pipeline embolisation device

INTRODUCTION: Direct percutaneous carotid artery puncture (DPCAP) enables endovascular treatment of cerebral aneurysms that are otherwise untreatable in patients with non-navigable proximal vessel tortuosity. Traditionally, microcatheters were advanced directly through the carotid sheath to the intracranial target. This method is insufficient for complex modern neurointerventions necessitating robust, distal large-bore intracranial support. METHODS: We retrospectively reviewed all neurointerventions performed by the senior author (ALC) to identify all aneurysms treated via DPCAP with utilisation of the 5F 0.058-inch inner diameter Navien distal intracranial catheter. RESULTS: DPCAP was used in 6 neurointerventions for these reasons: bilateral iliofemoral occlusion (n=2) and failed transfemoral embolisation secondary to severe tortuosity of arch/supra-aortic vasculature (n=4). Mean patient age was 75.3 years (range 67-85). All treatments were for anterior circulation aneurysms (A2-3, n=2; ophthalmic, n=3; ACOM, n=1). Intra-procedural Navien position along the internal carotid artery were as follows: petrous (n=1), petrocavernous (n=1), cavernous (n=2), supraclinoid (n=1) and ICA terminus (n=1). All neurointerventions (coil embolisation, n=3; stent-assisted coiling, n=2; Pipeline embolisation, n=1) were successful. No complications occurred during carotid puncture, Navien positioning and aneurysm embolisation. Two cervical haematomas were observed without significant adverse sequelae. All patients were discharged home at their pre-procedure neurological baseline. CONCLUSION: For neurointerventions of anterior circulation cerebral aneurysms in patients with complex proximal vasculature tortuosity or occlusion, DPCAP remains an effective technique. Use of the Navien catheter greatly enhances this approach by providing large-bore distal intracranial support necessary for modern neurointerventions. Cervical haematomas remain a known potential complication of DPCAP, particularly in patients on dual antiplatelet therapy.

This review summarises the reported clinical experience with flow diverters for the reconstruction of the parent artery of intracranial aneurysms, since their introduction 5 years ago. Over this period, the literature has documented treatment concepts and initial results. Safety concerns, some of which have proved unwarranted, have limited the use of these devices to the treatment of aneurysms which were likely to fail or had failed to be effectively treated by endosaccular coil embolisation. The emerging data now allows the risks of complications specific to this technology to be quantified and the emerging consensus on its efficacy has extended its use to include aneurysms suitable for conventional coil embolisation, in some centres. The need for antiplatelet prophylaxis will probably limit its use to anatomically complex and dissecting aneurysms in patients after spontaneous intracranial haemorrhage. This extending role highlights the need for systematic retrospective analysis of existing large case series and randomised comparative studies.