Clipping versus coiling: A critical re-examination of a decades old controversy

Abstract

Background Two major studies, The International Subarachnoid Aneurysm Trial and the Barrow Ruptured Aneurysm Trial, compare the long-term outcomes of clipping and coiling. Although these demonstrated coiling’s initial benefits, rebleeding and retreatment rates as well as converging patient outcomes sparked controversy regarding its durability. This article will critically examine the available evidence for and against clipping and coiling of intracranial aneurysms. Critics of endovascular treatment state that the initial benefit seen with endovascular coiling decreases over the duration of follow-up and eventually functional outcomes of both treatment modalities are similar. Combined with the increased rate of retreatment and rebleeding, these trials reveal that coiling is not as durable and not as effective as a long-term treatment compared to clipping. Also, due to the cost of devices following endovascular treatment and prolonged hospitalization following clipping, the financial burden has been considered controversial. Summary/Key Messages Short-term outcomes reveal better morbidity and mortality outcomes following coiling. Despite the higher rates of retreatment and rebleeding with coiling, there was no significant change in functional outcomes following retreatment. Furthermore, examining more recent trials reveals a decreased rate of recurrence and rebleeding with improved technology and expertise. Functional outcomes deteriorate for both cohorts over time while recent results revealed improved long-term cognitive outcomes and levels of health-related quality of life after coiling in comparison to clipping. The expense of longer hospital stays following clipping must be balanced against the expense of endovascular devices in coiling.

High‐frequency optical coherence tomography for endovascular management of cerebral aneurysms

“…Endovascular treatment is associated with shorter recovery times and improved disability-free survival at 10 years compared to neurosurgical clipping. [4][5][6][7] However, historical data suggests endovascular procedures have a high recurrence rate. 8 This fails to acknowledge the small subsets of aneurysms with complex positioning or morphology which may be contributing to these results.…”

“…Endovascular treatment of aneurysms is the established first‐line therapy for both unruptured and ruptured IAs. Endovascular treatment is associated with shorter recovery times and improved disability‐free survival at 10 years compared to neurosurgical clipping 4–7 . However, historical data suggests endovascular procedures have a high recurrence rate 8 .…”