Petr Ondra, Petrová Lucie, Bradáč Ondřej, Glodny Bernhard, Edlinger Michael, Thomé Claudius
Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria; Department of Neurosurgery, Resuscitation and Intensive Care of 1(st) Faculty of Medicine, Charles University in Prague, Military University Hospital Střešovice, Prague, Czech Republic.
Department of Neurosurgery, Resuscitation and Intensive Care of 1(st) Faculty of Medicine, Charles University in Prague, Military University Hospital Střešovice, Prague, Czech Republic; Department of Anesthesiology, Resuscitation and Intensive Care of 1(st) Faculty of Medicine, Charles University in Prague, Military University Hospital Střešovice, Prague, Czech Republic.
World Neurosurg. 2018 Jun;114:e137-e150. doi: 10.1016/j.wneu.2018.02.103. Epub 2018 Feb 25.
BACKGROUND/OBJECTIVE: The safety and efficacy of endovascular treatment of previously clipped aneurysms have not been well-established. We conducted a systematic review of the literature to evaluate the outcomes of endovascular treatment of previously clipped aneurysms.
A systematic search of MEDLINE, Embase, Scopus, and the Web of Science was performed for studies published until October 2017. We included studies with ≥2 patients that described endovascular treatment of previously clipped aneurysms. A random-effects meta-analysis was used to pool the following outcomes: technical success, aneurysm occlusion/recurrence/rebleed, ischemic/thrombotic/thromboembolic events, neurologic/procedure-related morbidity/mortality, and favorable neurologic outcomes. We performed subgroup analyses by aneurysm rupture status on presentation to the endovascular procedure, treatment timing, and by aneurysm location (anterior vs. posterior circulation).
In total, 27 studies with 271 patients were included. Overall complete occlusion was 76.1% (95% confidence interval [CI] 0.676-0.836) and technical success was 97.9% (95% CI 0.958-0.993). Combined procedure-related morbidity/mortality was 4.5% (95% CI 0.024-0.073). There were no statistically significant differences in any of the safety and efficacy outcomes by aneurysm location. Overall long-term favorable neurologic outcome was 78.5% (95% CI 0.732-0.834). All included studies are retrospective.
Our meta-analysis demonstrated that endovascular treatment is acceptably safe and effective. It is important to point out that the complication rate of treatment of these aneurysms is not negligible. These findings should be considered when deciding the best therapeutic strategy. Our findings may suggest that endovascular treatment of previously clipped aneurysms should only be considered in circumstances in which conservative management seems to be unsafe.
背景/目的：既往已夹闭动脉瘤的血管内治疗的安全性和有效性尚未得到充分证实。我们对文献进行了系统综述，以评估既往已夹闭动脉瘤的血管内治疗结果。
对MEDLINE、Embase、Scopus和科学网进行系统检索，查找截至2017年10月发表的研究。我们纳入了描述既往已夹闭动脉瘤血管内治疗且患者≥2例的研究。采用随机效应荟萃分析汇总以下结果：技术成功率、动脉瘤闭塞/复发/再出血、缺血性/血栓形成/血栓栓塞事件、神经/手术相关发病率/死亡率以及良好的神经学结局。我们根据血管内治疗时动脉瘤破裂状态、治疗时机以及动脉瘤位置（前循环与后循环）进行亚组分析。
总共纳入了27项研究，涉及271例患者。总体完全闭塞率为76.1%（95%置信区间[CI]0.676 - 0.836），技术成功率为97.9%（95%CI 0.958 - 0.993）。手术相关合并发病率/死亡率为4.5%（95%CI 0.024 - 0.073）。按动脉瘤位置分类，任何安全性和有效性结局均无统计学显著差异。总体长期良好神经学结局为78.5%（95%CI 0.732 - 0.834）。所有纳入研究均为回顾性研究。
我们的荟萃分析表明，血管内治疗具有可接受的安全性和有效性。需要指出的是，这些动脉瘤治疗的并发症发生率并非可以忽略不计。在决定最佳治疗策略时应考虑这些发现。我们的研究结果可能表明，既往已夹闭动脉瘤的血管内治疗仅应在保守治疗似乎不安全的情况下考虑。
