Novel application of a balloon-anchoring technique for the realignment of a prolapsed Pipeline Embolization Device: a technical report

Background Flow-diverting stents represent a substantial advancement in the treatment of cerebral aneurysms. They can, however, be associated with unique complications that may require management through adjunctive techniques. Objective To present a technical report of a salvage technique used to realign a prolapsed Pipeline Embolization Device (PED) during the treatment of a giant internal carotid artery (ICA) aneurysm. Methods A patient in his late 70s with an incidental giant supraclinoid ICA aneurysm presented for endovascular consideration. Treatment was planned using the PED. Following placement of the device there were two focal areas of incomplete expansion and balloon angioplasty was performed. This manipulation resulted in foreshortening of the distal aspect of the PED which caused the device to prolapse into the aneurysm. After multiple unsuccessful attempts to regain distal access, a salvage technique was attempted in which a balloon was inflated in the middle cerebral artery and, by applying traction, the PED was realigned with the parent artery. Results After the PED was realigned, direct distal catheter access was achieved and a second Pipeline device was deployed, successfully covering the aneurysm neck with resultant flow stasis. The patient had no postoperative issues and was discharged 2 days later without deficit. Conclusions The balloon-anchoring technique was successfully used to realign a PED that had prolapsed into a giant ICA aneurysm. This maneuver prevented potentially disastrous complications and allowed the satisfactory completion of the aneurysm embolization. This represents a useful salvage technique that should be considered when encountering a prolapsed stent.