Outcomes

In 1995 Fernando Vinuela (personal communication) reviewed the USA Multicenter GDC Study Group's results with 753 aneurysms treated in 715 patients. Complete occlusion of small aneurysms with small necks occurred in 62% of cases while complete occlusion in small aneurysms with wide necks was 33%. Large aneurysms with small necks and giant aneurysms with thrombus each had a 37% occlusion rate and giant aneurysms alone had 35% occlusion rates. Technical complications occurred in 11% of cases and included aneurysm perforation (15%), parent artery narrowing (05%), parent artery occlusion (3 8%), embolisation (3 7%), and coil migration (11%) (Figures 8.6, 8.7). Complications that had permanent clinical implications, however, occurred in only 4 4% of the cases. The procedure related mortality rate was 112% and the overall mortality rate for the entire study population was 52%. The postembolisation aneurysm haemorrhage rate was 126%. Aneurysm recanalisation occurred in 77% of small aneurysms, 15% of large aneurysms, 29% of giant aneurysms, and 31% of giant/partially thrombosed lesions.

Since 1994, results have improved as different sized and less traumatic coils were introduced into the market. These advances allow for denser fundus packing and improved obliteration rates with reduction in delayed recanalisation. More recent publications have provided some follow-up data relating to GDC results in the intermediate follow-up period.186188 Debrun recently reported his group's results in 144 patients treated between 1994 and 1997. When aneurysms with fundus to neck ratios of 2 were specifically analysed the mortality and permanent morbidity rate was 10%. Complete occlusion rates in this group for acutely ruptured aneurysms and non-acute aneurysms were 72% and 80%, respectively.128 Keuther et al. reported a series of 74 aneurysms managed with GDC embolisation over a 45 year period with average angiographic follow up of 14 years.129 Complete aneurysm obliteration was demonstrated in 40% of cases with an additional 52% of lesions showing 90-99% occlusion. Procedure related morbidity was 91%. No completely occluded lesions rehaemorrhaged in the follow-up period and 2 6% of partially occluded aneurysms rebled. Vinuela et al. published results for 403 coiled patients with

Figure 8.6 Lateral carotid arteriogram of posterior communicating aneurysm which was appreciated to be completely obliterated by endovascular coiling

SAH in the Multicenter Study.130 Complete occlusion was demonstrated in 71% of small aneurysms with a small neck, 35% of large aneurysms, and 50% of giant aneurysms. Procedure related morbidity was 89% and procedure related mortality was 17%.

Aneurysm embolisation using the GDC system offers an alternative to traditional surgical clipping in selected cases. The results of such treatment are not yet as effective as those of open surgery and delayed aneurysm recurrence may be a significant problem (Figures 8.6, 8.7). Nevertheless, in certain instances coiling is a viable option. Decisions must be made on a case by case basis. At our institution considerations include patient preference, age, medical condition, aneurysm geometry, and location. While the particular surgeon's and interventionalist's skills are not as relevant at institutions where both disciplines are practised at the highest level, such considerations are relevant where discrepancies exist.

Figure 8.7 Lateral carotid arteriogram six months following successful endovascular aneurysm coiling demonstrating coil compaction and re-growth of aneurysm neck
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