J Korean Neurosurg Soc.  2016 Sep;59(5):521-524. 10.3340/jkns.2016.59.5.521.

Inadvertent Complication of a Pipeline Embolization Device for Treatment with Vertebral Artery Dissecting Aneurysm : Distal Tip Fracture of Delivery Wire

• Park JS
• Kwak HS
• Lee JM

• KMID: 2351723
• DOI: http://doi.org/10.3340/jkns.2016.59.5.521

Abstract

Use of the Pipeline embolization device (PED) has increased based on studies about its safety and effectiveness, and new reports that describe peri- or postprocedural complications are now emerging. We report a rare periprocedural device-related complication that occurred during endovascular treatment with the pipeline embolization device for a dissecting aneurysm on the vertebral artery. A 55-year old woman was admitted due to left medullary infarction, and angiography showed a fusiform dilatation in the left vertebral artery that was suspicious for dissecting aneurysm. Endovascular treatment with PED was planned. Under general anesthesia, the procedure was performed without significant problems and a PED was deployed in an appropriate position. However, in the final step of the procedure, the distal tip of the PED delivery wire became engaged within a small branch of the posterior cerebral artery and fractured. Fortunately, imaging studies after the procedure revealed neither hemorrhagic nor ischemic stroke, and the patient recovered without neurological morbidities except initial symptoms.

Keyword

Pipeline embolization device; Aneurysm; Endovascular treatment

MeSH Terms

Anesthesia, General
Aneurysm
Aneurysm, Dissecting*
Angiography
Dilatation
Female
Humans
Infarction
Posterior Cerebral Artery
Stroke
Vertebral Artery*

Figure

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  Fig. 1 MRI with diffusion-weighted imaging (A) and MRA (B) demonstrating left medullary infarction (arrow) and fusiform dilatation of the left vertebral artery (arrowhead).

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  Fig. 2 Distal subtraction angiography during treatment of a vertebral artery fusiform aneurysm with the PED. A : Initial angiography showed a vertebral artery fusiform aneurysm (arrow). B : An angiogram following deployment of the PED showed a fully covered aneurysm. C : A post-procedural angiogram via microcatheter demonstrated a fractured distal tip on the delivery wire (arrowhead). PED : Pipeline embolization device.

Reference

1. Albuquerque FC, Park MS, Abla AA, Crowley RW, Ducruet AF, McDougall CG. A reappraisal of the Pipeline embolization device for the treatment of posterior circulation aneurysms. J Neurointerv Surg. 2015; 7:641–645. PMID: 25092926.

2. Becske T, Kallmes DF, Saatci I, McDougall CG, Szikora I, Lanzino G, et al. Pipeline for uncoilable or failed aneurysms : results from a multicenter clinical trial. Radiology. 2013; 267:858–868. PMID: 23418004.

3. Briganti F, Marseglia M, Leone G, Briganti G, Piccolo D, Napoli M, et al. Endovascular treatment of a small aneurysm of the superior cerebellar artery with a flow-diverter device. A case report. Neuroradiol J. 2013; 26:327–331. PMID: 23859291.

4. Chalouhi N, Tjoumakaris S, Dumont AS, Gonzalez LF, Randazzo C, Starke RM, et al. Treatment of posterior circulation aneurysms with the pipeline embolization device. Neurosurgery. 2013; 72:883–889. PMID: 23407289.

5. Chalouhi N, Tjoumakaris SI, Gonzalez LF, Hasan D, Pema PJ, Gould G. Spontaneous delayed migration/shortening of the pipeline embolization device : report of 5 cases. AJNR Am J Neuroradiol. 2013; 34:2326–2330. PMID: 23811979.

6. Chalouhi N, Zanaty M, Whiting A, Tjoumakaris S, Hasan D, Ajiboye N, et al. Treatment of ruptured intracranial aneurysms with the pipeline embolization device. Neurosurgery. 2015; 76:165–172. PMID: 25549187.

7. Ding D, Liu KC. Microsurgical extraction of a malfunctioned pipeline embolization device following complete deployment. J Cerebrovasc Endovasc Neurosurg. 2013; 15:241–245. PMID: 24167807.

8. Fiorella D, Lylyk P, Szikora I, Kelly ME, Albuquerque FC, McDougall CG. Curative cerebrovascular reconstruction with the Pipeline embolization device : the emergence of definitive endovascular therapy for intracranial aneurysms. J Neurointerv Surg. 2009; 1:56–65. PMID: 21994109.

9. Fiorella D, Woo HH, Albuquerque FC, Nelson PK. Definitive reconstruction of circumferential, fusiform intracranial aneurysms with the pipeline embolization device. Neurosurgery. 2008; 62:1115–1120. PMID: 18580809.

10. Hauck EF, Natarajan SK, Langer DJ, Hopkins LN, Siddiqui AH, Levy EI. Retrograde trans-posterior communicating artery snare-assisted rescue of lost access to a foreshortened pipeline embolization device : complication management. Neurosurgery. 2010; 67:495–502. PMID: 21099578.

11. Jabbour P, Chalouhi N, Tjoumakaris S, Gonzalez LF, Dumont AS, Randazzo C, et al. The Pipeline Embolization Device : learning curve and predictors of complications and aneurysm obliteration. Neurosurgery. 2013; 73:113–120. discussion 120. PMID: 23615106.

12. Kallmes DF, Hanel R, Lopes D, Boccardi E, Bonafé A, Cekirge S, et al. International retrospective study of the pipeline embolization device : a multicenter aneurysm treatment study. AJNR Am J Neuroradiol. 2015; 36:108–115. PMID: 25355814.

13. Keskin F, Erdi F, Kaya B, Poyraz N, Keskin S, Kalkan E, et al. Endovascular treatment of complex intracranial aneurysms by pipeline flow-diverter embolization device : a single-center experience. Neurol Res. 2015; 37:359–365. PMID: 25310354.

14. Lylyk P, Miranda C, Ceratto R, Ferrario A, Scrivano E, Luna HR, et al. Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device : the Buenos Aires experience. Neurosurgery. 2009; 64:632–642. discussion 642-643. quiz N6. PMID: 19349825.

15. Munich SA, Tan LA, Keigher KM, Chen M, Moftakhar R, Lopes DK. The Pipeline Embolization Device for the treatment of posterior circulation fusiform aneurysms : lessons learned at a single institution. J Neurosurg. 2014; 121:1077–1084. PMID: 25192476.

16. Navarro R, Yoon J, Dixon T, Miller DA, Hanel RA, Tawk RG. Retrograde trans-anterior communicating artery rescue of unopened Pipeline Embolization Device with balloon dilation : complication management. J Neurointerv Surg. 2015; 7:e7. PMID: 24510421.

17. Nelson PK, Lylyk P, Szikora I, Wetzel SG, Wanke I, Fiorella D. The pipeline embolization device for the intracranial treatment of aneurysms trial. AJNR Am J Neuroradiol. 2011; 32:34–40. PMID: 21148256.

18. Oh SY, Kim MJ, Kim BS, Shin YS. Treatment for giant fusiform aneurysm located in the cavernous segment of the internal carotid artery using the pipeline embolization device. J Korean Neurosurg Soc. 2014; 55:32–35. PMID: 24570815.

19. Park MS, Albuquerque FC, Nanaszko M, Sanborn MR, Moon K, Abla AA, et al. Critical assessment of complications associated with use of the Pipeline Embolization Device. J Neurointerv Surg. 2015; 7:652–659. PMID: 24968879.

20. Szikora I, Berentei Z, Kulcsar Z, Marosfoi M, Vajda ZS, Lee W, et al. Treatment of intracranial aneurysms by functional reconstruction of the parent artery : the Budapest experience with the pipeline embolization device. AJNR Am J Neuroradiol. 2010; 31:1139–1147. PMID: 20150304.

21. Yu SC, Kwok CK, Cheng PW, Chan KY, Lau SS, Lui WM, et al. Intracranial aneurysms : midterm outcome of pipeline embolization device--a prospective study in 143 patients with 178 aneurysms. Radiology. 2012; 265:893–901. PMID: 22996749.