, Lopes DK, Kallmes DF. Predictors of incomplete aneurysm occlusion after treatment with the pipeline embolization device: PREMIER trial 1 year analysis. J Neurointerv Surg. 2022;14(10):1014–7.

    Article  PubMed  Google Scholar 

  21. Trivelato FP, Salles Rezende MT, Ulhôa AC, Henrique de Castro-Afonso L, Nakiri GS, Abud DG. Occlusion rates of intracranial aneurysms treated with the pipeline embolization device: the role of branches arising from the sac. J Neurosurg 2018;1–7.

  22. Lin N, Brouillard AM, Krishna C, Mokin M, Natarajan SK, Sonig A, Snyder KV, Levy EI, Siddiqui AH. Use of coils in conjunction with the pipeline embolization device for treatment of intracranial aneurysms. Neurosurgery. 2015;76(2):142–9.

    Article  PubMed  Google Scholar 

  23. Shapiro M, Raz E, Becske T, Nelson PK. Building multidevice pipeline constructs of favorable metal coverage: a practical guide. AJNR Am J Neuroradiol. 2014;35(8):1556–61.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Shapiro M, Raz E, Becske T, Nelson PK. Variable porosity of the pipeline embolization device in straight and curved vessels: a guide for optimal deployment strategy. AJNR Am J Neuroradiol. 2014;35(4):727–33.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We thank Analisa Avila, MPH, ELS, of Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the language of a draft of this manuscript.

Funding

This study was supported by the National Natural Science Foundation of China (grant Nos 82271319).

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Author notes

  1. Linggen Dong, Chao Wang, Yang Wang and Ming Lv contributed equally to this article.

Authors and Affiliations

  1. Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China

    Linggen Dong, Chao Wang & Ming Lv

  2. Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China

    Linggen Dong, Chao Wang & Ming Lv

  3. Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China

    Xiheng Chen, Mingtao Li, Tong Li, He Liu & Yang Wang

  4. Department of Neurosurgery, Peking University International Hospital, Peking University, Beijing, China

    Yang Zhao, Ran Duan, Weitao Jin & Yukun Zhang

Authors
  1. Linggen Dong
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Contributions

CX, LM, LH, ZY, DR, JW, and ZY collected the data. Data were analyzed by WY and LM. DL and WC drafted the manuscript. WY and LM conceived and designed the research. WY and LM initiated and organized this study. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Corresponding authors

Correspondence to Yang Wang or Ming Lv.

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Ethics Approval and Consent to Participate

Individual patients’ written informed consent was waived owing to the retrospective nature of the study. The study protocol was reviewed and approved by the ethics committee of Beijing Tiantan Hospital, and the approval number given by the ethical board was KY 2018–098-02.

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The authors declare no competing interests.

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Dong, L., Wang, C., Chen, X. et al. Predicting Persistent Aneurysm Filling After Pipeline Embolization Device Treatment in Patients with Intracranial Aneurysm: Development and External Validation of a Nomogram Model. Transl. Stroke Res. (2023). https://doi.org/10.1007/s12975-023-01222-9

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