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

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.

Safety and efficacy of microsurgical treatment of previously coiled aneurysms: a systematic review and meta-analysis

“…In our study, we compared direct clipping without coil removal, clipping with coil removal, and parent vessel occlusion. In general, the preferred microsurgical treatment of coiled aneurysms is direct clipping [13,18,19,22]. However, to date, there has been little evidence beyond single-center case series to support this.…”

“…Regardless of the methods, the goal of surgery is to get the ability to place the clip on a persistent or enlarging pouch of the aneurysm beside the coil portion as well as the approach of clipping across the neck when the coils have compacted away from the neck. Coil extraction is not necessary if the aneurysm neck is available and clipping is possible without stenosing the parent artery [13,18]. Sometimes loops of coils prolapsing into the parent vessel make complete clip closure impossible or hazardous and coil removal must be performed [7,26].…”

Clipping of previously coiled cerebral aneurysms: efficacy, safety, and predictors in a cohort of 111 patients

“…1,21,27 Technical difficulties attributed to the coils present in the aneurysmal sac and neck are frequently encountered, making it difficult to properly clip the aneurysm and sometimes requiring removal of such coils. 9,11,25 The removal of coils for clip placement carries high morbidity. Each of the 3 patients who had coil extraction suffered a stroke postoperatively.…”

A Novel Aneurysm Clip Design for Atheromatous, Thrombotic, or Previously Coiled Lesions: Preliminary Experience With the “Compression Clip” in 6 Cases

“…16 In addition, the rapid evolution of endovascular technology coupled with growing evidence of its safety and efficacy has produced an expanding number of aneurysms previously treated with coils that have recanalized or recurred, often repeatedly. 8,14,15,[17][18][19] These patients are now being referred for or are independently seeking definitive microsurgical treatment. In these cases, simple clipping may be difficult or impossible because the coil mass within the aneurysm may preclude traditional aneurysm clips from closing.…”