Neurosurg Focus. 2019 Feb 1;46(2):E15. doi: 10.3171/2018.11.FOCUS18504.
OBJECTIVEThe development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).METHODSThe authors extracted data from the NIS database for the years 1998-2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.RESULTSA total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010-2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998-2011, bypass procedures for UIAs in 2012-2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.CONCLUSIONSDespite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors' findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.
血流导向装置的发展和广泛传播可能减少了手术旁路手术治疗复杂或巨大未破裂颅内动脉瘤（UIAs）的应用。本回顾性队列研究的目的是通过使用国家（全国）住院患者样本（NIS）观察血流导向装置引入前后美国 UIAs 脑血管重建手术的趋势。
作者使用 ICD-9/10 诊断和手术代码从 NIS 数据库中提取 1998 年至 2015 年的数据。将伴有旁路手术的原发性 UIA 患者纳入研究。分析了结果和住院费用。
在研究期间，共有 216212 例患者被诊断为 UIA。1998 年（n = 7718）至 2015 年（n = 17600），诊断为 UIA 的患者数量增加了 128%。仅有 1328 例 UIA 患者（0.6%）接受了脑血管旁路手术。在血流导向装置时代（2010-2015 年），接受旁路手术的患者比例保持在 0.4%。接受旁路手术的大多数患者是白人（51%），女性（62%），家庭收入中位数处于第三或第四四分位数（57%），并拥有私人保险（51%）。西部（33%）和中西部/中北部地区（30%）的旁路手术量最高，而东北部地区最低（15%）。与 1998-2011 年相比，2012-2015 年的 UIAs 旁路手术完全转移到了城市教学医院（100%）和择期手术（77%）。接受旁路手术的 UIA 患者的中位住院时间（9 天 vs 3 天，p < 0.0001）、中位住院费用（186746 美元 vs 66361 美元，p < 0.0001）和任何并发症发生率（51% vs 17%，p < 0.0001）大约是未接受旁路手术的患者的三倍。
尽管在 17 年的研究期间，UIAs 的诊断显著增加，但作为其治疗一部分的旁路手术比例保持稳定。因此，血管内动脉瘤治疗的进展似乎并未影响 UIAs 人群中旁路手术的数量。作者的发现表明，旁路手术在当代 UIAs 的治疗中可能仍然有一定的作用。
