Sorting Through Aneurysm Options
Date: November 1, 2011
When a thin, weak segment of one of the blood vessels in the brain swells with blood and threatens to rupture, the aneurysm can be repaired by one of several techniques. But which technique is best?
“There are risks and benefits to each approach,” says Alex Coon, one of a small number of neurosurgeons who can perform any of the procedures. “It’s important to consider each case on its own and make a very patient-centered decision.”
The two most common options are clipping and coiling. Clipping, developed 75 years ago at Johns Hopkins, involves placing miniature clamps on the neck of the aneurysm to seal it off. Coiling is a more recent alternative in which a metal coil is inserted through a small opening in an artery in the leg and threaded through other arteries until it’s finally pushed into place at the aneurysm. The coil causes the blood in the aneurysm to clot, again sealing it off. A metal stent is typically placed next to the coil to provide support and allow normal blood flow. One recent development called a pipeline embolization device combines the features of a stent and coil into one tube, simplifying placement.
Patients who undergo coiling can be back at work in two days, while clipping requires a week in the hospital and at least a month of recovery. But coiling, backed by less than 20 years of usage, is not yet known to be a permanent repair.
“We can’t say for sure that a 40-year-old with a coil won’t have to come back for another procedure,” says Coon. “Some patients say they don’t mind that risk, but for others it doesn’t make as much sense.”
Larger aneurysms aren’t good candidates for coiling, and Coon’s colleague Rafael Tamargo notes that even clipping can’t treat the very largest ones. Such “giant” aneurysms, says Tamargo, require redirecting the blood flow around the aneurysm with a section of blood vessel taken from the patient’s arm or leg. Johns Hopkins is one of a small number of medical centers that perform this complex surgery.
But Coon is confident that all aneurysm patients will have even more—and better—treatment options over time. “These are exciting times in the field,” he says.
- Challenge: Repair aneurysms before they rupture
- Approach: Emplace a coil in the aneurysm to seal it, and reroute blood vessels
- Progress: Coil patients are back at work in two days; even giant aneurysms are being repaired