Endovascular surgery

The risks, expectations and alternatives of this technique need to be fully understood. The risks include rupturing the aneurysm during the procedure (the very complication that the procedure aims to treat and prevent producing the problems indicated above), unexpected blood clotting within an artery of the brain (causing a stroke), and re-opening of the aneurysm at a later date causing a subarachnoid haemorrhage.

Endovascular surgery (or “coiling”) is the preferred treatment option for some aneurysms but aneurysms come in many locations, shapes and sizes and the best treatment requires an expert to evaluate whether the aneurysm is best treated by this technique, surgery or just maintained surveillance. In some cases the aneurysm can be treated with either microsurgical or endovascular technique and the recommendation as to the preferred technique for a individual needs to take into account many factors including the age of the patient (for the durability of the procedure), the skills of the proceduralists (and their track record of similar aneurysms), the need for progress surveillance angiography, and many other considerations.

Progress surveillance digital subtraction angiography is usually performed at 6 months, 12 months and 24 months following initial treatment. Further, follow-up studies may also be needed depending on the result of ongoing assessment of this treatment. If re-opening of the aneurysm occurs on these studies there is a risk of haemorrhage and treatment may need to be repeated or surgery performed.

Microsurgery aims to repair the aneurysm from the outside of the artery placing a strong spring clip across where the aneurysm arises from the artery – like pinching off the neck of a balloon. This prevents blood entering the aneurysm from the artery. At surgery a small window of bone is removed from the skull and with the use of the microscope the valleys of the brain are traversed without the need for cutting into the brain. This gains access to the artery with the aneurysm allowing the clip to be placed permanently across the neck of the aneurysm. At the end of the surgery the bone is replaced and secured.

The risks, expectations and alternatives of this technique need to be fully understood. The risks include rupturing the aneurysm during the procedure (the very complication that the procedure aims to treat and prevent producing the problems indicated above) and inadvertently blocking an artery of the brain.

This is the preferred treatment option for some aneurysms but aneurysms come in many locations, shapes and sizes and the best treatment requires an expert to evaluate whether the aneurysm is best treated by this technique, endovascular coil placement or just maintained surveillance. In some cases the aneurysm can be treated with either technique and the recommendation as to the preferred technique for a individual needs to take into account many things including the age of the patient (for the durability of the procedure), the skills of the proceduralists and their track record of similar aneurysms, the need for progress surveillance angiography, and many other considerations.

It is unusual to develop another aneurysm at the site of aneurysm repair by microsurgery. Therefore, progress surveillance is not usually recommended for the treated aneurysm but because new aneurysms can occur (in as many as 20% of cases) at other sites ongoing monitoring may be necessary. This may be done by CTA, MRA or digital subtraction angiography (although the latter is not always thought necessary).

For very complex aneurysms it is occasionally necessary to perform a bypass surgery to remove the aneurysmal section of artery from the circulation. This surgery may involve removing a segment of vein in the leg and substituting this vein into the brain circulation.