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The Current State of Aneurysm Surgery PDF

30 Pages·2013·6.88 MB·English
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Introduction The Current State of Aneurysm Surgery Michael T. Lawton, MD Chief, Vascular Neurosurgery Professor and Vice-Chairman Tong-Po Kan Endowed Chair University of California - San Francisco Absolute risk reduction, 6.9% Relative risk reduction, 22.6% Current Trends Aneurysm Surgery Disappearance of community aneurysm surgery Outline § Endovascular results § Basic techniques (MCA) § Complexity of care § Complex techniques (BTA) § Liability § § Medical economics Giant aneurysms § Patient appeal, preferences § Bypass Decentralized coiling, Centralized clipping MCA Aneurysms UCSF Experience “Clip First” Policy: Consecutive series, single surgeon § Favorable surgical anatomy Review period (years) 14 § Endovascular limitations Total aneurysms 3000 § Simple exposure Total patients 2301 § Multiple surgical options MCA aneurysms 805 § Minimally invasive, retractorless MCA aneurysm patients 701 § Low therapeutic risk Percentage 25% § Good outcomes Most common aneurysm Sylvian Split Sylvian Veins Fissures MCA Aneurysm Dissection MCA Aneurysm Clipping Clipping Techniques Endovascular Therapy for MCA Aneurysms (cid:0) (cid:1) (cid:2) (cid:3)(cid:4) (cid:5) (cid:6) (cid:7) (cid:8) (cid:9)(cid:10) (cid:7)(cid:11) (cid:10) (cid:12)(cid:4)(cid:7) (cid:10) (cid:6) (cid:7) (cid:13) (cid:14)(cid:4) (cid:5) (cid:6) (cid:7) (cid:8) (cid:15) (cid:5) (cid:16) (cid:7) (cid:5) (cid:17) Aneurysm Projection Contralateral MCA Clipping Aneurysm Surgery Outline § Basic techniques (MCA) § Complex techniques (BTA) § Giant aneurysms § Bypass Current Practice ISAT Eligible patients 9559 Charing Cross Hospital, London “All posterior circulation aneurysms, if Included patients 2143 Excluded patients 7416 technically feasible, were coiled” Anterior circulation 2085 Aneurysm unsuitable for Mayo Clinic, USA clipping or coiling Posterior circulation 58 (2.7%) “Endovascular treatment is definitely superior § Basilar apex 26 Uncertainty about best tx (lack of equipoise) to surgical clip ligation of basilar bifurcation § PICA 31 aneurysms” (cid:18)(cid:19) (cid:20)(cid:21) (cid:22)(cid:21) (cid:21) (cid:23)(cid:19) (cid:24) (cid:22)(cid:25) (cid:21) (cid:26)(cid:21) (cid:27)(cid:25)(cid:28) (cid:28) (cid:26) (cid:22) (cid:19) (cid:29)(cid:30) (cid:19) (cid:31) (cid:22) (cid:28) !(cid:19) " ! " (cid:24) #(cid:21) (cid:22)!(cid:19) (cid:26) (cid:21) (cid:26) (cid:28) (cid:24) $(cid:25)(cid:31) (cid:31) Posterior Circulation Aneurysms Cisterns Technically difficult, high morbidity Endovascular option is appealing Absence of definitive data What should neurosurgeons be doing? § Stop clipping § Limit aneurysm surgeons § Selected aneurysms Triangles Temporal Lobe Basilar Aneurysm Dissection Basilar Aneurysm Dissection %& ’ ( )*+ ) , +) - ( . / *+ 0 (cid:1)1 23 456 4 7 64 83 9 256 1 Transcavernous Approach Transcavernous Approach Indications § Low-riding aneurysm § No proximal control § Too tight Technique § Anterior clinoidectomy § Posterior clinoidectomy § Unroof cavernous sinus Anterior Clinoidectomy Anterior Clinoidectomy

Sylvian Split. Sylvian Veins. Page 3. Fissures. MCA Aneurysm Dissection Technically difficult, high morbidity. Endovascular option is appealing.
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