Pipeline Embolization: an Advanced Procedure to Stent Large Proximal Carotid Artery Aneurysms

A device that received FDA premarket approval in April 2011, the Pipeline Embolization Device allows for true reconstruction of large or 
giant wide-necked intracranial aneurysms (IAs).

The Pipeline Embolization Device is a fine-mesh stent that diverts blood flow away from the aneurysm in order to provide a complete and durable embolization while maintaining patency of the parent vessel. The stent is a bimetallic design of 75 percent cobalt chromium and 25 percent platinum tungsten; it comprises 48 densely braided strands. It is “customizable” in that multiple devices can be telescoped together, one inside the next, for longer constructs.

Proximal carotid artery aneurysms larger than 1 centimeter in diameter, which are often dysplastic are notorious for returning after surgery or endovascular procedures. The leading-edge Pipeline stent, which has seen positive success in Europe and South America for more than a year, allows for aneurysm repair that previously would have been dangerous to repair or inoperable. Essentially, it provides a potential cure for patients who otherwise have very poor long-term prognoses.

Approximately 300,000 brain aneurysms rupture each year, and less than 
1 percent of the 300,000 are large proximal carotid artery aneurysms. Interestingly, patients with these aneurysms are a bit older — age 50 to 70 — than the general population of aneurysm patients, whose age averages 40 to 60. We don’t know why that is; it’s possible that these aneurysms have simply had an extra decade or so to grow.

Previously, even for experienced neurosurgeons, the risks and outcomes with these large and giant aneurysms have been difficult to predict. There were three choices:

  • palliative treatment only
  • traditional brain surgery, in which a hairpin clip is inserted under the cranium, pinching the bubble of the aneurysm shut and allowing the brain and vessels to return to their natural shape
  • an endovascular procedure, in which a catheter is inserted at the thigh and, under X-ray, navigated to the head to allow the insertion of a stent. In some cases, these stents successfully circumvented the aneurysm but were not successful in preserving the blood vessel. In addition, for aneurysms with no defined bubble — dysplastic aneurysms — placement of the stent was challenging

The Pipeline Embolization Device offers another option: one specifically designed for this type of large aneurysms, which, even if surgery or an endovascular procedure is successful, often have recurred.

Previous generations of stents have allowed us to remodel the vessel around the aneurysm. Stents in general led to good outcomes in many cases by generating not only mechanical benefits, propping up the vessel wall, but biological benefits as well. As the vessel remodels itself and overgrows the stent, the vessel lining can actually grow over the stent, further strengthening the vessel. But older stents, because of their mesh construction, have not been completely successful at redirecting blood flow; blood can, in fact, simply flow through the mesh. The new device provides a mesh so tightly woven that it does redirect blood flow past the aneurysm so that the aneurysm can clot off and heal over itself.

The international success rate with this flow-diverting stent has been stellar: Some 90 to 95 percent of the aneurysms so treated never came back, according to the available literature. To put that in perspective, the risk of complications after simple aneurysm surgery is 3 to 4 percent; the complication rate in other stent procedures has been about 5 percent.

Dr. Shaye Moskowitz is a neurosurgeon in the Cleveland Clinic Neurological Institute’s Cerebrovascular Center. One of a few surgeons in the United States who performs Pipeline Embolization surgery, he specializes in procedures such as open-vascular surgery, craniotomies and clipping. He completed a fellowship in catheter-based neurosurgeries.

MD News September/October 2011, Cleveland/Akron/Canton


14 comments for “Pipeline Embolization: an Advanced Procedure to Stent Large Proximal Carotid Artery Aneurysms”

  1. Gravatar of drliaodrliao
    Posted Monday, July 16, 2012 at 11:02:16 PM

    a good article,and I want to know if this or other kind of stent that diverts blood flow can be used in M1 ,A1 or Acom now?

  2. Gravatar of hoyt t jacksonhoyt t jackson
    Posted Thursday, October 04, 2012 at 11:58:08 AM

    i had this proceedure in two parts in a two year period.the first at nyu in2010 the last at emory in atlanta 2 months ago.i would lie to hear from anyone that has had similar experisience.

  3. Gravatar of Mardi Gonzalez-CaleroMardi Gonzalez-Calero
    Posted Saturday, October 27, 2012 at 8:59:49 AM

    This is a phenominal breakthrough in modern science.. Brilliant!!
    I wish ut every success . Bravo ...

  4. Gravatar of Otto GvertOtto Gvert
    Posted Monday, November 19, 2012 at 4:31:37 PM

    I recently had the pipeline inserted in the right side of my brain. All is well. I would like to know what the followup is for say the next year.

  5. Gravatar of CGCG
    Posted Wednesday, January 09, 2013 at 7:59:29 AM

    I would like to know success rates versus coiling. I've had 2 craniotomies and my third aneurysm is in an unusual location on the internal carotid and the interventional radiologist my neuro referred me to is supposed to be one of the best at coiling; however, I'm only 46 so I worry about long term results

  6. Gravatar of cjpatcjpat
    Posted Thursday, January 31, 2013 at 5:32:54 PM

    My husband had a large, wide mouth anuerysm very close to his pituitary gland in late 2012. Coiling was done in one procedure to buy time and relief from the pain and one month after the pipeline was placed. It has just been 6 weeks and he is doing okay, but headaches are still ever present. Amazing surgery. We were dismissed from ICU to our car to return home after 1 day in the ICU. Wish there was more data and long term prognosis data available, but know we are part of history being made.

  7. Gravatar of Sharon Lawrence-LikwartzSharon Lawrence-Likwartz
    Posted Sunday, March 10, 2013 at 7:39:36 PM

    I am awaiting the possible use of the Pipeline procedure. I am in my 60's with a large (7 cent.) aneurysm on my left carodid behind my left eye..with another smaller presenting on my right carodid behind my right eye.I have very poor vision in the left eye from childhood which is causing much concern over any possible loss of vision from the right aneurysm which surrounds the smaller vessel feeding blood to the right eye.I am hoping for stellar results and that my Neurogergon will be in touch with Dr. Moskowitz, as he plans to be in discussion with other surgeons around the country before this procedure. Is there foundation for my concerns...?

  8. Gravatar of JanetJanet
    Posted Tuesday, January 21, 2014 at 4:34:29 PM

    I had the pipeline done at the end of November 2013, by Dr. Thacker in Dallas TX. Awesome Dr., would recommend him to anyone. He was there for many questions before and after the procedure. I do have small headaches that last no more than 30 minutes. How this was found is I was playing volleyball and got blurred vision, Dr said that he really didn't think that this was the cause. Guess we will see when spring comes, when the season starts up again. I pray that this fixed the vision, if not I am back to square one.

  9. Gravatar of MaryMary
    Posted Friday, April 18, 2014 at 4:25:13 PM

    I had the pipeline procedure about a month ago to correct 3 aneurysms, the largest was 1.7 cm, and the others were much smaller. I began experiencing throbbing headaches about a week bad that if I could get it out I would...I wouldn't have it done having the opportunity for a do over. I had headaches prior but nowhere near like the almost constant throbbing pain I have now...if I had a clue my headaches were going to be worse I would never have allowed them to place the stent.

  10. Gravatar of SUSAN SIMSSUSAN SIMS
    Posted Wednesday, May 28, 2014 at 11:31:02 AM

    I highly reccomend it! I went through clinical
    study in 2009. Just had 5 year check up and
    all is fantastic! To Mary #9 about your head
    ach, that is more than likely the clotting
    which is a good sign! After a little more time
    you will notice the headaches less and less
    I experienced the same thing and it scared
    me to death. The wonderful doctors that
    took care of me in NY gave me pain meds
    for it and it helped so much! I have no
    sign of the aneurysm now. It was in my
    right caradid artery behind my right eye.
    Very painful. Considered Giant and had
    very wide neck. Hard to treat. Pipeline was
    a lifesaver. I live in Atlanta but flew to NY
    to have this done before it was ever FDA
    approved. Believe me, you will get better!
    Hang in there and take care! God Bless
    You All!

  11. Gravatar of melissamelissa
    Posted Sunday, July 20, 2014 at 12:24:04 PM

    My mom is scheduled to have pipleline surgery in a few weeks to tahe care of 5 of her aneurysms then eventually I imagine if that surgery goes well she will have it done 2 more times being that she has a total of 13 aneurysms left that are currently untreated. 2 of them were coiled this past November to the people speaking of having the surgery done in NY anyone have it done in Buffalo? That's where my mom's going I'm really nervous..she's nervous considering that aneurysms are what took her dad and being that she's now recovering from her own ruptured aneurysm this past November..doing very well too I might add...

  12. Gravatar of Susie Susie
    Posted Wednesday, March 18, 2015 at 10:47:33 PM

    I had the procedure in Dec 2014. I to have experienced headaches but my doctor explained the clotting factor. My surgery was at the military medical center in San Antonio as I am a retiree. I must say my experience was the best and I had one of the best neurosurgeons. Sadly he will be leaving the military this year as he has elected to get out. I go back in May for a check. My prayer is that it has dried up. This is a brillant procedure and I am blessed to have it done by a great neurosurgeon.

  13. Gravatar of Susan Susan
    Posted Tuesday, May 26, 2015 at 6:59:45 PM

    On 2-25-14 I had an MRI on my brain which showed a 2.2 cm lesion of the left internal carotid artery pressing all the way down into my sinus cavity pressing on the nerves. This all began with having double vision in my left eye for over a year. Plus, I had been falling. Thought it was related to my back issues. Neuro dr stated the times I was falling the aneurysm was growing. On the film it looked like the size of a golf ball. It was considered inoperable and preparations began immediately to see if I qualified for the pipeline stent. It was truly my only hope. On April 10, 2014 the group of doctors at Tennessee Interventional Radiology Group in Chattanooga, TN performed the procedure placing the Pipeline stent in my brain. It was successful but took months for the aneurysm to dry up and close itself off. I tried to read everything I could to help me understand this type of stent and the recovery time. I believe it depends on the size of the aneurysm. It took about 6 wks for my headaches began and lasted for several months. They explained there is a lot of inflammation going on in there. I had an angiogram about every month. The last one was in July 2014 and they said it looked like a tennis ball inside my head from the inflammation. I was told my recovery was similar to someone having a brain injury. Certain foods made me sick. Certain smells were just as bad. I wasn't able to drive and had to have someone with me at all times. I was put on Plavix and a baby aspirin a day. By Oct. things did start turning around. Thanksgiving was better. Christmas was good. I had my yearly angiogram in April 2015. The aneurysm was still there but had completely dried up. Since, they are not sure per the company, I will have to stay on the Plavix for the rest of my life. I still have some double vision due to the nerve damage. Dr. Rankine is hoping it will straighten itself out. Basically, the nerve repairing itself. I go for my follow-up with him in Nov. 2015. I will have another follow up angiogram in April 2016. I was told the aneurysm would never come back with the pipeline stent in place. I hope this helps anyone going through this same situation. My daddy had passed away on the 23rd of Feb. 2014 which made my scenario very critcal due to the stress per the doctors. Who were afraid it might rupture before they could help me. They are all very pleased with my progress. As am I. I am truly Blessed. If there is anything I would want to tell others would be the recovery time. I was told 6 wks but I knew that couldn't be possible after 2 months. So, I just kept going to the doctors who performed my procedure and telling them things that were almost unbearable. Yes, I did have to take medications to help me through the pain. I am pain free. I actually believe I am a miracle and there is hope out there. God Bless each one of you!

  14. Gravatar of jenjen
    Posted Monday, October 26, 2015 at 5:34:46 PM

    I had an aneurysm aug.2014.a plate was put in my right side of my head./found out that aneurysms are symptom of polycystic kidney disease(diagnosed march 2015).i became a freak every time i had a i wanted an mri. in july 2015, they found another aneurysm.aug 2015 i had a stent put in,around the same place as the anxiety disorder is worse and the only machine that can check my blood is in anchorage ak.and its broken i feel all your pain and hope all is well. im just praying im done with these aneuryms!!!!


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