Pipeline shield reduces diffusion-weighted imaging-detected ischemia after intracranial aneurysm treatment compared with pipeline flex: a propensity score-matched retrospective cohort study

Background The Pipeline Flex embolization device with Shield technology (PED Shield, Medtronic, Irvine, CA, USA) is a flow diverter designed to reduce thrombogenicity through phosphorylcholine surface modification. Although in vitro and in vivo studies have demonstrated the thrombogenicity reducing effects of this technology, its effectiveness in real-world clinical practice remains unclear. This study aims to compare the number of post-procedure diffusion-weighted imaging (DWI)-positive lesions between PED Flex(Medtronic, Irvine, CA, USA) and PED Shield to assess the impact of surface modification. Methods This retrospective cohort study included patients with unruptured intracranial aneurysms treated with PED Flex or PED Shield between April 2016 and March 2024 at a single institution. Propensity score matching was performed to control for confounders, and the number of post-procedure DWI-positive lesions was evaluated as the primary outcome. Results In total, 148 procedures (132 patients, 138 aneurysms) were included, with 68 (46%) treated with PED Flex and 80 (54%) with PED Shield. Propensity score matching resulted in 47 matched pairs. After matching, the median number of post-procedure DWI-positive lesions was nine (interquartile range (IQR): 3–17) in the PED Flex group and three (IQR: 1–6) in the PED Shield group, with a significantly lower number in the PED Shield group (regression coefficient β = −10.70 [95% confidence interval (CI): −16.23 to −5.16), P<0.001). Conclusion After adjusting for confounders, the PED Shield group had significantly fewer post-procedure DWI-positive lesions than the PED Flex group, suggesting that phosphorylcholine surface modification technology may reduce thrombogenicity in real-world clinical practice.