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Research ArticleExpedited Publication
Open Access

The Pipeline Embolization Device for the Intracranial Treatment of Aneurysms Trial

P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke and D. Fiorella
American Journal of Neuroradiology January 2011, 32 (1) 34-40; DOI: https://doi.org/10.3174/ajnr.A2421
P.K. Nelson
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P. Lylyk
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I. Szikora
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S.G. Wetzel
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I. Wanke
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D. Fiorella
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    Fig 1.

    Laterally projecting left carotid aneurysm with residual filling after prior coiling. A, Subtracted carotid angiography in the frontal-projection working angle demonstrates residual filling of the aneurysm neck extending into the proximal fundus. B, Unsubtracted frontal projection in the working angle demonstrates a PED in position across the aneurysm neck. No additional embolization coils were added. The gap between the coil mass and PED construct (arrow) indicates the region of residual aneurysm filling. C, Follow-up angiogram in the frontal projection 6 months after treatment shows complete occlusion of the aneurysm. D, A native image in the frontal projection shows that the gap between the coil mass and PED construct has resolved (arrow). This finding indicates that the aneurysm has not only undergone complete thrombosis, but that the thrombus mass has been resorbed in the interim with contraction of the intra-aneurysmal thrombus-coil mass complex around the outside of the construct.

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    Fig 2.

    Dysplastic wide-neck partially thrombosed aneurysm arising from the proximal cavernous segment of the internal carotid artery. A and B, 3D images reconstructed from rotational angiographic source data demonstrate that the neck of the aneurysm incorporates >180° of the vessel circumference over a 10-mm segment of the carotid artery. C, Conventional angiography in the lateral working projection depicts the partially thrombosed wide-neck aneurysm arising from the circumferentially diseased segment. Just proximal to the aneurysmal segment is a mild focal stenosis (arrow). D, Native image in the lateral working-angle projection after treatment demonstrates the Pipeline construct in place across the aneurysm neck, with a loose packing of the aneurysm with embolization coils. E, Follow-up angiography at 180 days in the lateral working projection shows total occlusion of the aneurysm as well as complete anatomic remodeling of the diseased parent artery. The dysplastic aneurysmal vascular segment now has a smooth tubular configuration. The proximal stenosis has also completely remodeled and now is normal in caliber.

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    Fig 3.

    Left ICA parophthamalic-segment aneurysm in a patient with progressive ipsilateral vision loss. A and B, 3D reconstructed images from rotational source data show a very large wide-neck aneurysm arising from the parophthalmic segment of the left ICA. C, Initial angiogram in the frontal working projection demonstrates a very large aneurysm arising from the left ICA. D, Following reconstruction with a PED, filling of the aneurysm with contrast is diminished because flow has been redirected along the normal course of the ICA and into the left anterior circulation. The patient emerged from general anesthesia with an improvement in left-eye vision. E, A native image depicts the PED construct in position across the aneurysmal segment. F, Subtracted image from the 6-month follow-up angiogram shows anatomic reconstruction of the parent artery with complete aneurysm occlusion. G, Axial CT image at the level of the optic chiasm before treatment demonstrates the peripherally calcified fundus of the very large left ICA aneurysm projecting into the suprasellar cistern. H, Six-month follow-up axial CT image depicts a PED in place within the parent ICA with complete resolution of the aneurysm-thrombus mass. The suprasellar cistern, which was formerly effaced by the aneurysm, now appears normally filled with CSF. These serial images depict the physiologic progression that is possible in some cases after PED reconstruction—starting with mechanical flow diversion, progressing to physiologic aneurysm thrombosis and complete occlusion, followed by endoluminal parent artery reconstruction and, ultimately, anatomical restoration with resolution of the aneurysm-thrombus mass and dissipation of the regional mass effect.

Tables

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    Table 1:

    Characteristics of study aneurysms and treatment

    CharacteristicNo. (%) or Mean (Range)
    Target IA location
        Anterior
            Cavernous5 (16.1)
            Paraophthalmic15 (48.4)
            Superior hypophyseal4 (12.9)
            Posterior communicating4 (12.9)
            M1 segment1 (3.2)
        Posterior
            Distal pre-PICA vertebral1 (3.2)
            PICA vertebral1 (3.2)
    Neck ≥4 mm22 (71.0)
    Maximum aneurysm dimension (mm)11.5 (2.5–26.6)
        <10 mm20 (64.5)
        10–25 mm9 (29.0)
        ≥25 mm2 (6.5)
    Number of PEDs implanted
        118 (58.1)
        211 (35.5)
        31 (3.2)
        41 (3.2)
    Adjunctive coils placed16 (51.6)
    • View popup
    Table 2:

    Angiography findings at 180 days (n = 30)

    CategoryNo. (%)
    Target IA occlusion
        Complete28 (93.3)
        Residual neck0 (0.0)
        Residual filling2 (6.7)
    Device migration
        No29 (96.7)
        Yes0 (0.0)
        Unable to determine1 (3.3)
    Stenosis
        0%–25%28 (93.3)
        >25%–50%1 (3.3)
        >50%–75%0
        >75%–100%0
        Not judged1 (3.3)
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American Journal of Neuroradiology: 32 (1)
American Journal of Neuroradiology
Vol. 32, Issue 1
1 Jan 2011
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The Pipeline Embolization Device for the Intracranial Treatment of Aneurysms Trial
P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke, D. Fiorella
American Journal of Neuroradiology Jan 2011, 32 (1) 34-40; DOI: 10.3174/ajnr.A2421

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The Pipeline Embolization Device for the Intracranial Treatment of Aneurysms Trial
P.K. Nelson, P. Lylyk, I. Szikora, S.G. Wetzel, I. Wanke, D. Fiorella
American Journal of Neuroradiology Jan 2011, 32 (1) 34-40; DOI: 10.3174/ajnr.A2421
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