Intra-procedural complications, success rate, and need for retreatment of endovascular treatments in anterior communicating artery aneurysms: a systematic review and meta-analysis

Clipping of a Ruptured Small Anterior Communicating Artery Aneurysm: Technical Video

In recent years there has been a significant shift in the management of intracranial aneurysms, as most, both ruptured and unruptured, are being treated through an endovascular approach.1-3 However, there are still instances in which open surgical clipping is the best option for definitive management. Both patient factors, such as age and comorbidities, and aneurysm characteristics, such as size, morphology, and location, must be taken into consideration when treating aneurysms. This is especially true for anterior1 communicating artery aneurysms, as these have been treated successfully using multiple different techniques.4,5 There are no absolute guidelines indicating how a particular aneurysm should be treated and, therefore, one must be able to determine how to best manage a patient based on their own skill set, knowledge, and experience. We present a case of a 61-year-old woman who presented with a ruptured anterior communicating artery aneurysm. Initially she was brought to the angiography suite to undergo possible endovascular treatment of the aneurysm, but after reviewing the morphology and size of the aneurysm, we believed that this aneurysm could not be treated safely through an endovascular approach and surgical clipping was the better option. The patient consented to the procedure. In this operative video, we describe the technical aspects of the surgical procedure and the benefits of our approach (Video 1).

The safety and clinical outcomes of endovascular treatment versus microsurgical clipping of ruptured anterior communicating artery aneurysms: a 2-year follow-up, multicenter, observational study

Background and objective

Current data on the optimal treatment modality for ruptured anterior communicating artery (AComA) aneurysms are limited. We conducted this multicenter retrospective study to evaluate the safety and clinical outcomes of endovascular treatment (EVT) and microsurgical clipping (MC) for the treatment of ruptured AComA patients.

Methods

Patients with ruptured AComA aneurysms were screened from the Chinese Multicenter Cerebral Aneurysm Database. Propensity score matching (PSM) was used to adjust for baseline characteristic imbalances between the EVT and MC groups. The safety outcomes included total procedural complications, procedure-related morbidity/death and remedial procedure for complication. The primary clinical outcome was 2-year functional independence measured by the modified Rankin scale (mRS) score.

Results

The analysis included 893 patients with ruptured AComA aneurysms (EVT: 549; MC: 346). PSM yielded 275 pairs of patients in the EVT and MC cohorts for comparison. Decompressive craniectomy being more prevalent in the MC group (19.3% vs. 1.5%, p < 0.001). Safety data revealed a lower rate of total procedural complications (odds ratio [OR] = 0.62, 95% CI 0.39-0.99; p = 0.044) in the EVT group and similar rates of procedure-related morbidity/death (OR = 0.91, 95% CI 0.48-1.73; p = 0.880) and remedial procedure for complication (OR = 1.35, 95% CI 0.51-3.69, p = 0.657) between the groups. Compared with that of MC patients, EVT patients had a greater likelihood of functional independence (mRS score 0-2) at discharge (OR = 1.68, 95% CI 1.14-2.50; p = 0.008) and at 2 years (OR = 1.89, 95% CI 1.20-3.00; p = 0.005), a lower incidence of 2-year all-cause mortality (OR = 0.54, 95% CI 0.31-0.93; p = 0.023) and a similar rate of retreatment (OR = 1.00, 95% CI 0.23-4.40; p = 1.000).

Conclusion

Clinical outcomes after treatment for ruptured AComA aneurysms appear to be superior to those after treatment with MC, with fewer overall procedure-related complications and no increase in the retreatment rate. Additional studies in other countries are needed to verify these findings.

Endovascular Treatment of Small Anterior Communicating Artery Aneurysms: Safety and Efficacy in a Contemporary Cohort

BACKGROUND AND OBJECTIVES

Endovascular treatment (EVT) of small anterior communicating artery (ACoA) aneurysms accompanies a high risk of intraprocedural rupture (IR) because of anatomic location and aneurysm orientation. In this study, we aimed to investigate the safety and efficacy of EVT for small ACoA aneurysms in a contemporary cohort.

METHODS

ACoA aneurysms treated at the Medical University of South Carolina between April 2012 and March 2022 were retrospectively analyzed. Periprocedural baseline characteristics, aneurysm size, and clinical and radiological outcomes were collected. Aneurysms were dichotomized into <4 and ≥4 mm in maximum size. The IR rate, favorable occlusion rate (Raymond-Roy I and II), and the favorable outcome defined as modified Rankin Scale 0-2 were compared.

RESULTS

A total of 174 patients were identified, of whom 111 (63.8%) were female, and the median age was 57.7 (interquartile range 50.6-69.6) years. 98 (56.3%) aneurysms were ruptured, and 53 (30.5%) were <4 mm. IR was not observed in unruptured ACoA aneurysms, and there was no significant difference in the IR rates between <4 mm and ≥4 mm ruptured aneurysms (6.5% vs 4.5%, P = .65). Favorable occlusion rate and favorable outcome were observed in 94.7% and 78.2% of patients, respectively.

CONCLUSION

EVT of small ACoA aneurysms is safe and effective.

Woven EndoBridge Device for Unruptured Wide-Neck Bifurcation Aneurysm: A Multicenter 5-Year Follow-up

BACKGROUND AND OBJECTIVES

This multicenter study aimed to assess the safety and efficacy of the Woven EndoBridge (WEB) device for treating unruptured wide-neck intracranial bifurcation aneurysms (WIBAs) with short-, mid-, and long-term follow-ups (FUPs).

METHODS

Consecutive patients with unruptured WIBAs treated with WEB between December 2014 and January 2018 were included. Patient, aneurysm, and device characteristics were collected and analyzed retrospectively. Morbidity and mortality rates were determined by collecting intraprocedural, periprocedural, and delayed complications. Aneurysm occlusion was assessed at 1, 3, and 5 years using a 3-grade scale: complete occlusion, neck remnant, and residual aneurysm. Complete occlusion and neck remnant were considered as adequate occlusion. Patients who received re-treatment were also evaluated.

RESULTS

The study included 104 consecutive patients (55.8% female, mean age 58.6 ± 11.8 years). Aneurysm maximum size, neck, and dome-to-neck mean were, respectively, 6.9 ± 2.1 mm, 4.5 ± 1.2 mm, and 1.4 ± 0.3 mm. One-year FUP was collected for 95 patients, and 3- and 5-year FUPs were collected for 83 patients. Adequate occlusion was observed at 1-year FUP in 90.5% (86/95), 91.6% (76/83) was observed at 3-year FUP, and 92.8% (77/83) at 5-year FUP. None of the aneurysms bled after treatment. During FUP, 6/83 patients (7.2%) were re-treated for residual aneurysm. Morbidity and mortality rates closely related to aneurysm occlusion were 0% (0/104).

CONCLUSION

The WEB device was safe and effective for treating unruptured WIBAs, both in short-term and long-term FUPs.

Safety and Efficacy of Flow Diverters for Treatment of Unruptured Anterior Communicating Artery Aneurysms: Retrospective Multicenter Study

BACKGROUND

The anterior communicating artery (AComm) region is the most common site of intracranial aneurysms, with increased rupture risk compared with other locations. Overall, flow diverters present as a safe and efficacious treatment for intracranial aneurysms, but there is paucity of data for their use in the treatment of unruptured AComm aneurysms. We present the largest multicentric analysis evaluating the outcomes of flow diverters in AComm aneurysm treatment.

METHODS

Databases from 10 centers were retrospectively reviewed for unruptured AComm aneurysms treated with flow diverters. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed.

RESULTS

A total of 144 patients harboring 147 AComm aneurysms were treated between January 2012 and December 2021. Seventy-four were women (51.4%) and median age was 60 (IQR 50-67) years. All were unruptured AComm aneurysms. Half of the cohort had similar anterior cerebral artery sizes (51.4%). The most common morphology was saccular (94.6%), with a branch involvement in 32.7% of cases. Median vessel diameter was 2.4 mm, and the Pipeline Flex was the most prevalent device (32.7%). Median follow-up time was 17 months, with complete occlusion in 86.4% at the last follow-up. Functional independence (modified Rankin Scale score 0-2) was reported in 95.1%. Intraprocedural complications occurred in 5.6%, and postoperative complications were noted in 9.7% of cases. Combined major complication and mortality rate was 2.1%.

CONCLUSIONS

Our study suggests that flow diverters are a useful treatment for AComm aneurysms. Mid-term results indicated favorable aneurysm occlusion with a good safety profile. Additional prospective studies with longer follow-up periods and independent adjudication are warranted to better assess these results.

Endovascular Treatment of Anterior Communicating Artery Aneurysms: A Single-Center Experience from a Developing Country

Objective  In recent years, endovascular methods have been developed to treat intracranial aneurysms. To date, results of endovascular treatment (EVT) for anterior communicating aneurysms (ACoAs) have never been investigated in Iran. Thus, we sought to assess the mid-term angiographic and clinical outcomes of patients with ACoAs who underwent EVT in a tertiary center. Materials and Methods  Electronic health documents of patients with ACoAs who underwent EVT from March 2019 to July 2021 were retrospectively reviewed. Demographic and clinical characteristics of patients, procedural and clinical complications along with immediate and 12 months' postprocedural angiographic and clinical results were included in the analysis. Aneurysm occlusion status was classified based on the Raymond-Roy Occlusion Classification (RROC), and clinical outcomes were assessed using the modified Rankin Scale (mRS). Results  Of 38 patients with 38 ACoAs, 32 patients (84.21%) presented with subarachnoid hemorrhage of whom 23 (60.52%) had ruptured ACoAs. EVT included simple coiling in 29 patients (76.32%), balloon-assisted coiling in 6 (15.79%), and stent-assisted coiling in 3 (7.89%). Immediate and 12-month postprocedural angiograms demonstrated complete/near-complete occlusion (RROC I and II) in 32 (84.21%) and 35 patients (97.22%), respectively. Periprocedural complications occurred in five patients (13.15%), and the mortality rate was 5.26%. Thirty-two patients (84.21%) had favorable outcomes (mRS 0-2) at the last follow-up. Conclusion  EVT is a safe and beneficial procedure with favorable mid-term clinical and angiographic outcomes for ACoAs. Our results can lay the foundation for further studies in developing countries and are satisfactory enough for neurointerventionists to put EVT on the therapeutic agenda of ACoAs.