Use of concentric Solitaire stent to anchor Pipeline flow diverter constructs in treatment of shallow cervical carotid dissecting pseudoaneurysms

The flow-diverting Pipeline Embolization Device (PED; ev3 Neurovascular, Irvine, CA, USA) provides proven flow diversion for intracranial wide-necked and fusiform aneurysms. The tendency of the PED to migrate and foreshorten when its size is mismatched with the parent vessel makes its use more difficult for cervical carotid pseudoaneurysms, as the parent vessel regains its luminal diameter during the healing phase, and because of its mobility during head movement. We present a novel technique of using a Solitaire detachable stent (ev3 Neurovascular) to anchor PED constructs to mitigate these shortcomings. Two patients with shallow and broad-necked cervical carotid pseudoaneurysms with underlying parent vessel stenosis deemed poor candidates for conventional stent-supported coiling were treated using tandem overlapping PED centered over the neck of the pseudoaneurysm and a Solitaire concentric anchor was deployed to overlap distally and proximally. As predicted, both patients revealed carotid luminal gain after aneurysm thrombosis with attendant migration (3.8 and 2.8mm) and expansion of the PED construct (14% and 7.8%) which remained constrained within the Solitaire anchoring device with persistent luminal patency and no evidence of endoleak at follow-up (3 and 5 months). The use of a concentric anchoring stent can mitigate the inherent tendency of the braided flow-diverting PED to migrate and foreshorten as the target vessel heals upon pseudoaneurysm thrombosis. This novel technique opens the possibility of using PED to treat shallow or fusiform lesions in mobile cervical arteries previously relegated to stent-supported coiling or surgical reconstruction.