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Q. Can you explain a little more about aneurysms and the benefits of vascular versus endovascular surgery?A. An aneurysm is essentially a blister arising from a weak spot in the wall of a vessel. In the open technique or craniotomy, the surgeon makes an incision in the scalp, temporarily removes a piece of skull, and travels under the brain to find the aneurysm. A good amount of surgical dissection under the microscope is usually required to free the aneurysm and vessels from adjacent tissues and brain. Ultimately, a clip is placed on the aneurysm to pinch it shut. The clip stays there permanently. In the endovascular technique, the surgeon travels through the main artery ofthe leg in the groin, as is done during an angiogram. We use a very flexible plastic tube, called a catheter, that is advanced inside the brain vessels and ultimately inside the aneurysm itself. Through the catheter, loops of metal or coils are gradually deployed inside the aneurysm, ultimately forming a tight basket. At times, a balloon or stent is deployed in the main vessel to help keep the coils inside the aneurysm. This balloon-assisted or stent-assisted coiling technique becomes necessary for aneurysms with wide necks, the neck being the base of the aneurysm where it comes off the vessel wall. Of course, the more devices we use, the more complex the procedure gets, and the higher the risk of complications. Another thing to remember is that once a stent is deployed inside a brain vessel, the combination of two blood thinners, typically aspirin and Plavix, becomes necessary to prevent blood from clotting on the stent, which can leadto a stroke. For this reason, the wider the neck of the aneurysm, the more open surgery becomes the preferred modality. In contrast, a narrow neck makes the aneurysm more suitable for endovascular therapy. Virtually any aneurysm can be treated surgically, if needed. However, not all aneurysms can be treated endovascularly. Also, aneurysms can sometimes recur after endovascular therapy. In contrast, the risk of an aneurysm coming back after clipping is close to zero. It might happen, but it is extremely rare. If you are a 30-year-old patient, you are likely to tolerate and recover well from open brain surgery under general anesthesia. Also, you would have a long remaining life expectancy. For this reason, you would be better off with a more durable treatment, such as clipping. In contrast, if you are 75-year-old with multiple medical problems, then endovascular therapy would likely be a better option for you, despite the small risk of recurrence.
SBH Sucks BIG TIME