Tools and techniquesTreatment of distal anterior cerebral artery aneurysms with the Pipeline Embolization Device

•Aneurysms of the distal anterior cerebral artery (ACA) remain challenging to treat.•Minimally porus endoluminal devices may be used for distal ACA aneurysms.•Smaller diameter PEDs can be safely deployed in arteries smaller than 2 mm.

Aneurysms of the anterior cerebral artery (ACA) located distal to the anterior communicating artery complex (ACOM) remain challenging to treat with surgical clip reconstruction as well as with endovascular coil-embolization strategies. We have treated five complex geometry distal ACA aneurysms with endoluminal reconstruction using the Pipeline Embolization Device (PED). Two aneurysms were of the dysplastic fusiform type. Three aneurysms were of complex saccular configuration. Three aneurysms were treated electively at the outset with PED. One patient had previously undergone aborted clip reconstruction, and one was treated for recurrent aneurysm growth after coil embolization. The mean diameter of the ACA in this cohort was 1.96 mm proximal to the aneurysm and 1.79 mm distal to the aneurysmal segment. A single PED of 2.5 mm inner diameter was the sole treatment in four cases. Two PEDs, telescopically overlapped across the aneurysm, were used in the remaining case. All devices were deployed successfully. No parent artery occlusion or stenosis was observed. In all cases an associated branch vessel arising from the vicinity of the aneurysm or incorporated into its neck was covered by the endoluminal construct. At follow-up angiography, robust antegrade flow was maintained in the jailed branch. One patient experienced asymptomatic, delayed occlusion of the jailed branch. Complete aneurysm occlusion was seen in all patients. We confirm that PED can be deployed in parent vessels smaller than 2 mm diameter, and that endoluminal reconstruction with the PED may be a safe and effective treatment alternative for selected distal ACA aneurysms.