Gonda David D, Khalessi Alexander A, McCutcheon Brandon A, Marcus Logan P, Noorbakhsh Abraham, Chen Clark C, Chang David C, Carter Bob S
Division of Neurosurgery and.
J Neurosurg. 2014 Jun;120(6):1349-57. doi: 10.3171/2014.3.JNS131159. Epub 2014 Apr 11.
Using a database that enabled longitudinal follow-up, the authors assessed the long-term outcomes of unruptured cerebral aneurysms repaired by clipping or coiling.
An observational analysis of the California Office of Statewide Health Planning and Development (OSHPD) database, which follows patients longitudinally in time and through multiple hospitalizations, was performed for all patients initially treated for an unruptured cerebral aneurysm in the period from 1998 to 2005 and with follow-up data through 2009.
Nine hundred forty-four cases (36.5%) were treated with endovascular coiling, 1565 cases (60.5%) were surgically clipped, and 76 cases were treated with both coiling and clipping. There was no significant difference in any demographic variable between the two treatment groups except for age (median: 55 years for the clipped group, 58 years for the coiled group, p < 0.001). Perioperative (30-day) mortality was 1.1% in patients with coiled aneurysms compared with 2.3% in those with clipped aneurysms (p = 0.048). The median follow-up was 7 years (range 4-12 years). At the last follow-up, 153 patients (16.2%) in the coiled group had died compared with 244 (15.6%) in the clipped group (p = 0.693). The adjusted hazard ratio for death at the long-term follow-up was 1.14 (95% CI 0.9-1.4, p = 0.282) for patients with endovascularly treated aneurysms. The incidence of intracranial hemorrhage was similar in the two treatment groups (5.9% clipped vs 4.8% coiled, p = 0.276). One hundred ninety-three patients (20.4%) with coiled aneurysms underwent additional hospitalizations for aneurysm repair procedures compared with only 136 patients (8.7%) with clipped aneurysms (p < 0.001). Cumulative hospital costs per patient for admissions involving aneurysm repair procedures were greater in the clipped group (median cost $98,260 vs $81,620, p < 0.001) through the follow-up.
For unruptured cerebral aneurysms, an observed perioperative survival advantage for endovascular coiling relative to that for surgical clipping was lost on long-term follow-up, according to data from an administrative database of patients who were not randomly allocated to treatment type. A cost advantage of endovascular treatment was maintained even though endovascularly treated patients were more likely to undergo subsequent hospitalizations for additional aneurysm repair procedures. Rates of aneurysm rupture following treatment were similar in the two groups.
作者利用一个能够进行纵向随访的数据库，评估了通过夹闭术或血管内栓塞术治疗的未破裂脑动脉瘤的长期预后。
对加利福尼亚州全州卫生规划与发展办公室（OSHPD）数据库进行观察性分析，该数据库对患者进行长期随访并涵盖多次住院情况。研究对象为1998年至2005年期间首次接受未破裂脑动脉瘤治疗且截至2009年有随访数据的所有患者。
944例（36.5%）采用血管内栓塞术治疗，1565例（60.5%）采用手术夹闭术治疗，76例同时接受了栓塞术和夹闭术治疗。除年龄外，两个治疗组在任何人口统计学变量上均无显著差异（夹闭组中位数年龄：55岁，栓塞组58岁，p<0.001）。血管内栓塞治疗的动脉瘤患者围手术期（30天）死亡率为1.1%，而夹闭治疗的患者为2.3%（p = 0.048）。中位随访时间为7年（范围4 - 12年）。在最后一次随访时，栓塞组有153例患者（16.2%）死亡，夹闭组有244例（15.6%）死亡（p = 0.693）。血管内治疗的动脉瘤患者在长期随访时死亡的调整风险比为1.14（95%CI 0.9 - 1.4，p = 0.282）。两个治疗组的颅内出血发生率相似（夹闭组5.9%，栓塞组4.8%，p = 0.276）。193例（20.4%）接受栓塞治疗的动脉瘤患者因动脉瘤修复手术再次住院，而接受夹闭治疗的患者只有136例（8.7%）（p<0.001）。在随访期间，夹闭组涉及动脉瘤修复手术的患者每次住院的累计费用更高（中位数费用98,260美元对81,620美元，p<0.001）。
根据未随机分配治疗类型的患者管理数据库的数据，对于未破裂脑动脉瘤，血管内栓塞术相对于手术夹闭术在围手术期观察到的生存优势在长期随访中消失。尽管接受血管内治疗的患者更有可能因额外的动脉瘤修复手术而再次住院，但血管内治疗的成本优势仍然存在。两组治疗后动脉瘤破裂率相似。
