Twisting: Incidence and Risk Factors of an Intraprocedural Challenge Associated With Pipeline Flow Diversion of Cerebral Aneurysms

• Published in: Neurosurgery Vol. 88; no. 1; pp. 25 - 35
• Main Authors: Bender, Matthew T, Young, Robert W, Zarrin, David A, Campos, Jessica K, Caplan, Justin M, Huang, Judy, Tamargo, Rafael J, Lin, Li-Mei, Colby, Geoffrey P, Coon, Alexander L
• Format: Journal Article
• Language: English
• Published: United States Oxford University Press 01-01-2021; Wolters Kluwer Health, Inc
• Subjects: Adult; Aged; Aneurysms; Angiography; Blood Vessel Prosthesis - adverse effects; Carotid arteries; Catheters; Clopidogrel; Cohort Studies; Complications and side effects; Embolization; Embolization, Therapeutic - adverse effects; Embolization, Therapeutic - instrumentation; Embolization, Therapeutic - methods; Endovascular Procedures - adverse effects; Endovascular Procedures - instrumentation; Endovascular Procedures - methods; Female; Humans; Incidence; Intracranial Aneurysm - therapy; Intraoperative Complications - epidemiology; Intraoperative Complications - etiology; Ischemia; Male; Medical imaging; Middle Aged; Multivariate analysis; Neurosurgery; Patients; Risk Factors; Statistical analysis; Stent (Surgery); Stents; Stents - adverse effects; Stroke (Disease); Treatment Outcome; Maryland; California; Complication; Cerebral aneurysm; Flow diversion; Twisting; Pipeline embolization device
• ISSN: 0148-396X; 1524-4040
• DOI: 10.1093/neuros/nyaa309

Abstract
BACKGROUND
Pipeline Embolization Device (PED; Medtronic) “twisting” manifests with the appearance of a “figure 8” in perpendicular planes on digital subtraction angiography. This phenomenon has received little attention in the literature, requires technical precision to remediate, and has potential to cause ischemic stroke if not properly remediated.
OBJECTIVE
To report incidence, risk factors, and sequelae of PED twisting and to discuss techniques to remediate a PED twist.
METHODS
Case images were reviewed for instances of twisting from a prospectively-maintained, Institutional Review Board-approved cohort of patients undergoing flow diversion for cerebral aneurysm.
RESULTS
From August 2011 to December 2017, 999 PED flow diverting stents were attempted in 782 cases for 653 patients. A total of 25 PED twists were observed while treating 20 patients (2.50%, 25/999). Multivariate analysis revealed predictors of twisting to be: Large and giant aneurysms (odds ratio (OR) = 9.66, P = .005; OR = 27.47, P < .001), increased PED length (OR = 1.14, P < .001), and advanced patient age (OR = 1.07, P = .002). Twisted PEDs were able to be remediated 75% of the time, and procedural success was achieved in 90% of cases. PED twisting was not found to be a significant cause of major or minor complications. However, at long-term follow-up, there was a trend towards poor occlusion outcomes for the cases that encountered twisting.
CONCLUSION
Twisting is a rare event during PED deployment that was more likely to occur while treating large aneurysms with long devices in older patients. While twisting did not lead to major complications in this study, remediation can be challenging and may be associated with inferior occlusion outcomes.
Graphical Abstract
Graphical Abstract