Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e508-e517
World Neurosurgery

Original Article
Follow-Up Outcomes After Re-Embolization for Recanalized Aneurysms After Initial Coiling: Further Recurrence Rates and Related Risk Factors

https://doi.org/10.1016/j.wneu.2018.03.017Get rights and content

Highlights

  • There have been few studies that have investigated the follow-up outcomes of re-embolized aneurysms.

  • The majority of recoiled aneurysms (64.7%) displayed complete occlusion at the 6-month follow-up.

  • Posterior circulation, large aneurysm, and incomplete occlusion at the 2nd coiling were risks for re-recanalization.

  • The recanalization rates (48.8%) of the re-embolized aneurysms seem to be higher than those of the initial aneurysms.

Background

Although it is well known that coiled aneurysms can recanalize over time, long-term outcomes of re-embolization for recurred aneurysms have not been adequately investigated. We studied the retreatment outcomes of re-embolized aneurysms during follow-up monitoring and assessed the risk factors related to further recanalization.

Methods

A total of 129 patients with 133 aneurysms were retrospectively reviewed. Each aneurysm was subjected to re-embolization because of major recanalization after initial coil embolization and underwent midterm and extended monitoring after retreatment. Cumulative medical records and radiologic data were assessed. Repeat recurrence rates and related risk factors were assessed by binary logistic regression analysis.

Results

A total of 47 aneurysms (35.3%) showed re-recanalization at 6 months after re-embolization, with 17 and 30 instances of minor and major recanalization, respectively. Multivariate analysis indicated that posterior circulation (hazard ratio [HR], 6.129; P = 0.010), large aneurysm (>7 mm) (HR, 13.598; P < 0.001), and incomplete occlusion at the second coiling (HR, 9.975; P = 0.001) were significant factors for repeat recanalization. Of 86 aneurysms showing complete occlusion at the midterm, 76 were further evaluated (≥12 months), showing 18 aneurysms (23.7%) of delayed re-recanalization during a follow-up of 230.1 aneurysm-years. Of 15 aneurysms with minor recanalization at 6 months, 6 (40.0%) progressed to major recanalization during a follow-up of 44.0 aneurysm-years.

Conclusions

Most re-coiled aneurysms (64.7%) showed complete occlusion at the 6-month follow-up. However, posterior circulation, large aneurysm (>7 mm), and incomplete occlusion at the second coiling were risks for further recanalization. The midterm and delayed re-recanalization rates of the re-embolized aneurysms seem to be higher than those of the initial aneurysms.

Introduction

Coil embolization has been widely used as treatment for intracranial aneurysms since ISAT (International Subarachnoid Aneurysm Trial) proved its effectiveness and safety in preventing rebleeding after aneurysmal rupture.1, 2 However, coil embolization has a potential disadvantage, because sometimes the initial treatment leads to incomplete aneurysmal occlusion, with the resulting risk of bleeding and recanalization. In addition, the recurrence rate and need for further treatment are higher for coil embolization than for neurosurgical clipping.3 Previous studies found that retreatment rates of coiled aneurysms with recanalization ranged from 4.7% to 12.3% and repeat embolizations for recurrent aneurysms were safe and effective.4, 5, 6 Nevertheless, there have been few studies that have investigated the follow-up outcomes of re-embolized aneurysms and the predictors for re-recanalization. In this study, aneurysms undergoing repeat embolization for major recanalization were evaluated at a midterm (6 months) follow-up and over a longer period. We also determined repeat recanalization rates and assessed the risk factors related to further recanalization.

Section snippets

Patient Selection and Data Collection

The records of consecutive patients undergoing a re-embolization procedure for 255 aneurysms recurring after an initial coil embolization performed at a single institution between January 2008 and January 2016 were accessed for this retrospective review. During the same period, 3339 aneurysms were treated by endovascular management. Nonsaccular aneurysms (n = 28), partially thrombosed large or giant aneurysms (n = 4), recanalized aneurysms retreated more than 2 times (n = 51), and aneurysms

Characteristics of Aneurysms Undergoing Re-Embolization because of Major Recanalization After Initial Endovascular Treatment

A total of 129 patients harboring 133 aneurysms were retreated because of major recanalization after initial coil embolization and were monitored over the midterm and an extended period. Patients were predominantly female (91/133, 68.4%); the mean age of the study participants was 56.1 ± 10.5 years. Most lesions involved the anterior (113/133, 85.0%) rather than the posterior (20/133, 15.0%) circulation. Anterior circulation aneurysms occurred in the following vessels: anterior communicating

Discussion

Endovascular coil embolization has been widely used for the treatment of intracranial aneurysms and is well known for its low morbidity and mortality.1, 9, 10, 11 Despite its various advantages, a major concern with this treatment for cerebral aneurysm is that the risks of recurrence and need for additional treatment are higher than the risks after neurosurgical clipping.1, 3, 11 ISAT3 found that 191 of 1096 patients (17.4%) allocated to endovascular treatment underwent a further treatment,

Conclusions

Most re-coiled aneurysms showed complete occlusion at the 6-month follow-up. However, posterior circulation, large aneurysm (>7 mm) at the first treatment, and incomplete occlusion at the second coiling were predisposed to further recanalization. The midterm and delayed recanalization rates of the re-embolized aneurysms seem to be higher than the recanalization rates of the initial aneurysms.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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