Peer-Review ReportMicrosurgical Clipping for Recurrent Aneurysms After Initial Endovascular Coil Embolization
Introduction
Endovascular treatment of intracranial aneurysms has been widely accepted as an established treatment for aneurysmal subarachnoid hemorrhage (SAH) 20, 24. Although the International Subarachnoid Aneurysm Trial (ISAT) data proved the initial clinical advantage of endovascular treatment of ruptured aneurysms, coil instability necessitating aneurysm retreatment remains a major shortcoming of endovascular treatment 23, 28. In patients in whom relevant aneurysm recurrences are documented on imaging follow-up, both endovascular and surgical techniques can be used.
To assess the efficacy and safety of surgical treatment for recurrent aneurysms after previous embolization, we retrospectively studied angiographic results, clinical results, and complications in patients treated with additional surgery.
Section snippets
Methods
From April 2003 to April 2013, patients with recurrent aneurysms after initial endovascular coil embolization, who were treated at our institution were included in this study. During this period, 274 patients underwent endovascular treatment for intracranial aneurysms as the first-line treatment, including 105 patients with SAH and ruptured aneurysms (38.3%). Our retreatment indication for recurrent aneurysm after endovascular coil embolization is 1) residually more than 30% of the original
Results
During the 10-year study period, 21 patients, or 7.7 % of the group, received endovascular treatment for cerebral aneurysms, and experienced relevant aneurysm recurrences. Eight of the 21 patients refused the treatment and were followed by imaging studies. Therefore, 13 patients required additional treatment. Six patients were treated with endovascular recoiling, and 7 patients were treated surgically. The surgical series included 1 man and 6 women. The mean age was 60.3 years (range, 45–68
Discussion
In the present study, we demonstrated that the microsurgical treatment without coil removal for recurrent aneurysms after initial endovascular coil embolization was an effective and safe modality. Six of 7 cases were successfully treated with microsurgical direct neck clipping. For 1 patient, who had an unclippable recurrent aneurysm, a PAO under extracranial-intracranial bypass protection was safely performed.
Conclusion
For recurrent aneurysms after initial endovascular coil embolizations that are not feasible for standard recoiling, the microsurgical clipping without coil extraction is recommended when possible, and this policy led to successful clinical results in our practice. The tandem clipping method, in combination with a fenestrated clip, is crucial for direct neck clipping without coil removal for previously coiled recurrent aneurysms.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.