Treatment of Intracranial Aneurysms With Pipeline Embolization Device: Newer Applications and Technical Advances

  • Santosh B. Murthy
  • Jharna Shah
  • Halinder S. Mangat
  • Philip Stieg
Cerebrovascular Disorders (HP Adams, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Cerebrovascular Disorders

Opinion statement

Pipeline embolization device (PED) is a flow diverter used in the endovascular treatment of intracranial aneurysms, particularly those with unfavorable configurations. It works by causing progressive flow redirection leading to thrombosis within the aneurysm. PED was initially approved for adults with large or giant wide-necked (≥4 mm or no discernible neck) aneurysms of the internal carotid artery (ICA) from the petrous to the superior hypophyseal segments. Studies have shown a superior aneurysm occlusion rate of 85 % at 6 months for the PED and mortality ranging from 2.6 to 4 %. There appears to be a knowledge gap in terms of the duration of dual antiplatelet therapy and efficacy of assessing platelet inhibition. However, increasing operator experience and favorable longer-term outcome data have led to the exploration of PED for a wide array of off-label uses. Given the paucity of good-quality studies comparing PED with other endovascular/surgical treatment options, several multicenter randomized trials are currently underway to answer these important questions.

Keywords

Pipeline embolization device Flow diverter Intracranial aneurysm Subarachnoid hemorrhage 

Notes

Acknowledgments

A special thank you to Dr. Myrna Rosenfeld for taking the time to review this manuscript.

Compliance with Ethical Standards

Conflict of Interest

Santosh B. Murthy, Jharna Shah, Halinder S. Mangat, and Philip Stieg declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
  2. 2.
    Wakhloo AK, Tio FO, Lieber BB, Schellhammer F, Graf M, Hopkins LN. Self-expanding nitinol stents in canine vertebral arteries: hemodynamics and tissue response. AJNR Am J Neuroradiol. 1995;16(5):1043–51.PubMedGoogle Scholar
  3. 3.
    Geremia G, Haklin M, Brennecke L. Embolization of experimentally created aneurysms with intravascular stent devices. AJNR Am J Neuroradiol. 1994;15(7):1223–31.PubMedGoogle Scholar
  4. 4.
    Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, et al. Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol. 2010;31(6):1139–47. doi:10.3174/ajnr.A2023.CrossRefPubMedGoogle Scholar
  5. 5.
    Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, et al. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery. 2009;64(4):632–42. doi:10.1227/01.NEU.0000339109.98070.65. discussion 42–3; quiz N6.CrossRefPubMedGoogle Scholar
  6. 6.
    Krishna C, Sonig A, Natarajan SK, Siddiqui AH. The expanding realm of endovascular neurosurgery: flow diversion for cerebral aneurysm management. Methodist DeBakey Cardiovasc J. 2014;10(4):214–9. doi:10.14797/mdcj-10-4-214.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Wong GK, Kwan MC, Ng RY, Yu SC, Poon WS. Flow diverters for treatment of intracranial aneurysms: current status and ongoing clinical trials. J Clin Neurosci. 2011;18(6):737–40. doi:10.1016/j.jocn.2010.10.011.CrossRefPubMedGoogle Scholar
  8. 8.
    Canton G, Levy DI, Lasheras JC, Nelson PK. Flow changes caused by the sequential placement of stents across the neck of sidewall cerebral aneurysms. J Neurosurg. 2005;103(5):891–902. doi:10.3171/jns.2005.103.5.0891.CrossRefPubMedGoogle Scholar
  9. 9.
    Lopes D, Sani S. Histological postmortem study of an internal carotid artery aneurysm treated with the Neuroform stent. Neurosurgery. 2005;56(2):E416. discussion E.CrossRefPubMedGoogle Scholar
  10. 10.••
    Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, et al. Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology. 2013;267(3):858–68. doi:10.1148/radiol.13120099. This was a multicenter, prospective, interventional, single-arm trial of PED that demonstrated reasonable safety and efficacy in the treatment of large or giant intracranial internal carotid artery aneurysms.CrossRefPubMedGoogle Scholar
  11. 11.
    Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2011;32(1):34–40. doi:10.3174/ajnr.A2421.PubMedGoogle Scholar
  12. 12.••
    Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafe A, Cekirge S, et al. International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol. 2015;36(1):108–15. doi:10.3174/ajnr.A4111. This was a multicenter retrospective study of the PED that showed a high aneurysm occlusion rate and low rate of complications associated with the flow diverter.CrossRefPubMedGoogle Scholar
  13. 13.•
    Colby GP, Lin LM, Caplan JM, Jiang B, Huang J, Tamargo RJ, et al. Immediate procedural outcomes in 44 consecutive Pipeline Flex cases: the first North American single-center series. J Neurointerventional Surg. 2015. doi:10.1136/neurintsurg-2015-011894. This study is the first series of preliminary data on the second generation PED called Pipeline Flex that showed technical superiority and good short-term outcomes.Google Scholar
  14. 14.
    Martinez-Galdamez M, Gil A, Caniego JL, Gonzalez E, Barcena E, Perez S, et al. Preliminary experience with the Pipeline Flex Embolization Device: technical note. J Neurointerventional Surg. 2015;7(10):748–51. doi:10.1136/neurintsurg-2014-011385.CrossRefGoogle Scholar
  15. 15.
    Martinez-Galdamez M, Perez S, Vega A, Ruiz P, Caniego JL, Barcena E, et al. Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients. J Neurointerventional Surg. 2015. doi:10.1136/neurintsurg-2015-011669.Google Scholar
  16. 16.
    Pereira VM, Kelly M, Vega P, Murias E, Yilmaz H, Erceg G, et al. New Pipeline Flex device: initial experience and technical nuances. J Neurointerventional Surg. 2015;7(12):920–5. doi:10.1136/neurintsurg-2014-011347.CrossRefGoogle Scholar
  17. 17.
    Tse MM, Yan B, Dowling RJ, Mitchell PJ. Current status of pipeline embolization device in the treatment of intracranial aneurysms: a review. World Neurosurg. 2013;80(6):829–35. doi:10.1016/j.wneu.2012.09.023.CrossRefPubMedGoogle Scholar
  18. 18.•
    Murthy SB SS, Venkatasubba Rao CP, Bershad E, Suarez JI. Treatment of Unruptured Intracranial Aneurysms with Pipeline Embolization Device: A Systematic Review of Literature. J Clin Neurosci (In press). 2013. This is a systematic review on prior published data on the PED with documentation of periprocedural and delayed complication rates, and six-month aneurysm occlusion rates.Google Scholar
  19. 19.
    O’Kelly CJ, Spears J, Chow M, Wong J, Boulton M, Weill A, et al. Canadian Experience with the Pipeline Embolization Device for Repair of Unruptured Intracranial Aneurysms. AJNR Am J Neuroradiol. 2012. doi:10.3174/ajnr.A3224.Google Scholar
  20. 20.
    Yu SC, Kwok CK, Cheng PW, Chan KY, Lau SS, Lui WM, et al. Intracranial aneurysms: midterm outcome of pipeline embolization device—a prospective study in 143 patients with 178 aneurysms. Radiology. 2012. doi:10.1148/radiol.12120422.PubMedCentralGoogle Scholar
  21. 21.
    Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK. Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. AJNR Am J Neuroradiol. 2012;33(1):159–63. doi:10.3174/ajnr.A2719.CrossRefPubMedGoogle Scholar
  22. 22.•
    Murthy SB, Shah S, Shastri A, Venkatasubba Rao CP, Bershad EM, Suarez JI. The SILK flow diverter in the treatment of intracranial aneurysms. J Clin Neurosci : Off J Neurosurgical Soc Australasia. 2014;21(2):203–6. doi:10.1016/j.jocn.2013.07.006. This is a systematic review on prior published data on the SILK flow diverter with documentation of complication and aneurysm occlusion rates. The study also compares the SILK with the PED.CrossRefGoogle Scholar
  23. 23.
    Arrese I, Sarabia R, Pintado R, Delgado-Rodriguez M. Flow-diverter devices for intracranial aneurysms: systematic review and meta-analysis. Neurosurgery. 2013;73(2):193–9. doi:10.1227/01.neu.0000430297.17961.f1. discussion 9–200.CrossRefPubMedGoogle Scholar
  24. 24.•
    Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke; J Cereb Circ. 2013;44(2):442–7. doi:10.1161/STROKEAHA.112.678151. This is a meta-analysis on prior published literature on all flow diverters with detailed analysis of outcome and complication data.CrossRefGoogle Scholar
  25. 25.
    Amuluru K, Al-Mufti F, Singh IP, Prestigiacomo C, Gandhi C. Flow diverters for treatment of intracranial aneurysms: technical and clinical updates. World Neurosurg. 2015. doi:10.1016/j.wneu.2015.12.004.Google Scholar
  26. 26.
    Mut F, Lohner R, Chien A, Tateshima S, Vinuela F, Putman C, et al. Computational hemodynamics framework for the analysis of cerebral aneurysms. Int J Numer Method Biomed Eng. 2011;27(6):822–39. doi:10.1002/cnm.1424.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Puffer RC, Kallmes DF, Cloft HJ, Lanzino G. Patency of the ophthalmic artery after flow diversion treatment of paraclinoid aneurysms. J Neurosurg. 2012;116(4):892–6. doi:10.3171/2011.11.JNS111612.CrossRefPubMedGoogle Scholar
  28. 28.
    Murthy SB, Shah S, Venkatasubba Rao CP, Bershad EM, Suarez JI. Treatment of unruptured intracranial aneurysms with the pipeline embolization device. J Clin Neurosci : Off J Neurosurgical Soc Australasia. 2014;21(1):6–11. doi:10.1016/j.jocn.2013.03.014.CrossRefGoogle Scholar
  29. 29.
    Fischer S, Vajda Z, Aguilar Perez M, Schmid E, Hopf N, Bazner H, et al. Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology. 2012;54(4):369–82. doi:10.1007/s00234-011-0948-x.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Turowski B, Macht S, Kulcsar Z, Hanggi D, Stummer W. Early fatal hemorrhage after endovascular cerebral aneurysm treatment with a flow diverter (SILK-Stent): do we need to rethink our concepts? Neuroradiology. 2011;53(1):37–41. doi:10.1007/s00234-010-0676-7.CrossRefPubMedGoogle Scholar
  31. 31.
    Byrne JV, Beltechi R, Yarnold JA, Birks J, Kamran M. Early experience in the treatment of intra-cranial aneurysms by endovascular flow diversion: a multicentre prospective study. PLoS One. 2010;5(9). doi:10.1371/journal.pone.0012492.
  32. 32.
    Cruz JP, Chow M, O’Kelly C, Marotta B, Spears J, Montanera W, et al. Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms. AJNR Am J Neuroradiol. 2012;33(4):603–8. doi:10.3174/ajnr.A3065.CrossRefPubMedGoogle Scholar
  33. 33.
    Colby GP, Lin LM, Coon AL. Revisiting the risk of intraparenchymal hemorrhage following aneurysm treatment by flow diversion. AJNR Am J Neuroradiol. 2012;33(7):E107. doi:10.3174/ajnr.A3201. author reply E8.CrossRefPubMedGoogle Scholar
  34. 34.
    Daou B, Starke RM, Chalouhi N, Barros G, Tjoumakaris S, Rosenwasser RH, et al. P2Y12 reaction units: effect on hemorrhagic and thromboembolic complications in patients with cerebral aneurysms treated with the pipeline embolization device. Neurosurgery. 2016;78(1):27–33. doi:10.1227/NEU.0000000000000978.CrossRefPubMedGoogle Scholar
  35. 35.
    John S, Bain M, Hui F, Hussain MS, Masaryk T, Rasmussen P, et al. Long-term follow-up of in-stent stenosis after pipeline flow diversion treatment of intracranial aneurysms. Neurosurgery. 2015. doi:10.1227/NEU.0000000000001146.PubMedGoogle Scholar
  36. 36.
    Berge J, Tourdias T, Moreau JF, Barreau X, Dousset V. Perianeurysmal brain inflammation after flow-diversion treatment. AJNR Am J Neuroradiol. 2011;32(10):1930–4. doi:10.3174/ajnr.A2710.CrossRefPubMedGoogle Scholar
  37. 37.
    Moon K, Albuquerque FC, Ducruet AF, Crowley RW, McDougall CG. Resolution of cranial neuropathies following treatment of intracranial aneurysms with the Pipeline Embolization Device. J Neurosurg. 2014;121(5):1085–92. doi:10.3171/2014.7.JNS132677.CrossRefPubMedGoogle Scholar
  38. 38.
    Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Hasan D, Khoury J, et al. Pipeline embolization device in the treatment of recurrent previously stented cerebral aneurysms. AJNR Am J Neuroradiol. 2015. doi:10.3174/ajnr.A4613.PubMedGoogle Scholar
  39. 39.
    Chalouhi N, Chitale R, Starke RM, Jabbour P, Tjoumakaris S, Dumont AS, et al. Treatment of recurrent intracranial aneurysms with the Pipeline Embolization Device. J Neurointerv Surg. 2014;6(1):19–23. doi:10.1136/neurintsurg-2012-010612.CrossRefPubMedGoogle Scholar
  40. 40.
    Daou B, Starke RM, Chalouhi N, Tjoumakaris S, Khoury J, Hasan D, et al. The use of the pipeline embolization device in the management of recurrent previously coiled cerebral aneurysms. Neurosurgery. 2015;77(5):692–7. doi:10.1227/NEU.0000000000000901.CrossRefPubMedGoogle Scholar
  41. 41.
    Ding D, Starke RM, Evans AJ, Jensen ME, Liu KC. Endovascular treatment of recurrent intracranial aneurysms following previous microsurgical clipping with the Pipeline Embolization Device. J Clin Neurosci. 2014;21(7):1241–4. doi:10.1016/j.jocn.2013.12.008.CrossRefPubMedGoogle Scholar
  42. 42.
    Lin N, Brouillard AM, Keigher KM, Lopes DK, Binning MJ, Liebman KM, et al. Utilization of Pipeline embolization device for treatment of ruptured intracranial aneurysms: US multicenter experience. J Neurointerv Surg. 2015;7(11):808–15. doi:10.1136/neurintsurg-2014-011320.CrossRefPubMedGoogle Scholar
  43. 43.
    Chalouhi N, Zanaty M, Whiting A, Tjoumakaris S, Hasan D, Ajiboye N, et al. Treatment of ruptured intracranial aneurysms with the pipeline embolization device. Neurosurgery. 2015;76(2):165–72. doi:10.1227/NEU.0000000000000586. discussion 72.CrossRefPubMedGoogle Scholar
  44. 44.
    Brinjikji W, Piano M, Fang S, Pero G, Kallmes DF, Quilici L et al. Treatment of ruptured complex and large/giant ruptured cerebral aneurysms by acute coiling followed by staged flow diversion. J Neurosurg. 2015:1–8. doi:10.3171/2015.6.JNS151038.
  45. 45.
    Chalouhi N, Zanaty M, Whiting A, Yang S, Tjoumakaris S, Hasan D, et al. Safety and efficacy of the Pipeline Embolization Device in 100 small intracranial aneurysms. J Neurosurg. 2015;122(6):1498–502. doi:10.3171/2014.12.JNS14411.CrossRefPubMedGoogle Scholar
  46. 46.
    Lin LM, Colby GP, Kim JE, Huang J, Tamargo RJ, Coon AL. Immediate and follow-up results for 44 consecutive cases of small (<10 mm) internal carotid artery aneurysms treated with the pipeline embolization device. Surg Neurol Int. 2013;4:114. doi:10.4103/2152-7806.117711.CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    Saatci I, Yavuz K, Ozer C, Geyik S, Cekirge HS. Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol. 2012;33(8):1436–46. doi:10.3174/ajnr.A3246.CrossRefPubMedGoogle Scholar
  48. 48.
    Lin N, Lanzino G, Lopes DK, Arthur AS, Ogilvy CS, Ecker RD, et al. Treatment of distal anterior circulation aneurysms with the pipeline embolization device: a US multicenter experience. Neurosurgery. 2015. doi:10.1227/NEU.0000000000001117.Google Scholar
  49. 49.
    Puri AS, Massari F, Asai T, Marosfoi M, Kan P, Hou SY, et al. Safety, efficacy, and short-term follow-up of the use of Pipeline Embolization Device in small (<2.5mm) cerebral vessels for aneurysm treatment: single institution experience. Neuroradiology. 2015. doi:10.1007/s00234-015-1630-5.PubMedGoogle Scholar
  50. 50.
    Zanaty M, Chalouhi N, Tjoumakaris SI, Gonzalez LF, Rosenwasser R, Jabbour P. Flow diversion for complex middle cerebral artery aneurysms. Neuroradiology. 2014;56(5):381–7. doi:10.1007/s00234-014-1339-x.CrossRefPubMedGoogle Scholar
  51. 51.
    Park SH, Yim MB, Lee CY, Kim E, Son EI. Intracranial fusiform aneurysms: it’s pathogenesis, clinical characteristics and managements. J Korean Neurosurgical Soc. 2008;44(3):116–23. doi:10.3340/jkns.2008.44.3.116.CrossRefGoogle Scholar
  52. 52.
    Nakatomi H, Segawa H, Kurata A, Shiokawa Y, Nagata K, Kamiyama H, et al. Clinicopathological study of intracranial fusiform and dolichoectatic aneurysms: insight on the mechanism of growth. Stroke; J Cereb Circ. 2000;31(4):896–900.CrossRefGoogle Scholar
  53. 53.
    Fischer S, Perez MA, Kurre W, Albes G, Bazner H, Henkes H. Pipeline embolization device for the treatment of intra- and extracranial fusiform and dissecting aneurysms: initial experience and long-term follow-up. Neurosurgery. 2014;75(4):364–74. doi:10.1227/NEU.0000000000000431. discussion 74.CrossRefPubMedGoogle Scholar
  54. 54.
    Natarajan SK, Lin N, Sonig A, Rai AT, Carpenter JS, Levy EI et al. The safety of Pipeline flow diversion in fusiform vertebrobasilar aneurysms: a consecutive case series with longer-term follow-up from a single US center. J Neurosurg. 2015:1–9. doi:10.3171/2015.6.JNS1565.
  55. 55.
    Tsang AC, Leung KM, Lee R, Lui WM, Leung GK. Primary endovascular treatment of post-irradiated carotid pseudoaneurysm at the skull base with the Pipeline embolization device. J Neurointerventional Surg. 2015;7(8):603–7. doi:10.1136/neurintsurg-2014-011154.CrossRefGoogle Scholar
  56. 56.
    Brzezicki G, Rivet DJ, Reavey-Cantwell J. Pipeline Embolization Device for treatment of high cervical and skull base carotid artery dissections: clinical case series. J Neurointerventional Surg. 2015. doi:10.1136/neurintsurg-2015-011653.Google Scholar
  57. 57.
    Nossek E, Zumofen D, Nelson E, Raz E, Potts MB, Desousa KG, et al. Use of Pipeline Embolization Devices for treatment of a direct carotid-cavernous fistula. Acta Neurochir. 2015;157(7):1125–9. doi:10.1007/s00701-015-2446-0. discussion 30.CrossRefPubMedGoogle Scholar
  58. 58.
    Lin LM, Colby GP, Jiang B, Pero G, Boccardi E, Coon AL. Transvenous approach for the treatment of direct carotid cavernous fistula following Pipeline embolization of cavernous carotid aneurysm: a report of two cases and review of the literature. J Neurointerventional Surg. 2015;7(8):e30. doi:10.1136/neurintsurg-2014-011235.rep.CrossRefGoogle Scholar
  59. 59.
    COCOA 2010 Annual Report - Food and Drug Administration. http://www.fda.gov/downloads/AdvisoryCommittees/…/UCM247158.pdf.
  60. 60.
    Multicenter randomized study for medico-economic evaluation of embolization with flow diverter stent in the endovascular treatment of unruptured saccular wide-necked intracranial aneurysms,” in ClinicalTrials.Gov, NCT01811134, National Library of Medicine (US), Bethesda MD, USA, 2000, http://clinicaltrials.gov/ct2/show/record/NCT01811134.
  61. 61.
    A randomized trial comparing flow diversion and best- standard treatment—the FIAT trial,” in ClinicalTrials.Gov, NCT01349582, National Library of Medicine (US), Bethesda, Md, USA, 2000, http://www.clinicaltrials.gov/ct2/show/ NCT01349582.
  62. 62.
    LARGE aneurysm randomized trial: flow diversion versus traditional endovas- cular coiling therapy,” in ClinicalTrials.Gov, NCT01762137, National Library of Medicine (US), Bethesda, Md, USA, 2000, http://clinicaltrials.gov/ct2/show/record/NCT01762137.
  63. 63.
    Multicenter randomized trial on selective endovascular aneurysm occlusion with coils versus parent vessel reconstruction using the SILK flow diverter (MARCO POLO post-market clinical investigation),” in ClinicalTri- als.Gov, NCT01084681, National Library of Medicine (US), Bethesda, Md, USA, 2000, http://www.clinicaltrials.gov/ct2/ show/NCT01084681.
  64. 64.
    Safety and Effectiveness of an Intracranial Aneurysm Embolization System for Treating Large or Giant Wide Neck Aneurysms (SCENT). ClinicalTrials.gov Identifier: NCT01716117. https://clinicaltrials.gov/ct2/show/NCT01716117.

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Santosh B. Murthy
    • 1
    • 2
  • Jharna Shah
    • 3
  • Halinder S. Mangat
    • 1
    • 4
  • Philip Stieg
    • 4
  1. 1.Division of Stroke and Neurocritical Care, Department of NeurologyWeill Cornell Medical College/New York Presbyterian HospitalNew YorkUSA
  2. 2.Feil Family Brain and Mind Research InstituteWeill Cornell Medical CollegeNew YorkUSA
  3. 3.Division of Neurosciences Critical Care, Department of NeurologyJohns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Department of NeurosurgeryWeill Cornell Medical CollegeNew YorkUSA

Personalised recommendations