A Long-Term View at Clipping Versus Coiling for Ruptured Aneurysm
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SPANNING THE GLOBE
A Long-Term View at Clipping Versus Coiling for Ruptured Aneurysm Alejandro A. Rabinstein
Published online: 9 June 2009 Ó Humana Press Inc. 2009
The results of the long-term follow-up of the ISAT patients are mostly confirmatory [1]. ISAT remains the most influential trial comparing clipping versus coiling of ruptured aneurysms. Only cases that fulfilled the condition of clinical equipoise were enrolled. In other words, only patients who were considered adequate candidates for clipping and for coiling were randomized. The initial report of the results of the study indicated that coiling was associated with a relative reduction in the risk of death and dependency at 1 year of 23.9% compared with clipping (absolute risk reduction 7.4%) [2]. During the first year after treatment, coiled patients had a slightly higher incidence of rebleeding from the treated aneurysm and required re-treatment (typically additional coiling) 6.9 times more often than clipped patients [2, 3]. However, there were concerns about the durability of coiling in patients who are often quite young at the time of their subarachnoid hemorrhage. During a mean follow-up of 9 years (range 6–14 years), the risk of rebleeding from the treated aneurysm remained low in both groups, although it was higher in the coiling group (the difference was actually significant in the per protocol analysis, which accounted for a patient assigned to the clipping group who requested to be coiled instead and later rebled). It is possible that current risk of aneurysm rebleeding after coiling could be lower than those seen in ISAT because technological improvement now allows higher rates of complete aneurysm obliteration, but this possibility remains to be proven. There were no differences in fatal cases of rebleeding between the two groups.
A. A. Rabinstein (&) Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA e-mail: [email protected]
Clipping did not eliminate the risk of late rebleeding from the treated aneurysm. Bleeding could also occur from another previously known but untreated aneurysm or from aneurysms which formed de novo after enrollment in the trial. Table 1 shows the distribution of cases of rebleeding according to bleeding source and treatment arm. The risk of death at 5 years was significantly lower in the coiled group (relative risk 0.77). Yet, the chances of independent survival for those patients surviving 5 years were similar in both groups. This apparent discrepancy is probably explained by functional improvement of patients with initial moderate disability in both groups and the demise of some patients with severe disability which had contributed to the difference in functional outcome among survivors at 1 year. Notably, the mortality rate of trial patients surviving more than 1 year was higher than the mortality expected for the general population (standardized mortality rate 1.57). There are several important lessons to be learned from this follow-up data. All patients with subarachnoid hemorrhage should h
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