BACKGROUND Pipeline Embolization Device (PED; Medtronic) "twisting" manifests with the appearance of a "figure 8" in perpendicular planes on digital subtraction angiography. This phenomenon has received little attention in the literature, requires technical precision to remediate, and has potential to cause ischemic stroke if not properly remediated. OBJECTIVE To report incidence, risk factors, and sequelae of PED twisting and to discuss techniques to remediate a PED twist. METHODS Case images were reviewed for instances of twisting from a prospectively-maintained, Institutional Review Board-approved cohort of patients undergoing flow diversion for cerebral aneurysm. RESULTS From August 2011 to December 2017, 999 PED flow diverting stents were attempted in 782 cases for 653 patients. A total of 25 PED twists were observed while treating 20 patients (2.50%, 25/999). Multivariate analysis revealed predictors of twisting to be: Large and giant aneurysms (odds ratio (OR) = 9.66, P = .005; OR = 27.47, P < .001), increased PED length (OR = 1.14, P < .001), and advanced patient age (OR = 1.07, P = .002). Twisted PEDs were able to be remediated 75% of the time, and procedural success was achieved in 90% of cases. PED twisting was not found to be a significant cause of major or minor complications. However, at long-term follow-up, there was a trend towards poor occlusion outcomes for the cases that encountered twisting. CONCLUSION Twisting is a rare event during PED deployment that was more likely to occur while treating large aneurysms with long devices in older patients. While twisting did not lead to major complications in this study, remediation can be challenging and may be associated with inferior occlusion outcomes.

中文翻译：

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扭曲：与脑动脉瘤管道分流相关的程序内挑战的发生率和风险因素

背景管道栓塞装置（PED；Medtronic）“扭曲”在数字减影血管造影的垂直平面中表现为“8 字形”的外观。这种现象在文献中很少受到关注，需要精确的技术来修复，如果修复不当，有可能导致缺血性中风。目的 报告 PED 扭曲的发生率、危险因素和后遗症，并讨论修复 PED 扭曲的技术。方法 从前瞻性维护的、机构审查委员会批准的接受脑动脉瘤分流术的患者队列中，对病例图像中的扭曲实例进行了审查。结果 2011年8月至2017年12月，653例患者共782例，尝试置入PED导流支架999枚。在治疗 20 名患者时，共观察到 25 次 PED 扭转 (2.50%, 25/999)。多变量分析显示扭曲的预测因素是：大动脉瘤和巨大动脉瘤（优势比 (OR) = 9.66，P = .005；OR = 27.47，P < .001），PED 长度增加（OR = 1.14，P < .001）和高龄患者（OR = 1.07，P = .002）。扭曲的 PED 能够在 75% 的时间内得到修复，并且在 90% 的案例中取得了程序上的成功。未发现 PED 扭曲是导致主要或次要并发症的重要原因。然而，在长期随访中，遇到扭转的病例有闭塞效果不佳的趋势。结论 扭转是 PED 部署期间的罕见事件，在老年患者中使用长器械治疗大动脉瘤时更有可能发生扭转。