Neurointervention.  2017 Sep;12(2):83-90. 10.5469/neuroint.2017.12.2.83.

Usefulness of the Pipeline Embolic Device for Large and Giant Carotid Cavernous Aneurysms

• Miyachi S
• Hiramatsu
• Ohnishi H
• Yagi R
• Kuroiwa T

• KMID: 2389500
• DOI: http://doi.org/10.5469/neuroint.2017.12.2.83

Abstract

PURPOSE
Conventional coil embolization for large carotid cavernous aneurysms (CCAs) has limited utility due to its inability to prevent recurrences and reduce mass effect. Trapping of the parent artery may have a risk of ischemic complications due to intracranial perfusion disorders. We successfully treated 24 patients with large CCAs using a flow diverter (Pipelineâ„¢ embolic device: PED), and this report discusses the safety and efficacy of this method.
MATERIALS AND METHODS
Twenty four patients (23 females, mean age 71.5 years old) with large CCAs, including 6 giant CCAs, were treated with a PED over three years. Under sufficient dual anti-platelet management, the PED was deployed over the orifice of the aneurysm. Two patients required multiple telescoping stents. Clinical and radiological states were checked with MRI at 1, 3 and 6 months post-surgically. Angiographic follow-up was performed at 6 months.
RESULTS
In all patients, PED was appropriately deployed. Stagnation of contrast with eclipse signs was observed post-angiogram in 21 cases. One patient requiring 5 telescoping stents experienced temporary ischemic symptoms. Fourteen patients experienced improvement of ocular motor impairment deficiency, including 6 patients who recovered. Angiograms at 6 months follow-up showed complete occlusion in 63% (12/19) of patients, and MRI showed reduction of aneurysm volume in 89% (17/19) of patients.
CONCLUSION
Flow diverters for large CCAs showed promising clinical and radiological efficacy. They can shrink the aneurysm and improve symptoms without sacrificing the parent artery. It will be necessary to summarize the cases and to verify the long-term results.

Keyword

Carotid cavernous aneurysm; Endovascular treatment; Flow diverter; Pipelineâ„¢ embolic device

MeSH Terms

Aneurysm*
Arteries
Embolization, Therapeutic
Female
Follow-Up Studies
Humans
Magnetic Resonance Imaging
Methods
Parents
Perfusion
Recurrence
Stents

Figure

• 

  Fig. 1 A giant aneurysm of complete occlusion (Case No. 1). Right carotid angiogram showed a giant CCA protruding laterally (A, B). After deploying a PED (4.0 × 25 mm), the neck cone-beam CT revealed a marked eclipsed sign (C). Angiogram taken at 6 months showed complete occlusion of the aneurysm (D). MRI demonstrated the shrinkage of the aneurysm (E: right: just after the treatment, left: 6 months follow-up).

• 

  Fig. 2 A giant aneurysm requiring telescoping stent (Case No. 2). Left carotid angiogram showed a dysplastic, giant CCA without a neck and another tandem aneurysm on the near proximal side (A, B). Five PEDs were connected with partial overlapping to cover the neck of both aneurysms on two stages (C). Post-MRI showed multiple small ischemic lesions (D). Angiogram taken at 6 months showed complete occlusion of the aneurysm (E).

• 

  Fig. 3 A case of remaining neck (Case No. 11). Right carotid angiogram showed a large CCA (A). PED was successfully deployed (B), and the postoperative angiogram demonstrated a marked eclipse sign (C). The angiogram 6 months later showed that the aneurysm had diminished in size, but a small remnant neck remained (D, E). A follow-up angiogram at 6 months showed the deviation of the body of PED and an original neck remained as the other pathway (D, E).

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