Endovascular surgery increases scope for aneurysm treatment
MedWire News: Endovascular management of posterior communicating artery (PCoA) aneurysms increases the variety of aneurysms of this nature that are eligible for surgical treatment, US researchers report.
They warn, however, that the endovascular technique is more technically demanding than conventional clipping, and advise that surgeons will need to "recalibrate their expectations with this once straightforward aneurysm."
Michael Lawton (University of California, San Francisco) and team say that most neurosurgeons are familiar with microsurgical clipping of PCoA aneurysms, but clipping is most effective when used on structurally simple PCoA aneurysms.
Given that PCoA aneurysms have features suited to endovascular coiling, such as easy catheter accessibility, small size, and narrow neck, endovascular coiling may be a good management option for PCoA aneurysms that are too complex for clipping.
The researchers investigated the outcomes of 218 PCoA aneurysm patients (mean age 57.3 years) treated microsurgically over an 11-year period. Favorable outcomes (neurologic functioning and aneurysm resolution) were more common among those with simple (n=113) than complex PCoA aneurysms (n=105), at respective rates of 86.6% and 78.2%.
Simple PCoA aneurysms were defined by the absence of previous endovascular coiling, anterior clinoidectomy, large size, calcification, rupture, fetal posterior cerebral artery, complex clipping, and an adherent anterior choroidal artery (AChA). PCoA aneurysms with any of these features were defined as complex.
When specific aneurysm complexities were assessed, Lawton and team found that adherent AChA was the most common type of PCoA aneurysm complexity seen. Previous endovascular coiling was associated with improved patient outcomes, whereas all other types of complexities showed no association with outcomes.
The investigators say that the observations made among this group of patients demonstrate that endovascular coiling may be ideal for treating the complex aneurysms that microsurgical clipping does not guarantee a favorable outcome for.
Lawton and co-investigators say that a multistep approach may be needed to deal with complex PCoA aneurysms.
They conclude in Neurology that this approach "requires more advanced techniques including anterior clinoidectomy, microdissection of an adherent AChA, complex clipping techniques, and the ability to deal with intraoperative aneurysm rupture."
By Lauretta Ihonor