OBJECTIVE With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure. METHODS One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes. RESULTS The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018). CONCLUSIONS Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

Background & Aims: Early-stage HCC can be treated with thermal ablation or stereotactic body radiation therapy (SBRT). We retrospectively compared local progression, mortality, and toxicity among patients with HCC treated with ablation or SBRT in a multicenter, US cohort. Approach & Results: We included adult patients with treatment-naïve HCC lesions without vascular invasion treated with thermal ablation or SBRT per individual physician or institutional preference from January 2012 to December 2018. Outcomes included local progression after a 3-month landmark period assessed at the lesion level and overall survival at the patient level. Inverse probability of treatment weighting was used to account for imbalances in treatment groups. The Cox proportional hazard modeling was used to compare progression and overall survival, and logistic regression was used for toxicity. There were 642 patients with 786 lesions (median size: 2.1 cm) treated with ablation or SBRT. In adjusted analyses, SBRT was associated with a reduced risk of local progression compared to ablation (aHR 0.30, 95% CI: 0.15–0.60). However, SBRT-treated patients had an increased risk of liver dysfunction at 3 months (absolute difference 5.5%, aOR 2.31, 95% CI: 1.13–4.73) and death (aHR 2.04, 95% CI: 1.44–2.88, p < 0.0001). Conclusions: In this multicenter study of patients with HCC, SBRT was associated with a lower risk of local progression compared to thermal ablation but higher all-cause mortality. Survival differences may be attributable to residual confounding, patient selection, or downstream treatments. These retrospective real-world data help guide treatment decisions while demonstrating the need for a prospective clinical trial.

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Purpose: High-fidelity virtual reality simulators are available to practice tasks in a safe and forgiving environment. However, such simulators are expensive and not readily available. The aim of this study was to gauge the usefulness of an inexpensive homemade physical simulator and its ability to quantify differences in the level of proficiency in basic catheter-wire handling skills among individuals with various levels of expertise within an interventional radiology department. Materials: The performance of nonexperts (trainees and technologists) was compared with that of endovascular physician specialists (experts). Twenty-four nonexperts and 11 experts completed two tasks with this simulator: 1) inserting a wire and withdrawing the indwelling catheter without displacing the tip of the wire, and 2) inserting a catheter and withdrawing the indwelling wire. Metrics on the time taken to complete the task and the errors made during the task were recorded. Surveys were conducted to record the confidence level of participants on a scale of 1 (least) to 10 (most). Opinions of the experts regarding the realism of the simulator and its readiness to be part of a training curriculum were also collected on a similar scale. Data were analyzed using paired and unpaired t-tests. Results: Before the simulation, nonexperts reported lower levels of confidence in their ability to perform the tasks compared to experts (mean, 5.5 vs 9.36; p < 0.01). Nonexperts took longer than experts to complete the tasks, and they made more errors. After completing the simulation, nonexperts reported significantly higher levels of confidence (mean, 8.7; p < 0.01). The experts believed that compared to patient-based training, the realism offered by this simulator was good (mean, 7.1). They supported its use in training and evaluation (mean, 8.5 and 8.1, respectively) before trainees transition to patientbased learning.Conclusions: This study suggests that an inexpensive homemade simulator can play a useful role in offering a safe environment for trainees and technologists to master basic catheter-wire handling skills. Experts considered this setup to be realistic and supported its use in teaching and assessment.