Endovascular neurosurgeons at Penn Medicine are now offering the PipelineTM embolization device (PED, eV3, Inc., Plymouth, MN) as a treatment for adults with wide-necked intracranial aneurysms, a group of endovascular lesions for which effective treatment was, until recently, an unmet need. A tubular covered endoluminal stent composed of flexible bimetallic mesh, the PED is only available at select, specialized centers in the United States at this time.
The treatment of wide-necked aneurysms is complicated by the width of the orifice at the vessel wall, an anomaly that can preclude both clipping and coil embolization. Unlike these techniques, which block or fill the aneurysm, the PED excludes the aneurysm by providing a scaffold within the parent artery that recreates the vessel’s structure.
The PED is introduced through a catheter in the femoral artery. Once inside the brain, the device is deployed within the vessel across the neck of the aneurysm, disrupting blood flow into the dilated segment. Eventually the PED is incorporated into the vessel wall by neoendothelial growth, and ultimately achieves complete occlusion of the aneurysm. The parent artery and adjacent branch vessels are preserved.
The PED uses a proprietary delivery system requiring specialized training to achieve the unique techniques for catheter positioning and stent deployment. At Penn Medicine, the procedure expands the options for patients
with aneurysmal disease, a spectrum of treatments that also includes coil embolization, open surgery (clipping) and balloon remodeling.
Mr. U, a 57-year-old patient, was referred to the Department of Neurosurgery by his ophthalmologist for evaluation after a two month period of progressively worsening headaches, retro-orbital pain
At Penn, an MRI discovered a large mass posterior to the left orbit (Fig 1). A subsequent neuroradiological evaluation via three-dimensional cerebral angiography further defined the lesion as a large, wide-necked aneurysm of the cavernous internal carotid artery
After a discussion of his options, Mr. U opted to have a PED procedure. He was premedicated with aspirin and Plavix®, and was admitted on the morning of his procedure.
Immediately before surgery, he underwent general anesthesia and a femoral artery sheath was placed. Neuromonitoring was performed by a neurologist.
After performing diagnostic angiography to determine exact vessel measurements for stent selection, two PEDs were deployed in the internal carotid artery across the neck of the aneurysm.
Post-procedure angiography confirmed good stent placement and immediate stagnation of contrast in the aneurysm, indicating initiation of occlusion (Fig 3). Mr. U was extubated and transferred to the neurology critical care unit in stable condition.
On post-op day one, he was transferred to the floor and discharged home on post op day two. He reported significant relief from his retro-orbital headache. He will undergo repeat angiography in six months to ensure complete occlusion of the aneurysm.
At Penn Medicine, an expert multidisciplinary team of neurosurgeons, neurologists, diagnostic and interventional neuroradiologists, neurointensivists and neuroanesthesiologists provides highly specialized care for all aspects of cerebrovascular disease.
Performing PipelineTM Surgery at Penn Medicine for Wide-Necked
and Giant Intracranial Aneurysms
Michelle J. Smith, MD
Assistant Professor of Neurosurgery
Robert W. Hurst, MD
Professor of Radiology
Bryan A. Pukenas, MD
Assistant Professor of Radiology
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, PA 19104
For neurological emergencies, please call 877.936.7366
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