Off-Label Use of the Pipeline Embolization Device for Reconstruction of Dissections involving tortuous segments of the Extracranial Internal Carotid Artery

Introduction: Internal carotid artery dissection (ICD) is a common cause of cerebral ischemia in adults. Medical management has been the standard of care; however, endovascular ICA reconstruction has certain indications. The Pipeline Embolization Device (PED) is a flow-diverting (low porosity), self-expanding, braided platinum and nickel-cobalt chromium alloy stent and is indicated for wide neck or large aneurysms of the ICA from the petrous to the superior hypophyseal segments. The flexible nature of PED stents, with their high wall coverage, make them amenable as stents for reconstructing arterial dissections diagnosed in the tortuous segments of the extracranial ICA. We present our experience using PEDs for ICA reconstruction in cases of distal cervical or petrous segment dissection or dissecting aneurysms and review the literature on this contemporary indication of flow diverter devices.

Methods: Total of eight patients who had ICD or dissecting aneurysms underwent endovascular reconstruction at our center using PED stent implants. Patients were selected based on pre-morbid mRS ≤ 1a and NIHSS ≥ 3 and radiologic data consistent with ICA dissection or dissecting aneurysms.

Results: Eight patients with a mean age of 61.5 years (range 31 - 78) who underwent off-label PED surgery were analyzed and have been illustrated in this short series. Six of those patients presented with stroke like symptoms with tandem occlusion. The technical success rate was 100% with all cases achieving reperfusions of thrombolysis in cerebral infarction (TICI) grades 2b.

Conclusion : In our series of patients with distal cervical or petrous segment ICA dissection or dissecting aneurysms managed by PED implantation, we found that their use to be feasible, safe, and effective in achieving arterial recanalization. Further studies will clarify the role of this technique.