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Aneurysm clipping after endovascular treatment with coils: a report of 13 cases

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Abstract

In 1996, Civit et al. (Neurosurgery, 38:955–961, 1996) reported a series of eight patients whose aneurysms were clipped after previous embolization with coils. This paper highlighted the safety of this surgery in second line, with a low complication rate and a favorable outcome. The two major surgical indications were either after deliberate partial occlusion of the aneurysm (N = 3) or partial occlusion after endovascular treatment (N = 3). Reviewing 13 additional patients from 1996 to June 2005, the authors compared the surgical indications and focused on the technical problems of clipping after coiling. Thirteen patients (men = 6, women = 7) with aneurysm clipping following one or more endovascular embolizations have been operated on since 1996. The patients’ files were reviewed retrospectively by both a senior consultant neurosurgeon and a neuroradiologist. Demographic data included sex, age at admission, relevant medical history, initial endosaccular treatment and its quality (partial or complete effectiveness), the rationale for surgery, and the complications arising from the different treatments. In addition to the patient’s clinical follow-up, angiograms were performed soon after the surgical procedure, 3 months, 1 year, and 5 years after the coiling, respectively. None of the initial endovascular treatments was complete. Surgical indication was related firstly to anatomical particularities of the aneurysm (width of the neck, N = 5; arterial branches from the aneurysm, N = 4; no individualized neck in a small aneurysm, N = 1); secondly to a shift of the coils with delayed aneurysm regrowth and repermeabilization, N = 4; and thirdly to rebleeding, N = 3. All the patients who were operated on underwent complete surgical exclusion of their aneurysm (controlled by angiogram). Twelve out of 13 patients recovered satisfactorily (92.3%), attaining the same neurological state they presented prior to surgery. One patient died after the operation. He had already been in a serious condition because of severe rebleeding following the embolization. Aneurysm clipping following a previous endovascular embolization procedure is a rare, although not so exceptional, indication. It is a safe and effective procedure, probably under-used. Nowadays, “hemostatic” and incomplete embolization of an aneurysm increases the risk of future growth and rebleeding of the residual pouch. An additional aneurysm clipping may therefore be required rapidly after embolization.

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Acknowledgement

No financial support was received or requested by the authors during the writing of this article.

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Authors and Affiliations

  1. Department of Neurosurgery, Hôpital central, Nancy University, 29, Avenue du Maréchal de Lattre de Tassigny, 54035, Nancy, France

    Olivier Klein, Sophie Colnat-Coulbois, Thierry Civit, Jean Auque, Catherine Pinelli & Jean-Claude Marchal

  2. Department of interventional neuroradiology, Hôpital Central, Nancy University, Nancy, France

    Serge Bracard

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  1. Olivier Klein
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  2. Sophie Colnat-Coulbois
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  3. Thierry Civit
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  4. Jean Auque
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  5. Serge Bracard
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  6. Catherine Pinelli
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  7. Jean-Claude Marchal
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Correspondence to Olivier Klein.

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Comments

Michael T. Lawton, San Francisco, USA

In this report, 13 patients with previously coiled aneurysms were treated microsurgically, with indications that included incomplete coiling, aneurysm recurrence, and rehemorrhage. All aneurysms were clipped directly, and none required complex maneuvers like coil extraction, bypass, or arterial reconstruction. Favorable outcomes were observed in 92% of patients, validating the safety of this approach. The authors arrive at important conclusions that deserve emphasis. First, “hemostatic coiling” or deliberate, initial incomplete coiling intended to lower the rebleeding risk is inadvisable because it fails to obliterate the aneurysm, does not prevent rerupture, and complicates later microsurgical therapy. Second, aneurysm recurrence after coiling occurs frequently enough that vigilant surveillance with angiography is required. Third, inappropriate patient selection will only exacerbate the problem of incompletely coiled and recurrent aneurysms. I have come to similar conclusions based on my experience with 43 patients with previously coiled aneurysms that I have treated microsurgically. When endovascular therapy is not going to eliminate the aneurysm, I favor stopping the procedure, withdrawing coils, and operating acutely. Once coils are deployed, the aneurysm’s collapsibility and maneuverability is compromised, and clipping becomes more difficult. Ineffective coiling must be recognized early, and neurosurgeons and interventionalists should collaborate closely to transfer primary care. I agree with the authors that simple clipping is the preferred microsurgical technique, but I have not been able to clip all of my aneurysms, particularly the recurrent aneurysms and the large or giant aneurysms. I also advise against coil extraction with these unclippable aneurysms because the aneurysm must be opened, adherent coils must be mobilized, and arterial tissue and branch arteries are endangered. Instead, I am quick to resort to a bypass strategy which is more methodical, predictable, and safe. Finally, the process of selecting patients is too critical and complex to simply relegate microsurgery to a secondary role. Most middle cerebral artery aneurysms and many anterior communicating artery aneurysms have anatomy that strongly favors clipping, and patients should be offered this treatment initially before primary endovascular therapy fails. In my view, microsurgery should remain an integral treatment option for aneurysm patients. As such, microsurgery should address the problem of inappropriate patient selection and the rising incidence of incompletely coiled and recurrent aneurysms.

Siamak Asgari, Essen, Germany

The authors present a retrospective analysis of 13 patients with clipping after coiling of cerebral artery aneurysms. In the Introduction, they reference their own former series of eight patients with clipping after coiling. The first reports appeared 2 years earlier, in 1994. Coil compaction is a frequent long-term complication of endovascular treatment. In 2002, 64 cases of clipping after coiling were presented in the literature [1]. Therefore, the actual series does not give basically new information. The authors confirm our own experiences with clipping after coiling [1], as direct clipping without coil extraction or reconstructive procedures was effective in all cases. A major problem of this paper is the open question of patients with coil compaction and endovascular retreatment. Why did the authors perform angiography 1 and 5 years after clip ligation? Further, the authors recommend incomplete coiling of the aneurysm in the presence of vasospasm to operate later on. In my opinion, this is a wrong strategy. There are other and better options in managing these problems, e.g., surgical clipping at chronical stage or interventional strategy with complete GDC packing and intraarterial spasmolysis or angioplasty.

Reference

1. Asgari S, Doerfler A, Wanke I, Schoch B, Forsting M, Stolke D (2002) Complementary management of partially occluded aneurysms by using surgical or endovascular therapy. J Neurosurg 97:843–850

Kiyohiro Houkin, Sapporo, Japan

Endovascular treatment is becoming the main option for the occlusion of the cerebral aneurysm. However, this technique has many drawbacks to overcome.

The coil migration, aneurysm rupture, thrombo-embolic complication, acute occlusion of the normal parent artery, and coil compaction are easily reminded. Among these issues, the incomplete coil occlusion of the aneurysm dome and coil protrusion into parent artery seems to be commonly seen.

Additional surgical treatment for these incomplete coil treatments is occasionally discussed in some papers. It is often demonstrated that the secondary surgical obliteration of the aneurysm neck after incomplete embolization is not always easy, and a complicated technique including the bypass surgery is often reported.

In this study, the authors reported a good number of the surgically treated cerebral aneurysms after incomplete embolization. This study provides us with the practical and useful experience of surgery for these tough cases.

Their experience has demonstrated that the additional surgical treatment for the incomplete embolization is not always complicated but simple in many cases. In other words, the important message from this paper is that the surgical treatment for these cases should not be hesitated.

I am happy and tremendously encouraged for the surgery after reading this paper. I believe that early appropriate surgery in acute stage after incomplete embolization is not always difficult. On the other hand, the surgical treatment for the partially coiled cerebral aneurysm in chronic stage should be considered in same way. Cerebral revascularization option and other options should be prepared in such cases.

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Klein, O., Colnat-Coulbois, S., Civit, T. et al. Aneurysm clipping after endovascular treatment with coils: a report of 13 cases. Neurosurg Rev 31, 403–411 (2008). https://doi.org/10.1007/s10143-008-0151-7

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