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Clinical and angiographic outcomes in patients with intracranial aneurysms treated with the pipeline embolization device: intra-procedural technical difficulties, major morbidity, and neurological mortality decrease significantly with increased operator experience in device deployment and patient management

Neuroradiology volume 59, pages 1291–1299 (2017)Cite this article

Abstract

Purpose

Flow diversion constitutes a pivotal advancement in endovascular intracranial aneurysm treatment, but requires development of a new skill set. The aim of this study is to determine whether outcomes after treatment with the Pipeline Embolization Device improve with experience.

Methods

We retrospectively reviewed all patients with intracranial aneurysms treated with Pipeline at two centers over a 4.5-year period. Baseline patient and aneurysm characteristics, complications, and angiographic outcomes were analyzed.

Results

One hundred forty patients underwent 150 Pipeline procedures to treat 167 intracranial aneurysms during the study period, 109 women, mean age 55.4 years. One hundred twenty-six aneurysms were ICA, mean size 10.2 mm and mean neck 6.4 mm. Intra-procedural technical difficulties were higher during the first 75 procedures compared with the subsequent 75 (13.3 vs 2.7%; p = 0.03), as combined major morbidity and neurological mortality (14.7 vs 4%; p = 0.046). In multivariate regression analysis, increased operator experience with Pipeline remained an independent predictor of intra-procedural technical difficulties (p = 0.02, odds ratio (OR) 0.015, 95% CI 0.0004–0.55) and combined major morbidity and neurological mortality (p = 0.03, OR 0.16, 95% CI 0.03–0.84). At last follow-up, 123 aneurysms were completely occluded (81.5%, mean 24 months). In our cohort, age ≤ 53 years was an independent predictor of complete aneurysm occlusion at last follow-up (p = 0.001, OR 0.92, 95% CI 0.88–0.97). Five aneurysms were retreated (3.3%).

Conclusion

The Pipeline embolization device is an effective treatment for intracranial aneurysms. The risk of intra-procedural technical difficulties and combined major morbidity and neurological mortality decreases significantly with increased operator experience in Pipeline deployment and patient management.

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Fig. 1

References

  1. Lylyk P, Miranda C, Ceratto R et al (2009) Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64:632–642

    Article  PubMed  Google Scholar 

  2. Szikora I, Berentei Z, Kulcsar Z et al (2010) Treatment of intracranial aneurysms by functional reconstruction of the parent artery: the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol 31:1139–1147

    Article  CAS  PubMed  Google Scholar 

  3. Nelson PK, Lylyk P, Szikora I et al (2011) The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol 32:34–40

    Article  CAS  PubMed  Google Scholar 

  4. Lubicz B, Collignon L, Raphaeli G et al (2011) Pipeline flow-diverter stent for endovascular treatment of intracranial aneurysms: preliminary experience in 20 patients with 27 aneurysms. World Neurosurg 76:114–119

    Article  PubMed  Google Scholar 

  5. Fischer S, Vajda Z, Aguilar Perez M et al (2012) Pipeline embolization device (PED) for neurovascular reconstruction: initial experience in the treatment of 101 intracranial aneurysms and dissections. Neuroradiology 54:369–382

    Article  PubMed  Google Scholar 

  6. McAuliffe W, Wycoco V, Rice H et al (2012) Immediate and midterm results following treatment of unruptured intracranial aneurysms with the pipeline embolization device. AJNR Am J Neuroradiol 33:164–170

    Article  CAS  PubMed  Google Scholar 

  7. Deutschmann HA, Wehrschuetz M, Augustin M et al (2012) Long-term follow-up after treatment of intracranial aneurysms with the Pipeline embolization device: results from a single center. AJNR Am J Neuroradiol 33:481–486

    Article  CAS  PubMed  Google Scholar 

  8. Cruz JP, Chow M, O’Kelly C et al (2012) Delayed ipsilateral parenchymal hemorrhage following flow diversion for the treatment of anterior circulation aneurysms. AJNR Am J Neuroradiol 33:603–608

    Article  CAS  PubMed  Google Scholar 

  9. Chitale R, Gonzalez LF, Randazzo C et al (2012) Single center experience with pipeline stent: feasibility, technique and complications. Neurosurgery 71:679–691

    Article  PubMed  Google Scholar 

  10. Phillips TJ, Wenderoth JD, Phatouros CC et al (2012) Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol 33:1225–1231

    Article  CAS  PubMed  Google Scholar 

  11. Saatci I, Yavuz K, Ozer C et al (2012) 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 33:1436–1446

    Article  CAS  PubMed  Google Scholar 

  12. Kan P, Siddiqui AH, Veznedaroglu E et al (2012) Early postmarket results after treatment of intracranial aneurysms with the pipeline embolization device. A U.S. multicenter experience. Neurosurgery 71:1080–1087 discussion 1087-8

    Article  PubMed  Google Scholar 

  13. Yu SC, Kwok CK, Cheng PW et al (2012) Intracranial aneurysms: midterm outcome of pipeline embolization device. A prospective study in 143 patients with 178 aneurysms. Radiology 265:893–901

    Article  PubMed  Google Scholar 

  14. Colby GP, Lin LM, Gomez JF et al (2013) Immediate procedural outcomes in 35 consecutive pipeline embolization cases: a single-center, single-user experience. J Neurointerv Surg 5:237–246

    Article  PubMed  Google Scholar 

  15. O’Kelly CJ, Spears J, Chow M et al (2013) Canadian experience with the pipeline embolization device for repair of unruptured intracranial aneurysms. AJNR Am J Neuroradiol 34:381–387

    Article  PubMed  Google Scholar 

  16. Becske T, Kallmes DF, Saatci I et al (2013) Pipeline for uncoilable or failed aneurysms: results from a multicenter clinical trial. Radiology 267:858–868

    Article  PubMed  Google Scholar 

  17. Jabbour P, Chalouhi N, Tjoumakaris S et al (2013) The pipeline embolization device: learning curve and predictors of complications and aneurysm obliteration. Neurosurgery 73:113–120 discussion 120

    Article  PubMed  Google Scholar 

  18. Piano M, Valvassori L, Quilici L et al (2013) Midterm and long-term follow-up of cerebral aneurysms treated with flow diverter devices: a single-center experience. J Neurosurg 118:408–416

    Article  PubMed  Google Scholar 

  19. Chalouhi N, Zanaty M, Whiting A et al (2015) Safety and efficacy of the pipeline embolization device in 100 small intracranial aneurysms. J Neurosurg 122:1498–1502

    Article  PubMed  Google Scholar 

  20. Kallmes DF, Hanel R, Lopes D et al (2015) International retrospective study of the pipeline embolization device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36:108–115 Erratum in: AJNR Am J Neuroradiol 36:E39–40

    Article  CAS  PubMed  Google Scholar 

  21. Kallmes DF, Brinjikji W, Boccardi E et al (2016) Aneurysm study of pipeline in an observational registry (ASPIRe). Interv Neurol 5:89–99

    Article  PubMed  PubMed Central  Google Scholar 

  22. Colby GP, Lin LM, Caplan JM et al (2016) Immediate procedural outcomes in 44 consecutive pipeline flex cases: the first North American single-center series. J Neurointerv Surg 8:702–709

    Article  PubMed  Google Scholar 

  23. Becske T, Potts MB, Shapiro M et al (2017) Pipeline for uncoilable or failed aneurysms: 3-year follow-up results. J Neurosurg 127:81–88

    Article  PubMed  Google Scholar 

  24. Kallmes DF, Brinjikji W, Cekirge S et al (2017) Safety and efficacy of the pipeline embolization device for treatment of intracranial aneurysms: a pooled analysis of 3 large studies. J Neurosurg 127:775–780

  25. Colby GP, Bender MT, Lin LM et al (2017) Endovascular flow diversion for treatment of anterior communicating artery region cerebral aneurysms: a single-center cohort of 50 cases. J Neurointerv Surg 9:679–685

    Article  PubMed  Google Scholar 

  26. Becske T, Brinjikji W, Potts MB et al (2017) Long-term clinical and angiographic outcomes following pipeline embolization device treatment of complex internal carotid artery aneurysms: five-year results of the pipeline for uncoilable or failed aneurysms trial. Neurosurgery 80:40–48

    PubMed  Google Scholar 

  27. Lee DH, Arat A, Morsi H et al (2008) Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience. AJNR Am J Neuroradiol 29:1389–1394

    Article  CAS  PubMed  Google Scholar 

  28. Altay T, Kang HI, Woo HH et al (2011) Thromboembolic events associated with endovascular treatment of cerebral aneurysms. J Neurointerv Surg 3:147–150

    Article  PubMed  Google Scholar 

  29. Deshmukh V, Hu YC, McDougall CG et al (2012) Histopathological assessment of delayed ipsilateral parenchymal hemorrhages after the treatment of paraclinoid aneurysms with the pipeline embolization device [abstract]. Neurosurgery 71:E551–E552

    Article  Google Scholar 

  30. Delgado Almandoz JE, Crandall BM, Scholz JM et al (2013) Pre-procedure P2Y12 reaction units value predicts perioperative thromboembolic and hemorrhagic complications in patients with cerebral aneurysms treated with the pipeline embolization device. J Neurointerv Surg 5(Suppl 3):iii3–ii10

    Article  PubMed  Google Scholar 

  31. Akbari SH, Reynolds MR, Kadkhodayan Y et al (2013) Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures. J Neurointerv Surg 5:337–343

    Article  PubMed  Google Scholar 

  32. Goh C, Churilov L, Mitchell P et al (2013) Clopidogrel hyper-response and bleeding risk in neurointerventional procedures. AJNR Am J Neuroradiol 34:721–726

    Article  CAS  PubMed  Google Scholar 

  33. Delgado Almandoz JE, Crandall BM, Scholz JM et al (2014) Last-recorded P2Y12 reaction units value is strongly associated with thromboembolic and hemorrhagic complications occurring up to 6 months after treatment in patients with cerebral aneurysms treated with the pipeline embolization device. AJNR Am J Neuroradiol 35:128–135

    Article  CAS  PubMed  Google Scholar 

  34. Delgado Almandoz JE, Kadkhodayan Y, Crandall BM et al (2014) Variability in initial response to standard clopidogrel therapy, delayed conversion to clopidogrel hyper-response, and associated thromboembolic and hemorrhagic complications in patients undergoing endovascular treatment of unruptured cerebral aneurysms. J Neurointerv Surg 6:767–773

    Article  PubMed  Google Scholar 

  35. Chalouhi N, Zanaty M, Jabbour PM et al (2014) Intracerebral hemorrhage after pipeline embolization: management of antiplatelet agents and the case for point-of-care testing. Case reports and review of literature. Clin Neurol Neurosurg 124:21–24

    Article  PubMed  Google Scholar 

  36. Daou B, Starke RM, Chalouhi N et al (2016) P2Y12 reaction units: effect on hemorrhagic and thromboembolic complications in patients with cerebral aneurysms treated with the pipeline embolization device. Neurosurgery 78:27–33

    Article  PubMed  Google Scholar 

  37. Kayan Y, Delgado Almandoz JE, Fease JL et al (2016) Incidence of delayed ipsilateral intraparenchymal hemorrhage after stent-assisted coiling of intracranial aneurysms in a high-volume single center. Neuroradiology 58:261–266

    Article  PubMed  Google Scholar 

  38. Kayan Y, Delgado Almandoz JE, Fease JL et al (2017) Efficacy of a two-test protocol for achieving a therapeutic response to clopidogrel prior to elective endovascular intracranial aneurysm treatment and an ‘induced’ postoperative hyper-response. J Neurointerv Surg 9:792–796

    Article  PubMed  Google Scholar 

  39. McAuliffe W, Wenderoth JD (2012) Immediate and midterm results following treatment of recently ruptured intracranial aneurysms with the Pipeline embolization device. AJNR Am J Neuroradiol 33:487–493

    Article  CAS  PubMed  Google Scholar 

  40. Cruz JP, O'Kelly C, Kelly M et al (2013) Pipeline embolization device in aneurysmal subarachnoid hemorrhage. AJNR Am J Neuroradiol 34:271–276

    Article  CAS  PubMed  Google Scholar 

  41. Çinar C, Oran İ, Bozkaya H et al (2013) Endovascular treatment of ruptured blister-like aneurysms with special reference to the flow-diverting strategy. Neuroradiology 55:441–447

    Article  PubMed  Google Scholar 

  42. Yoon JW, Siddiqui AH, Dumont TM et al (2014) Feasibility and safety of pipeline embolization device in patients with ruptured carotid blister aneurysms. Neurosurgery 75:419–429 discussion 429

    Article  PubMed  Google Scholar 

  43. Chan RS, Mak CH, Wong AK et al (2014) Use of the pipeline embolization device to treat recently ruptured dissecting cerebral aneurysms. Interv Neuroradiol 20:436–441

    Article  PubMed  PubMed Central  Google Scholar 

  44. Lin N, Brouillard AM, Keigher KM et al (2015) Utilization of pipeline embolization device for treatment of ruptured intracranial aneurysms: US multicenter experience. J Neurointerv Surg 7:808–815

    Article  PubMed  Google Scholar 

  45. Chalouhi N, Zanaty M, Whiting A et al (2015) Treatment of ruptured intracranial aneurysms with the pipeline embolization device. Neurosurgery 76:165–172 discussion 172

    Article  PubMed  Google Scholar 

  46. Linfante I, Mayich M, Sonig A et al (2017) Flow diversion with pipeline embolic device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature. J Neurointerv Surg 9:29–33

    Article  PubMed  Google Scholar 

  47. Martinez-Galdamez M, Lamin SM, Lagios KG et al (2017) 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 9:772–776

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors would like to acknowledge Sandee K. Verootis, Radiology Department, Abbott Northwestern Hospital, for her contribution in the data collection for this study.

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Authors and Affiliations

  1. Division of Neurointerventional Radiology, Neuroscience Institute, Abbott Northwestern Hospital, 800 E. 28th Street, Minneapolis, MN, 55407, USA

    Josser E. Delgado Almandoz, Yasha Kayan, Adam N. Wallace, Jill M. Scholz, Jennifer L. Fease & Anna M. Milner

  2. Division of Interventional Neuroradiology, Clínica El Ávila, Caracas, Venezuela

    Andrea Tenreiro & Oscar Tenreiro-Picón

  3. Division of Critical Care Medicine, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA

    Maximilian Mulder

  4. Division of Neurological Surgery, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA

    Kyle M. Uittenbogaard

Authors
  1. Josser E. Delgado Almandoz
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  2. Yasha Kayan
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Corresponding author

Correspondence to Josser E. Delgado Almandoz.

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Funding

No funding was received for this study.

Conflict of interest

JEDA and YK are proctors for the Pipeline Embolization Device.

Ethics approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of Abbott Northwestern Hospital and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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For this type of retrospective study formal consent is not required.

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Delgado Almandoz, J.E., Kayan, Y., Tenreiro, A. et al. Clinical and angiographic outcomes in patients with intracranial aneurysms treated with the pipeline embolization device: intra-procedural technical difficulties, major morbidity, and neurological mortality decrease significantly with increased operator experience in device deployment and patient management. Neuroradiology 59, 1291–1299 (2017). https://doi.org/10.1007/s00234-017-1930-z

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  • DOI: https://doi.org/10.1007/s00234-017-1930-z

Keywords

  • Aneurysm
  • Pipeline
  • Flow diverter
  • Stroke
  • Hemorrhage