Pipeline Embolization Device with Shield Technology for Intracranial Aneurysms: An Initial U.S. Experience

Background: Thromboembolic complications remain a major reason for morbidity and mortality after flow diversion, in addition to hemorrhagic complications not limited to the brain predicated on the prolonged need for dual antiplatelet therapy. Surface modification to decrease thrombogenicity and accelerate aneurysm occlusion is a promising alteration to mitigate those risks. The Pipeline embolization device with Shield Technology possesses such characteristics; however, it has not yet been approved in the United States.

Case description: We present the case of a 38-year-old woman with a Spetzler-Martin grade 4 left parietal arteriovenous malformation with a total of 8 feeding vessel aneurysms and recent rupture of 1 of those aneurysms that was treated with balloon-assisted coil embolization. Four M1-segment middle cerebral artery aneurysms and 1 supraclinoid internal carotid artery aneurysm were treated with 2 Pipeline embolization Shield devices after a compassionate use request was approved. At 3 weeks after the procedure, the patient experienced a minor ischemic stroke after having missed the prescribed dual antiplatelet therapy. At the 3-month follow-up examination, the patient was neurologically intact and all the aneurysms were occluded. Dual antiplatelet therapy was discontinued.

Conclusions: Flow diverters with surface modification to decrease thrombogenicity and accelerate aneurysm occlusion are promising endovascular tools for patients at high risk of complications with dual antiplatelet therapy. The present case represents one of the first cases performed in the United States using such a device. Despite the favorable outcome in the present case, the question of whether such technology obviates the need for dual antiplatelet therapy remains to be determined.