Endovascular Coiling versus Surgical Clipping of Very Small Ruptured Anterior Communicating Artery Aneurysms.

BACKGROUND: Endovascular coiling of anterior communicating artery (ACoA) aneurysms has evolved dramatically. Ruptured ACoA aneurysms are more likely to be smaller. We aimed to investigate the safety and efficacy of endovascular coiling of very small ruptured ACoA aneurysms compared with surgical clipping. METHODS: We conducted a retrospective analysis of consecutive 111 patients with very small ruptured ACoA aneurysms treated with endovascular coiling or surgical clipping in our single center. Very small aneurysms were defined as aneurysm maximal size ≤3.0 mm. Patients were grouped into coiling and clipping groups. Baseline characteristics, postoperative complications, and clinical outcomes were compared between the 2 groups. RESULTS: Forty-six patients (41.1%) underwent successfully coiling, and 65 patients (58.0%) underwent surgical clipping, including 2 patients who failed coiling and crossed over to surgical clipping. The mean size of the ruptured ACoA aneurysms was 2.6 ± 0.5 mm (range, 1.0-3.0 mm). Patients with smaller aneurysms (P = 0.028) or A1 segment complete configuration (P = 0.009) more often underwent surgical clipping, and patients with A1 segment symmetric configuration more often underwent coiling (P = 0.011). There were not statistically significant differences in intraoperative rupture, early rebleeding, cerebral infarction, and seizure in patients treated with clipping and coiling. Clinical outcomes were similar between the 2 groups. There was no retreatment in both groups. CONCLUSIONS: Patients with very small ruptured ACoA aneurysms can be safely and effectively treated with endovascular coiling. However, smaller ACoA aneurysms still require surgical clipping. A smaller aneurysm size limits the use of endovascular coiling.

Fistula from Congenital Subclavian Artery to Azygos Vein with Congestive Heart Failure in an Adult.

Congenital arteriovenous communications arising from subclavian artery are very rare. We report the first case of multiple congenital arteriovenous fistulas between the right subclavian artery and azygos vein presenting with congestive heart failure.

Predicting intraprocedural rupture and thrombus formation during coiling of ruptured anterior communicating artery aneurysms.

BACKGROUND: Intraprocedural rupture and thrombus formation are serious complications during coiling of ruptured intracranial aneurysms, and they more often occur in patients with anterior communicating artery (ACoA) aneurysms. OBJECTIVE: To identify independent predictors of intraprocedural rupture and thrombus formation during coiling of ruptured ACoA aneurysms. METHODS: Between January 2008 and February 2015, 254 consecutive patients with 255 ACoA aneurysms were treated with coiling. We retrospectively reviewed intraoperative angiograms and medical records to identify intraprocedural rupture and thrombus formation, and re-measured aneurysm morphologies using CT angiography images. Multivariate logistic regression models were used to determine independent predictors of intraprocedural rupture and thrombus formation. RESULTS: Of the 231 patients included, intraprocedural rupture occurred in 10 (4.3%) patients, and thrombus formation occurred in 15 (6.5%) patients. Patients with smaller aneurysms more often experienced intraprocedural rupture than those with larger aneurysms (3.5±1.3 mm vs 5.7±2.3 mm). Multivariate analysis showed that smaller ruptured aneurysms (p=0.003) were independently associated with intraprocedural rupture. The threshold of aneurysm size separating rupture and non-rupture groups was 3.5 mm. Multivariate analysis showed that a history of hypertension (p=0.033), aneurysm neck size (p=0.004), and parent vessel angle (p=0.023) were independent predictors of thrombus formation. The threshold of parent vessel angle separating thrombus and non-thrombus groups was 60.0°. CONCLUSIONS: Ruptured aneurysms <3.5 mm were associated with an increased risk of intraprocedural rupture, and parent vessel angle <60.0°, wider-neck aneurysms, and a history of hypertension were associated with increased risk of thrombus formation during coiling of ruptured ACoA aneurysms.

Stent-assisted coiling versus coiling alone of ruptured anterior communicating artery aneurysms: A single-center experience.

OBJECTIVE: Endovascular coiling of anterior communicating artery (ACoA) aneurysms has evolved; however, stent-assisted coiling of ruptured aneurysms remains controversial. We aimed to compare periprocedural complications, angiographic and clinical outcomes after stent-assisted coiling with coiling alone of ruptured ACoA aneurysms. METHODS: We performed a retrospective review of consecutive 222 patients with ruptured ACoA aneurysms treated with endovascular coiling within 7 days after ictus. Patients were grouped into stent-assisted coiling and coiling alone groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. RESULTS: 63 (28.4%) patients underwent stent-assisted coiling and 159 (71.6%) underwent coiling alone. There were no statistically significant differences in age, sex, clinical grading and Fisher grade. Larger aneurysms (P=0.002) and wider-neck aneurysms (P<0.001) were more often treated with stent-assisted coiling within 72h (P=0.025). Intraprocedural aneurysm rupture occurred in 6 (9.5%) patients treated with stent-assisted coiling compared with in 5 (3.1%) treated with coiling alone (P<0.048). Thrombus formation occurred in 10 (15.9%) patients after stent-assisted coiling compared with 6 (3.8%) after coiling alone (P=0.002). Stent-assisted coiling achieved a lower rate of immediate occlusion than coiling alone (P=0.045). Postoperative complications, clinical outcomes, and follow-up aneurysm occlusion did not significantly differ. CONCLUSIONS: Stent-assisted coiling of ruptured ACoA aneurysms was associated with a higher rate of intraprocedural complications and associated with a lower immediate occlusion rate. However, Postoperative complications and clinical outcomes did not differ. Long-term angiographic results require further study.

Smoking Associated with Increased Aneurysm Size in Patients with Anterior Communicating Artery Aneurysms.

BACKGROUND: Hypertension and smoking are risk factors for aneurysm formation or rupture. We aimed to identify differences in aneurysm morphologies associated with hypertension or smoking in patients with anterior communicating artery (AcoA) aneurysms. METHODS: Between December 2007 and February 2015, 574 consecutive patients with AcoA aneurysms were identified from the Electronic Medical Record System. We extracted data on histories of hypertension alone, smoking alone, nonhypertension and nonsmoking, and both hypertension and smoking. The morphologic parameters of aneurysms were remeasured via computed tomography angiography image reconstruction. Multivariate logistic regression analyses were used to determine the differences in morphologies in patients with hypertension or who smoked. RESULTS: In the study, 495 patients with single AcoA aneurysm were included. Age, sex, vessel size, aneurysm size and height, size ratio, A1 segment configuration, and aneurysm shape were significantly different among the groups. A larger aneurysm occurred more often in patients who only smoked compared with those without hypertension who did not smoke (adjusted odds ratio, 1.19; 95% confidence interval, 1.04-1.36; P = 0.012). Patients with hypertension who also smoked more commonly had a larger aneurysm size than those with hypertension alone (adjusted odds ratio, 0.89; 95% confidence interval, 0.79-0.99; P = 0.040). There were significant differences in age, sex, and aneurysm morphology between the smoking patients and those with hypertension alone. CONCLUSIONS: Aneurysm size was an independent morphologic parameter associated with smoking in patients with ACoA aneurysms compared with other aneurysm morphologies. Smoking may be associated independently with increased aneurysm size and should be given up in patients with AcoA aneurysms.

Completely reversed flow in the vertebral artery does not always indicate subclavian steal phenomenon.

We evaluated the causes, differential diagnosis and clinical significance of completely reversed flow (CRF) in the vertebral artery (VA). Twenty-three patients diagnosed with CRF in the VA by Doppler ultrasound were studied retrospectively. CRF was divided into intermittent CRF and continuous CRF. The peak reversed velocity (PRV) and ratio of time in intermittent CRF to one cardiac cycle (tICRF/CC) were calculated. Causes of CRF were determined on the basis of previous angiography results. The results indicated that subclavian steal phenomenon (SSP) caused all cases of continuous CRF (n = 8). Intermittent CRF was caused by SSP (n = 6) or proximal VA occlusion (n = 9). PRV and tICRF/CC were increased in SSP as compared with VA occlusion (p < 0.05). Using a cutoff of tICRF/CC = 0.30, we achieved excellent accuracy in predicting the cause of intermittent CRF (100%) and posterior circulatory infarction (91%). Thus, analysis of CRF patterns and measurements of VA parameters can be used in differential diagnosis of the causes of CRF and in prediction of posterior circulatory infarction.

Bidirectional flow in the vertebral artery is not always indicative of the subclavian steal phenomenon.

OBJECTIVE: To evaluate the causes of bidirectional flow in the vertebral artery detected by Doppler sonography and its differential diagnosis. METHODS: Twenty-nine patients with bidirectional flow in the vertebral artery were retrospectively studied. The vertebral artery parameters, including peak antegrade velocity (PAV), peak reversed velocity (PRV), maximum peak velocity (MPV), peak systolic velocity, resistive index (RI), and diameter, were measured. The MPV was defined as the MPV of bidirectional flow regardless of the velocity of antegrade or retrograde flow. To better predict the cause of bidirectional flow, receiver operating characteristic curves were constructed for these parameters, and the best cutoff values were obtained. The cause of bidirectional flow was determined by angiography. RESULTS: The causes of bidirectional flow were classified as the subclavian steal phenomenon (n = 21) and factors unrelated to the steal phenomenon (n = 8, including a hypoplastic vertebral artery [n = 4] and proximal vertebral artery stenosis and occlusion [n = 4]). Significant differences were observed between the steal phenomenon and non-steal phenomenon groups (P< .05) for MPV, PRV, PAV, target vertebral artery diameter, and contralateral RI. To determine the cause of bidirectional flow, areas under the receiver operating characteristic curves for the different parameters were obtained: 0.929 for MPV, 0.881 for PRV, 0.824 for PAV, 0.753 for target vertebral artery diameter, and 0.845 for contralateral RI. The cutoff value for MPV was 26.1 cm/s, and the accuracy was 93% (27 of 29). CONCLUSIONS: Bidirectional flow in the vertebral artery is not always indicative of the subclavian steal phenomenon. Measurement of hemodynamic parameters in the vertebral artery, such as MPV, can facilitate determination of the cause of bidirectional flow.