The Source for Neurovascular News and Education

August 23, 2019

 

Questions still remain, particularly with respect to safety and feasibility in the 72 hours after rupture.

 

 

With the advent of better tools and more experience, stent-assisted coiling of wide-neck aneurysms is as safe as coiling without stent placement and its outcomes remain superior, according to a single-center case series published online August 17, 2018, ahead of print in the Journal of Neurosurgery.

 

Commenting on the study for Neurovascular Exchange, Bing Zhao, MD (First Affiliated Hospital of Wenzhou Medical University, China), pointed out that “coiling of the wide-neck ruptured aneurysms is challenging. Treatments of these aneurysms require more assistance to prevent coil protrusion. Stent-assisted coiling is used for selected wide-necked ruptured aneurysms nowadays; however, the safety is still [a primary] concern among patients and physicians.

 

Several studies have demonstrated the superiority of stent-assisted coiling compared with balloon-assisted coiling or coiling alone for the treatment of unruptured wide-neck aneurysms, note lead author Qiao Zuo, MD (Changhai Hospital, Second Military Medical University, Shanghai, China), and colleagues in their study.

 

While the efficacy of stent-assisted coiling for ruptured aneurysms also has been shown to be excellent, early studies called into question the level of periprocedural safety, leading the American Heart Association and the American Stroke Association to recommend in their 2012 guidelines on the management of aneurysmal subarachnoid hemorrhage that it only be employed when less risky options have been excluded.

 

“With improvement of neurointerventional devices and experiences on ruptured aneurysm embolization” write the authors, “several recent studies reported comparable complication rates between coiling with stent placement and coiling without stent placement on acutely ruptured aneurysms. Our previous study also showed that the angiographic and clinical outcomes of coiling with stent placement for 211 acutely ruptured aneurysm from 2000 to 2011 were comparable to those reported for coiling alone or balloon-assisted coiling techniques.”

 

To further evaluate the perioperative safety and efficacy of stent-assisted coiling of ruptured aneurysms, the investigators retrospectively compared the outcomes of 133 patients who underwent coiling with stent placement to those of 289 patients who underwent coiling without stent placement between January 2012 and December 2014.

 

Both groups were similar with respect to all baseline characteristics except for a higher proportion of posterior communicating artery aneurysms and lower proportion of anterior cerebral artery and anterior communicating artery aneurysms in the stent-assisted coiling group. There were no differences between groups with respect to the immediate embolization results or clinical outcomes.

 

Angiographic evaluation revealed that occlusion rates were significantly higher and recurrence rates significantly lower among those receiving stent-assisted coiling.

 

Angiographic Outcomes of Coiling

 

Stent Placement

(n = 133)

No Stent Placement

(n = 289)

P Value

Occlusion Rate

82.5%

66.7%

0.007

Recurrence Rate

3.5%

14.5%

0.007

 

Complication rates were similar for those who did and did not receive stents.

 

Complication Rates With and Without Stent Placement

 

With

Without

P Value

Intraprocedural Rupture

3.0%

1.0%

0.288

Intraprocedural Thrombosis

2.3%

1.4%

0.810

Aneurysm Rebleeding

1.5%

1.4%

1.000

Postprocedural Thrombosis

0.7%

0

0.315

Procedure-Related Hemorrhagic Event

0.8%

0.7%

1.000

 

Multivariable analysis revealed no significant predictors for the total perioperative procedure-related complications, hemorrhagic complications, or ischemic complications. One patient treated with coiling alone developed coil protrusion.

 

Procedure-related mortality was 1.5% in the stent-assisted coiling group and 0.7% in the coiling-only group (P = 0.796).

 

“The perioperative procedure-related complications and mortality rate did not differ significantly between the coiling/stent group and the coiling/no-stent group for patients with acutely ruptured aneurysms,” conclude the authors. “Considering the better angiographic follow-up results, coiling with stent placement might be a feasible, safe, and promising option for treatment in the acute phase of selected wide-necked ruptured intracranial aneurysms.”

 

The findings are particularly notable, said Zhao, because of the study included a large number of patients treated recently at a high-volume center.

 

Based on the results seen here, “coiling with stent placement may be considered for selected wide-necked ruptured aneurysms, such as [those occurring in the] internal carotid artery and posterior communicating artery [that are treated] in the 28 days after the initial rupture,” he concluded.

 

That said, the patient population is not necessarily representative of the real world because it included people who were treated more than 28 days after the initial rupture. “This may cause selection bias,” he noted. “Most rebleeding occurred within 72 hours, and procedure-related complications also often occurred within 72 hours after the initial onset.” In addition to being from a nonrandomized, single-center study, the data also offer only a limited amount of information on aneurysm morphology and neck size, Zhao said.

 

Ongoing clinical questions relate to defining the best antiplatelet management strategy for patients treated with stent-assisted coiling, identifying which complications are associated with antiplatelet management, and identifying who stent-assisted coiling is likely to be safest in. “How to select patients treated with coiling stent placement in acutely ruptured aneurysms is unknown,” he said. “Moreover, the feasibility and safety of stent-assisted coiling in the acute stage of the rupture (within 72 hours) is still unknown.”

 

 


Source:

Zuo Q, Yang P, Lv N, et al. Safety of coiling with stent placement for the treatment of ruptured wide-necked intracranial aneurysms: a contemporary cohort study in a high-volume center after improvement of skills and strategy. J Neurosurg. 2018;Epub ahead of print.

 

Disclosures:

Zuo and Zhao report no relevant conflicts of interest.

 

 

 

 

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