J Cerebrovasc Endovasc Neurosurg.  2013 Sep;15(3):241-245. 10.7461/jcen.2013.15.3.241.

Microsurgical Extraction of a Malfunctioned Pipeline Embolization Device Following Complete Deployment

• Ding D
• Liu KC

• KMID: 1491446
• DOI: http://doi.org/10.7461/jcen.2013.15.3.241

Abstract

The Pipeline Embolization Device (PED) is an effective treatment approach for complex intracranial aneurysms. Intraprocedural complications during PED deployment are seldom reported. We report a rare complication of a PED malfunction identified immediately following complete deployment during endovascular treatment of a giant middle cerebral artery (MCA) bifurcation aneurysm. After multiple failed attempts at endovascular retrieval of the malfunctioned PED, the patient was taken for microsurgical extraction due to accumulation of thrombus on the proximal unopened portion of the stent and widespread distal dissemination of emboli. After removing the PED from the vessel lumen and resecting the giant aneurysm, we could not reanastamose the proximal MCA to the distal segment. The management of PED malfunction is poorly understood. While removal of an incompletely deployed PED may be undertaken with limited adverse effects, retrieval of a fully deployed PED is associated with a much higher risk of morbidity. Until larger case series of such complications better define the risks and benefits of endovascular or microsurgical retrieval of malfunctioned PEDs, the management of these rare intraprocedural complications will be based on the unique aspects of each individual case and the expertise of the treating neurointerventionalist.

Keyword

Endovascular procedures; Intracranial aneurysm; Intraoperative complications; Stents; Stroke

MeSH Terms

Aneurysm
Endovascular Procedures
Glycosaminoglycans
Humans
Intracranial Aneurysm
Intraoperative Complications
Middle Cerebral Artery
Risk Assessment
Stents
Stroke
Thrombosis
Glycosaminoglycans

Figure

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  Fig. 1 Computed tomography angiography (CTA) head (A) axial, (B) coronal, and (C) sagittal views demonstrating a giant, partially thrombosed 4.5×3.3 cm right middle cerebral artery (MCA) bifurcation aneurysm with an atherosclerotic, calcified dome. Digital subtraction angiography (DSA), right internal carotid artery (ICA) injection, (D) antero-posterior (AP) and (E) lateral views again demonstrating the giant MCA bifurcation aneurysm. Most of the aneurysm sac does not fill with contrast due to a significant degree of intrasaccular thrombosis.

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  Fig. 2 Initial treatment DSA, (A) AP and (B) lateral views, demonstrating the incompletely deployed PED with a proximally pinched portion and retained transcend microguidewire. The microguidewire was eventually removed but the proximally stenosed portion of the stent could not be dilated and the stent could not be retrieved. (C) CTA head, coronal view, following the initial treatment DSA demonstrating the incompletely deployed PED (arrow) with stenosis of the proximal segment of the stent. (D) Magnetic resonance imaging diffusion weighted imaging, axial view, following the second failed retrieval DSA demonstrating multifocal acute infarcts of the right MCA distribution (DSA: digital subtraction angiography, AP: antero-posterior, PED: pipeline embolization device, CTA: computed tomography angiography, MCA: middle cerebral artery).

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  Fig. 3 (A) Intraoperative photograph after dural opening demonstrating the atherosclerotic, calcified dome (arrow) of the giant MCA bifurcation aneurysm. (B) Intraoperative photograph after opening the aneurysm dome and debulking the intrasaccular thrombus demonstrating removal of the incompletely PED (arrow) from the lumen of the MCA M1 segment. Post-operative CTA head 3-dimensional reconstruction, (C) axial and (D) coronal views, demonstrating absence of the right MCA at its origin from the ICA bifurcation (arrow). After aneurysm resection, the detached posterior division of the MCA M2 segment was unable to be reanastamosed to proximal the M1 segment (MCA: middle cerebral artery, PED: pipeline embolization device, CTA: computed tomography angiography, ICA: internal carotid artery).

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