The Current State of Aneurysm Surgery

30 Pages·2013·6.88 MB·English

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