Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms

Restricted access

Object

In recent years, endovascular treatment of cerebral artery aneurysms (CAAs) has received greater attention. The authors evaluated patient demographics, endovascular and surgical approaches, and basic outcomes in the treatment of CAAs in a nationally representative administrative database.

Methods

Using the Nationwide Inpatient Sample from 1998 to 2003, diagnosed CAA coded as either an unruptured or ruptured lesion and treated with surgical clip occlusion, wrapping combined with endovascular repair, or endovascular repair alone was included in the present study.

Results

Treatment of CAAs significantly increased for unruptured (from 4036 to 8334 cases, p = 0.002) but not ruptured (from 9330 to 11,269 cases, p = 0.231) lesions. Endovascular treatment of CAAs in particular also increased in patients with unruptured (from 11 to 43%, p <0.001) and ruptured (from 5 to 31%, p <0.001) lesions. In 2003, the mortality rate associated with unruptured CAAs treated using clip occlusion (1.36%) or endovascular repair (1.41%) was similar, whereas rate differences were noted between these treatments for ruptured CAAs (12.7% for clip occlusion compared with 16.6% for endovascular repair; p = 0.05). Endovascular treatment of unruptured CAAs was associated with a shorter length of stay (LOS) and higher rate of discharge to home compared with those for clip occlusion. The LOS was also shorter in patients with endovascularly treated ruptured CAAs. Aneurysm type (odds ratio [OR] 10.1, ruptured lesion), patient age (OR 1.28, each 10 years), comorbid conditions (OR 1.08, each condition), and hospital case volume (OR 0.97, each additional case) were significant predictors of death in the regression model.

Conclusions

Endovascular techniques for the treatment of CAAs are being used increasingly in the US, although the majority of patients with this pathological entity still undergo surgical clip occlusion. In cases of unruptured CAAs, endovascular treatment is associated with a shorter LOS and higher discharge-to-home rate. Aneurysm status, patient age, comorbid conditions, and hospital case volume are significant predictors of death. Finally, demographic differences exist between the populations presenting with unruptured or ruptured CAAs.

Abbreviations used in this paper:CAA = cerebral artery aneurysm; CI = confidence interval; HV = highest volume; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; ISAT = International Subarachnoid Hemorrhage Trial; LOS = length of stay; LV = lowest volume; NIS = Nationwide Inpatient Sample; OR = odds ratio.

Article Information

Address reprint requests to: John A. Cowan Jr., M.D., Department of Neurosurgery, University of Michigan Health System, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, Michigan 48109-0338. email: jacowan@umich.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Bar graphs depicting the estimated numbers of unruptured (upper) and ruptured (lower) CAAs in the US from 1998 to 2003. The overall utilization rate and procedure distribution for both presentation types were statistically significant (p <0.001). Endo = endovascular.

  • View in gallery

    Bar graphs showing the utilization of endovascular coil embolization for unruptured (upper) and ruptured (lower) CAAs by patient age group. Asterisk indicates the age group in which endovascular utilization exceeds surgical clip occlusion.

References

  • 1

    Anonymous: Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 339:172517331998

    • Search Google Scholar
    • Export Citation
  • 2

    Bardach NSZhao SGress DRLawton MTJohnston SC: Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke 33:185118562002

    • Search Google Scholar
    • Export Citation
  • 3

    Britz GW: ISAT trial: coiling or clipping for intracranial aneurysms?. Lancet 366:7837852005

  • 4

    Cowan JA JrDimick JBWainess RMUpchurch GR JrThompson BG: Outcomes after cerebral aneurysm clip occlusion in the United States: the need for evidence-based hospital referral. J Neurosurg 99:9479522003

    • Search Google Scholar
    • Export Citation
  • 5

    David CAVishteh AGSpetzler RFLemole MLawton MTPartovi S: Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 91:3964011999

    • Search Google Scholar
    • Export Citation
  • 6

    Eskridge JMSong JK: Endovascular embolization of 150 basilar tip aneurysms with Guglielmi detachable coils: results of the Food and Drug Administration multicenter clinical trial. J Neurosurg 89:81861998

    • Search Google Scholar
    • Export Citation
  • 7

    Guglielmi GVinuela FDion JDuckwiler G: Electrothrombosis of saccular aneurysms via endovascular approach. Part 2: Preliminary clinical experience. J Neurosurg 75:8141991

    • Search Google Scholar
    • Export Citation
  • 8

    Guglielmi GVinuela FDuckwiler GDion JLylyk PBerenstein A: Endovascular treatment of posterior circulation aneurysms by electrothrombosis using electrically detachable coils. J Neurosurg 77:5155241992

    • Search Google Scholar
    • Export Citation
  • 9

    Guglielmi GVinuela FSepetka IMacellari V: Electrothrombosis of saccular aneurysms via endovascular approach. Part 1: Electrochemical basis, technique, and experimental results. J Neurosurg 75:171991

    • Search Google Scholar
    • Export Citation
  • 10

    Harbaugh REHeros RCHadley MN: More on ISAT. Lancet 361:7837842003

  • 11

    Houchens RElixhauser A: Final Report on Calculating Nationwide Inpatient Sample (NIS) Variances. HCUP Methods Series Report #2003–2Washington, DCUS Agency for Healthcare Research and Quality2005. (http://www.hcup-us.ahrq.gov/reports/CalculatingNISVariances200106092005.pdf) [Accessed 5 June 2007]

    • Export Citation
  • 12

    Johnston SCZhao SDudley RABerman MFGress DR: Treatment of unruptured cerebral aneurysms in California. Stroke 32:5976052001

    • Search Google Scholar
    • Export Citation
  • 13

    Kuether TANesbit GMBarnwell SL: Clinical and angiographic outcomes, with treatment data, for patients with cerebral aneurysms treated with Guglielmi detachable coils: a single-center experience. Neurosurgery 43:101610251998

    • Search Google Scholar
    • Export Citation
  • 14

    Lee TBaytion MSciacca RMohr JPPile-Spellman J: Aggregate analysis of the literature for unruptured intracranial aneurysm treatment. AJNR Am J Neuroradiol 26:190219082005

    • Search Google Scholar
    • Export Citation
  • 15

    Lempert TEMalek AMHalbach VVPhatouros CCMeyers PMDowd CF: Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes. Stroke 31:1001102000

    • Search Google Scholar
    • Export Citation
  • 16

    Lindsay KW: The impact of the International Subarachnoid Aneurysm Treatment Trial (ISAT) on neurosurgical practice. Acta Neurochir (Wien) 145:97992003

    • Search Google Scholar
    • Export Citation
  • 17

    Malisch TWGuglielmi GVinuela FDuckwiler GGobin YPMartin NA: Intracranial aneurysms treated with the Guglielmi detachable coil: midterm clinical results in a consecutive series of 100 patients. J Neurosurg 87:1761831997

    • Search Google Scholar
    • Export Citation
  • 18

    Molyneux AKerr RStratton ISandercock PClarke MShrimpton J: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:126712742002

    • Search Google Scholar
    • Export Citation
  • 19

    Molyneux AJKerr RSYu LMClarke MSneade MYarnold JA: International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:8098172005

    • Search Google Scholar
    • Export Citation
  • 20

    Qureshi AISuri MFKhan JKim SHFessler RDRinger AJ: Endovascular treatment of intracranial aneurysms by using Guglielmi detachable coils in awake patients: safety and feasibility. J Neurosurg 94:8808852001

    • Search Google Scholar
    • Export Citation
  • 21

    Qureshi AISuri MFNasar AKirmani JFDivani AAHe W: Trends in hospitalization and mortality for subarachnoid hemorrhage and unruptured aneurysms in the United States. Neurosurgery 57:1 Suppl182005

    • Search Google Scholar
    • Export Citation
  • 22

    Raftopoulos CMathurin PBoscherini DBilla RFVan Boven MHantson P: Prospective analysis of aneurysm treatment in a series of 103 consecutive patients when endovascular embolization is considered the first option. J Neurosurg 93:1751822000

    • Search Google Scholar
    • Export Citation
  • 23

    Raymond JGuilbert FWeill AGeorganos SAJuravsky LLambert A: Long-term angiographic recurrences after selective endovascular treatment of aneurysms with detachable coils. Stroke 34:139814032003

    • Search Google Scholar
    • Export Citation
  • 24

    Serbinenko FA: Balloon catheterization and occlusion of major cerebral vessels. J Neurosurg 41:1251451974

  • 25

    Serbinenko FA: [Catheterization and occlusion of major cerebral vessels and prospects for the development of vascular neurosurgery.]. Vopr Neirokhir 35:17271971. (Rus)

    • Search Google Scholar
    • Export Citation
  • 26

    Solander SUlhoa AVinuela FDuckwiler GRGobin YPMartin NA: Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils. J Neurosurg 90:8578641999

    • Search Google Scholar
    • Export Citation
  • 27

    Solomon RAMayer SATarmey JJ: Relationship between the volume of craniotomies for cerebral aneurysm performed at New York state hospitals and in-hospital mortality. Stroke 27:13171996

    • Search Google Scholar
    • Export Citation
  • 28

    Stein SC: Brief history of surgical timing: surgery for ruptured intracranial aneurysms. Neurosurg Focus 11:E32001

  • 29

    Tateshima SMurayama YGobin YPDuckwiler GRGuglielmi GVinuela F: Endovascular treatment of basilar tip aneurysms using Guglielmi detachable coils: anatomic and clinical outcomes in 73 patients from a single institution. Neurosurgery 47:133213422000

    • Search Google Scholar
    • Export Citation
  • 30

    Thornton JBashir QAletich VADebrun GMAusman JICharbel FT: What percentage of surgically clipped intracranial aneurysms have residual necks?. Neurosurgery 46:129413002000

    • Search Google Scholar
    • Export Citation
  • 31

    Thornton JDebrun GMAletich VABashir QCharbel FTAusman J: Follow-up angiography of intracranial aneurysms treated with endovascular placement of Guglielmi detachable coils. Neurosurgery 50:2392502002

    • Search Google Scholar
    • Export Citation
  • 32

    Tsutsumi KUeki KMorita AUsui MKirino T: Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke 32:119111942001

    • Search Google Scholar
    • Export Citation
  • 33

    US Census Bureau: Population Estimates (http://www.census.gov/popest/estimates.php) [Accessed 5 June 2007]

  • 34

    Vanninen RKoivisto TSaari THernesniemi JVapalahti M: Ruptured intracranial aneurysms: acute endovascular treatment with electrolytically detachable coils—a prospective randomized study. Radiology 211:3253361999

    • Search Google Scholar
    • Export Citation
  • 35

    Vinuela FDuckwiler GMawad M: Guglielmi detachable coil embolization of acute intracranial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg 86:4754821997

    • Search Google Scholar
    • Export Citation
  • 36

    Wanke IDoerfler ADietrich UEgelhof TSchoch BStolke D: Endovascular treatment of unruptured intracranial aneurysms. AJNR Am J Neuroradiol 23:7567612002

    • Search Google Scholar
    • Export Citation
  • 37

    Wiebers DOWhisnant JPHuston J IIIMeissner IBrown RD JrPiepgras DG: Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:1031102003

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 242 242 22
Full Text Views 217 159 3
PDF Downloads 123 92 2
EPUB Downloads 0 0 0

PubMed

Google Scholar