Early angiographic response to Pipeline Vantage flow diverter embolization of intracranial carotid aneurysms

The Pipeline Vantage 027 flow diverter became available a year ago in the United States. We report an observational study of its safety and early angiographic response in the treatment of internal carotid artery (ICA) aneurysms. All patients treated with the Vantage 027 for ICA aneurysms from April to November 2024 at a single center were included. Intraprocedural contrast-enhanced cone-beam CT was used to evaluate vessel wall apposition. A novel proximal ledge deformity is defined as delayed elevation of one stent edge into the lumen while the opposite edge remains wall-apposed. Twenty-four aneurysms (mean size 4.2±2.7 mm) in 20 patients underwent Vantage 027 embolization. Clinical follow-up at 6 months revealed no major/minor stroke and a single reversible ischemic attack following dual anti-platelet therapy (DAPT) non-compliance. Follow-up angiography in all patients revealed complete occlusion in 19/24 aneurysms at a median of 3.5 months (79%). Severe ≥50% stenosis was noted in 7/20 (35%) with distal fishmouth deformity in 12/20 (60%); both fishmouthing (p=0.003) and severe stenosis (p=0.04) were associated with younger age. We also observed a proximal ledge in 5/20 (25%) with luminal caliber compromise. Although Vantage 027 ICA aneurysm embolization resulted in early robust aneurysm involution, it was associated with an age-dependent fishmouthing braid deformity and a proximal ledge deformity possibly requiring extended DAPT. These results encourage further analysis of the vascular response to Vantage 027 and similar stents.