Off-label use of the pipeline embolization device for reconstruction of the extracranial internal carotid artery.

Background: Internal carotid artery dissection (ICD) is a common cause of cerebral ischemia in adults. Medical management has been the standard of care; however, endovascular internal carotid artery (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, makes 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: This study was a retrospective review of patients with ICD or dissecting aneurysms who underwent endovascular reconstruction at our center using PED stent implants. Patients were selected based on pre-morbid modified Rankin Scores ≤1a and National Institutes of Health Stroke Scale (NIHSS) ≥3 and radiologic data consistent with ICA dissection.

Results: Eight patients with a mean age of 55.6 years (range: 31-82 years) and median NIHSS score of 8 (Interquartile range IQR: 2.75-16) who underwent off-label PED surgery were analyzed and are illustrated in this short series. The technical success rate was 100%, with all cases achieving reperfusions of thrombolysis in cerebral infarction grades ≥2b.

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