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PubMedDate not supplied

Position of clip placement after vacuum-assisted breast biopsy: is a unilateral two-view postbiopsy mammogram necessary?

The objective of this study was to compare the accuracy of current methods of determining clip location (immediate stereotactic images versus postprocedure two-view mammograms) after stereotactic-guided, vacuum-assisted breast biopsy (VABB). Retrospective review was made of 101 lesions for which a localizing clip was placed during stereotactic VABB. Clip-to-lesion distances were measured by 1) stereotactic images (x, y, and z coordinates), and 2) postbiopsy two-view mammograms compared to prebiopsy two-view mammograms. The mean clip-to-lesion distance was 5.7 mm from stereotactic images, while the mean clip-to-lesion distances were 3.6 and 9.4 mm from same-view and orthogonal-view mammogram measurements, respectively. Stereotactic coordinate measurements compared to orthogonal-view mammogram clip-to-lesion measurements showed a significant difference (p < 0.001), as did the same-view mammogram compared to both stereotactic images and orthogonal-view mammogram (p < 0.001). The number of clips found to be less than 20 mm from the lesion (defined as clinically significant) was significantly higher for measurements from orthogonal-view mammograms (n = 19) compared to both stereotactic images (n = 0) and same-view mammograms (n = 5) (p < 0.001). Determination of clip location based on stereotactic images significantly underestimated the clip-to-lesion distance. Stereotactic images obtained at the conclusion of clip placement during VABB are not reliable in determining clip location relative to the targeted lesion. Although stereotactic images can confirm deployment of the clip, a two-view postbiopsy mammogram is necessary to determine clip location relative to the targeted lesion.

Biopsy, Needle↗
PubMed1996

Safety evaluation of laparoscopically applied clips.

We have evaluated in vitro, the security of laparoscopically applied clips, through two commercially available clip appliers: the Endo Clip II (US Surgical) and the Ligaclip (Ethicon). The clip performance was tested with respect to dislodgment and leakage. Dislodgment was attempted both transversely and at 45 degrees with respect to the main axis of the tubular structures tested. The mean maximum force (N = 24) necessary to dislodge a clip applied to silicone tubing (2.1, 2.4, 3.2 mm o.d.) and porcine vascular tissue was measured. The maximum force needed to transversely dislodge a clip applied to silicone tubing, ranged from 262 +/- 9 g (2.1 mm) to 315 +/- 11 g (3.2 mm) for the Endo Clip II applier, while the values for the Ligaclip were 220 +/- 28 g (2.1 mm) and 273 +/- 11 g (3.2 mm), respectively. To achieve dislodgment at 45 degrees pull, corresponding forces of 294 +/- 8 g (2.1 mm) and 369 +/- 14 g (3.2 mm) for the Endo Clip II, and 254 +/- 14 g (2.1 mm) and 297 +/- 13 g (3.2 mm) for the Ligaclip (N = 24) were required. Transverse dislodgment forces, for clips applied to tissue, were 556 +/- 146 g for the Endo Clip II and 356 +/- 170 for the Ligaclip (N = 6). Leakage tests were also performed under pulsatile blood circulation at mean pressure of approximately 800 mm Hg. No tested clips applied to either silicone tubing or tissue allowed for any blood leakage. The dislodgment test showed that the Endo Clip II exhibits superior performance compared to the Ligaclip, based on the fact that it requires more force for transverse and semiaxial dislodgment. In the leakage test, both clip appliers performed equivalently.

Animals↗
PubMed2005

EB1 and EB3 control CLIP dissociation from the ends of growing microtubules.

EBs and CLIPs are evolutionarily conserved proteins, which associate with the tips of growing microtubules, and regulate microtubule dynamics and their interactions with intracellular structures. In this study we investigated the functional relationship of CLIP-170 and CLIP-115 with the three EB family members, EB1, EB2(RP1), and EB3 in mammalian cells. We showed that both CLIPs bind to EB proteins directly. The C-terminal tyrosine residue of EB proteins is important for this interaction. When EB1 and EB3 or all three EBs were significantly depleted using RNA interference, CLIPs accumulated at the MT tips at a reduced level, because CLIP dissociation from the tips was accelerated. Normal CLIP localization was restored by expression of EB1 but not of EB2. An EB1 mutant lacking the C-terminal tail could also fully rescue CLIP dissociation kinetics, but could only partially restore CLIP accumulation at the tips, suggesting that the interaction of CLIPs with the EB tails contributes to CLIP localization. When EB1 was distributed evenly along the microtubules because of overexpression, it slowed down CLIP dissociation but did not abolish its preferential plus-end localization, indicating that CLIPs possess an intrinsic affinity for growing microtubule ends, which is enhanced by an interaction with the EBs.

Amino Acid Sequence↗
PubMed1998

Carotid arteriotomy closure using a vascular clip system.

PURPOSE: To compare a newly released vascular clip system (Vascular Clip-applier System; Auto Suture Company, Norwalk, CT) designed for sutureless vessel closures and anastomoses with standard suture closure of carotid arteriotomies after carotid endarterectomies. PATIENTS AND METHODS: Sixteen consecutive patients with symptomatic and severe carotid stenoses were randomly allocated to receive either standard suture (running 6-0 monofilament) or clip artery closures after undergoing carotid endarterectomies. The speed of arteriotomy closure was calculated for each procedure, and hemostasis, complications, and postoperative carotid patency were determined and recorded for each patient. RESULTS: The clip applier system performed well, and arteriotomy closure with clips was significantly faster than suture closure (0.36 cm/min in the sutured group versus 0.52 cm/min in the clipped group, P = 0.019). Carotid patency assessed by ultrasonography 4 to 8 weeks after surgery showed that all arteries in both groups were patent. Two hemostasis problems occurred in the clip closure group, one minor that was caused by the use of incorrect clip size and one major that was probably caused by a combination of sudden arterial hypertension and clip failure. This complication resulted in a large neck hematoma and cross-clamp ischemia during the ensuing suture repair of the arterial dehiscence. CONCLUSIONS: As a result of this small study, we determined that clip closure of carotid arteriotomies was feasible, but it remains questionable whether the increased speed of a sutureless closure is clinically important for this procedure. Concerns regarding the strength of clip closure of an endarterectomized vessel and the cost of clip closure compared with standard suture techniques suggest that there may be no clinically significant benefits of arterial clip closure over suture closure after carotid endarterectomy, and there is potentially some risk.

Aged↗
PubMed1984

Intracranial clips: an examination of the devices used for aneurysm surgery.

A properly functioning aneurysm clip is of paramount importance in the surgical ablation of intracranial aneurysms. An appropriate match between the closing force needed to ablate an aneurysm and the force exerted by the aneurysm clip must be achieved. In this study, the opening and closing forces exerted by several commonly used aneurysm clips were tested. There was a strong correlation between the classification of the clips, according to the Dujovny system, and their mechanical behavior. Minimal variability among different lots of the same clip type and minimal hysteresis were generally exhibited by the alpha mobile fulcrum class clips, such as the Yasargil, Vari-Angle McFadden, Scoville, and Mayfield clips. Significant exceptions included several types of Mayfield and Drake clips. In contrast, pivot class clips generally showed twice as much lot variability among different lots, as well as a significant amount of hysteresis. Clips of this class include the Vari-Angle, Heifetz, and Pivot clips. Because significant variations in clip force exist and because several other factors can compound these differences, it is suggested that aneurysm clips be individually tested for their closing forces before they are used in an operation.

Humans↗
PubMed2006

Multislice computed tomography angiography screening for new aneurysms in patients with previously clip-treated intracranial aneurysms: Feasibility, positive predictive value, and interobserver agreement.

OBJECT: Multislice computed tomography (CT) angiography may be useful for screening patients with intracranial aneurysms that are treated with clip occlusion. However, cobalt clips produce much more artifact on CT scans than titanium clips, which may hamper the evaluation of the image obtained at the clip site. METHODS: The authors screened 415 patients with previously ruptured aneurysms that had been treated using cobalt clips. Screening was performed using multislice CT angiography. The feasibility of this modality for screening these patients (based on the complication risk, CT angiography quality, and artifact avoidance) and interobserver agreement were evaluated. Patients in whom the presence of an aneurysm was suspected based on results of CT angiography studies underwent digital subtraction (DS) angiography. False-negative and false-positive findings were recorded, and the positive predictive value (PPV) was calculated. Eight patients (1.9%) had allergies to the contrast material. The quality of the CT angiography image was suboptimal in 14%. In 52%, clip artifacts hampered evaluation of the clip site. In 65 patients who underwent DS angiography, there were nine false-positive and eight false-negative reports related to aneurysms that were either small, located at the clip site, or were infundibula. The PPV on a per-patient basis was 86% (95% confidence interval [CI] 75-94%); for aneurysms at the clip site it was 83% (95% CI 61-95%); and for aneurysms at different locations it was 91% (95% CI 81-97%). The interobserver agreement was good (kappa = 0.69; 95% CI 0.60-0.78). CONCLUSIONS: Except for the evaluation of images from the clip site, CT angiography has good feasibility with good PPV and interobserver agreement. Drawbacks are that very small aneurysms can be missed and that visualization is poor at the clip site in patients in whom cobalt clips have been placed for occlusion. This second problem can be expected to resolve with the increasing use of titanium clips.

Adult↗
PubMed1981

A variable-force microvascular clip.

An easily adjustable, variable-force microvascular clip is described. This clip is superior to other clips currently available because it is essentially three clips in one. Its advantages are that it can reduce the amount of table area needed to store clips during surgery and it offers the surgeon greater flexibility in the selection of clips with different closing forces. This clip was developed by modifying the segments of a basic alpha-type clip, designing a computer program to analyze the force contributions made by each segment of the clip, constructing several clips with different blade lengths, and testing them in a microvascular surgery research program. The clip we have developed is easy to use, reduces clutter on the instrument table, aand offers the surgeon a wide choice of closing forces with a minimal number of clips.

Humans↗
PubMed1997

Early phase alterations in endothelium dependent vasorelaxation responses due to aneurysm clip application and related manipulations.

Mechanically induced vasoconstriction observed throughout surgery and in the immediate postoperative period was investigated to assess the effects of various microsurgical manipulations. Factors such as the type of aneurysm clip, duration of temporary clipping and peri-adventitial tissue stripping were the variables in this study. Microsurgical clips were applied on guinea pig "cervical carotid arteries" in which peri-adventitia had been removed microsurgically. Arterial rings were removed immediately after surgery. Endothelium dependent relaxations were measured and morphological investigations were performed using light microscopy. It was observed that as the clip application period increased, relaxation responses decreased. Peri-adventitial tissue stripping caused a marked decrease in the relaxation responses in all types of the clips. Microvascular clips, in spite of their lower closing forces, had the greatest deleterious effect on relaxation responses of the vessel, in both normal and peri-adventitial tissue stripped. When the peri-adventitial tissue of the vessel had been stripped, convolutions of the lamina elastica interna were found to be lost in parallel with the decreased tonus of the artery. In the vessels subjected to clipping endothelial denudation and cracking took place. As a conclusion it can be stated that both peri-adventitial tissue stripping and microvascular clip application have deleterious effects in the early postoperative period. While choosing clips from minimal occlusion force tables, care must be taken to choose clips with less width; and while performing microvascular anastomosis, temporary clips with a lesser width must be used in place of microvascular clips. Adventitial stripping must not be unnecessarily generous during microvascular anastomosis.

Animals↗
PubMed2001

Impact of boost irradiation with surgically placed radiopaque clips on local control in breast-conserving therapy.

BACKGROUND: The purpose of this study was to determine whether boost irradiation relying on radiopaque clips placed surgically around the resected margin of breast cancer contributes to increasing the local control rate in patients with close or positive margins in breast-conserving therapy (BCT). METHODS: Among 837 patients with breast cancer who underwent BCT between November 1987 and December 1998, 181 patients with close or positive surgical margins received boost irradiation following conventional tangential whole breast irradiation. Since 1994, four radiopaque clips were surgically placed around the resected margin of the breast cancer in 155 patients treated with wide excision. The four clips were clearly and accurately identified with a CT-simulator (CT-S). The boost irradiation field was automatically determined with a safety margin of 3 cm according to one-to-one correspondence of radiopaque clips to pathologically close or positive surgical margins. In the remaining 26 patients treated before 1994, the boost irradiation field was determined according to the skin tattoo of the primary tumor. RESULTS: The median follow-up period of the 155 patients receiving the radiopaque clips was 42 months (range: 19 to 78), and that of the 26 patients without the clips was 87 months. Local recurrence was observed in two of the 155 patients who underwent boost irradiation using the radiopaque clips 39 and 54 months after the surgery, while 4 of the 26 patients developed local recurrence 14, 23, 51, and 76 months after BCT. In three of the four patients without the clips developing local recurrences, local recurrences were observed at the margin of the boost irradiation field. The 5-year local recurrence-free survival rate of patients who received boost irradiation with the radiopaque clips was 97%, and that of patients without the clips was 88%. The difference of local recurrence-free survival rates between the patients with and without the clips was significant (p<0.05). CONCLUSION: Surgically placed radiopaque clips appear to be useful for determining adequate boost field in the BCT using the CT-S and help increase the local control rate.

Adult↗
PubMed2000

Clip migration causes choledocholithiasis after laparoscopic cholecystectomy.

The migration of surgical clips after laparoscopic procedures was first reported in 1992, but such instances are extremely rare. We herein demonstrate a case of a migrated metal clip, which had been applied originally to the cystic duct, but thereafter had moved to the common bile duct. This clip caused choledocholithiasis in a patient 1 year after a laparoscopic cholecystectomy. A 63-year-old man underwent a laparoscopic cholecystectomy. During the operation, the inflamed cystic duct was divided accidentally, and three clips were applied immediately. The patient complained of upper abdominal pain from postoperative day 8. Endoscopic retrograde cholangiography demonstrated bile leakage from the cystic duct, but showed no clips or choledochal stones. The patient complained of severe upper abdominal and back pain 1 year after the operation. Endoscopic retrograde cholangiography showed a metal clip in the common bile duct and choledochal stones above the clip. The clip and the cholesterol stones were removed using a basket catheter. Three clips applied to the cystic duct should have been removed because of the necrosis in the remaining cystic duct. Thereafter, the clip may have migrated through the stump of the cystic duct into the lower part of the common bile duct. This clip seems to have later caused choledocholithiasis resulting from stagnation of the bile flow. Bile leakage after an operation seems to increase the risk of clip migration. Regardless of the primary lesion, a careful follow-up evaluation is necessary for patients demonstrating complications.

Cholangiography↗
PubMed2002

Clip migration in stereotactic biopsy.

BACKGROUND: Needle localization breast biopsy (NLBB) is the standard for removal of breast lesions after vacuum assisted core biopsy (VACB). Disadvantages include a miss rate of 0% to 22%, a positive margin rate of approximately 50%, and vasovagal reactions (approximately 20%). We hypothesized that clip migration after VACB is clinically significant and may contribute to the positive margin rates seen after NLBB. METHODS: We performed a retrospective review of postbiopsy films in patients who had undergone VACB with stereotactic clip placement for abnormal mammograms. We measured the distance between the clip and the biopsy site in standard two view mammograms. The location of the biopsy air pocket was confirmed using the prebiopsy calcification site. The Pythagorean Theorem was used to calculate the distance the clip moved within the breast. Pathology reports on NLBB or intraoperative hematoma-directed ultrasound-guided breast biopsy (HUG, which localizes by US the VACB site) were reviewed to assess margin status. RESULTS: In all, 165 postbiopsy mammograms on patients who had VACB with clip placement were reviewed. In 93 evaluable cases, the mean distance the clip moved was 13.5 mm +/- 1.6 mm, SEM (95% CI = 10.3 mm to 16.7 mm). Range of migration was 0 to 78.3 mm. The median was 9.5 mm. In 21.5% of patients the clip was more than 20 mm from the targeted site. Migration of the clip did not change with the age of the patient, the size of the breast or location within the breast. In the subgroup of patients with cancer, margin positivity (including those with close margins) after NLBB was 60% versus 0% in the HUG group. CONCLUSIONS: Significant clip migration after VACB may contribute to the high positive margin status of standard NLBBs. Surgeons cannot rely on needle localization of the clip alone and must be cognizant of potential clip migration. HUG as an alternative biopsy technique after VACB eliminates operator dependency on clip location and may have superior results in margin status.

Adult↗
PubMed1998

Aneurysm clip MR artifacts. Titanium versus stainless steel and influence of imaging parameters.

PURPOSE: The aim of this study was to evaluate the extent to which titanium aneurysm clips could improve the quality of MR imaging compared with stainless steel clips, and to determine whether the clip artifacts could be reduced by controlling certain MR imaging parameters in frequently used pulse sequences. MATERIAL AND METHODS: The metal artifacts induced by 3 aneurysm clips were compared in 3 pulse sequences. The clips were: a Yasargil titanium aneurysm clip FT 752 T; a Yasargil standard aneurysm clip FE 752 K; and, for comparison, a ferromagnetic Scoville aneurysm clip En-58J. The pulse sequences were: spin echo (SE); gradient echo (GE); and fast SE. An evaluation was made of 3 imaging parameters with regard to their influence on the size of the metal artifacts. The parameters were: bandwidth; echo time (TE); and echo-train length. RESULTS: The titanium clip showed artifacts that were about 60% smaller than those from the stainless steel clip. The only parameter that influenced artifact size to any major degree was bandwidth in the SE sequences but not in the GE sequences. GE sequences induced larger artifacts than SE sequences and showed larger artifacts with longer TE. CONCLUSION: Titanium aneurysm clips reduced MR artifacts by approximately 60% compared to stainless steel clips. Artifacts were further reduced by using SE-based sequences with a high bandwidth or, if necessary, GE sequences with a low TE.

Artifacts↗
PubMed1998

Evidence for a role of CLIP-170 in the establishment of metaphase chromosome alignment.

CLIPs (cytoplasmic linker proteins) are a class of proteins believed to mediate the initial, static interaction of organelles with microtubules. CLIP-170, the CLIP best characterized to date, is required for in vitro binding of endocytic transport vesicles to microtubules. We report here that CLIP-170 transiently associates with prometaphase chromosome kinetochores and codistributes with dynein and dynactin at kinetochores, but not polar regions, during mitosis. Like dynein and dynactin, a fraction of the total CLIP-170 pool can be detected on kinetochores of unattached chromosomes but not on those that have become aligned at the metaphase plate. The COOH-terminal domain of CLIP-170, when transiently overexpressed, localizes to kinetochores and causes endogenous full-length CLIP-170 to be lost from the kinetochores, resulting in a delay in prometaphase. Overexpression of the dynactin subunit, dynamitin, strongly reduces the amount of CLIP-170 at kinetochores suggesting that CLIP-170 targeting may involve the dynein/dynactin complex. Thus, CLIP-170 may be a linker for cargo in mitosis as well as interphase. However, dynein and dynactin staining at kinetochores are unaffected by this treatment and further overexpression studies indicate that neither CLIP-170 nor dynein and dynactin are required for the formation of kinetochore fibers. Nevertheless, these results strongly suggest that CLIP-170 contributes in some way to kinetochore function in vivo.

Animals↗
PubMed1997

Migration of metallic clips used during laparoscopic cholecystectomy and formation of gallstones around them: surgical implications from a prospective study.

Two groups of patients, with laparoscopic cholecystectomy (LC) were prospectively studied. All patients had serial plain abdominal X-ray examinations at various intervals after operation, to record the position of clips placed during LC. Seventy-one patients had less cystic duct (CD) dissection and > or =4 clips placed during the procedure. One hundred and fifteen patients had a larger CD dissection and only 4 clips placed (2 on the cystic artery and 2 on the CD, without additional clips on smaller vessels). In the former group, 7 patients had clip migration within 1 month and 11 within 1 year vs 1 either at 1 month or 1 year in the latter group (p = 0.01 and <0.001, respectively). During the follow-up, a 72-year-old man belonging to the former group had a recurrent common duct brown pigment stone containing a metallic clip 26 months after operation. He was treated successfully by endoscopic sphincterotomy. Factors predisposing to clip migration were short cystic stump, inadvertent clip dislodgment or incorrect placement, cystic duct ischemic necrosis, and local suppurative complications. Data from 29 patients with GS formed around suture material or phytobezoars observed during a prospective study and from the physicochemical and structural analysis of a cumulative series of 64 GS containing foreign bodies are also presented and discussed. It is suggested that metallic clips can migrate from their initial sites at various intervals within the peritoneal cavity or into the common duct and serve as a nidus for GS formation. Metallic clip migration in most cases is due to technical factors and can usually be prevented. However, it is not possible to prevent either clip migration or GS formation in every case, since even well-placed clips can migrate due to suppurative complications or local ischemic damage, and, once that penetration within the bile tract has occurred, GS are usually going to form, irrespective of the nature and the shape of the foreign body.

Adolescent↗
PubMed1996

Titanium aneurysm clips: Part III--Clinical application in 16 patients with subarachnoid hemorrhage.

This report describes the first clinical use of newly developed titanium clips in the treatment of 16 patients with subarachnoid hemorrhage. There were no immediate or delayed complications related to the titanium clips. Thirteen patients had good outcomes, and one patient had moderate disabilities (mean follow-up, 5.4 mo). Two patients with Hunt and Hess Grade IV hemorrhages died postoperatively. The average cross-sectional areas of clip artifact on postoperative magnetic resonance imaging studies was 0.96, 1.36, and 1.05 cm2 on T1-, T2-, and intermediate-weighted images, respectively. In comparison, a matched control group with cobalt alloy clips had average cross-sectional areas of 3.13, 3.70, and 2.81 cm2 on T1-, T2-, and intermediate-weighted images, respectively. The average artifact volumes on gradient echo magnetic resonance images for titanium and cobalt alloy clips were 1.8 and 10.1 cm3, respectively. In addition, the gap on magnetic resonance imaging angiograms from clip artifacts was 0.9 cm with titanium and 2.6 cm with cobalt alloy clips. In conclusion, titanium aneurysm clips seem to be safe and effective and seem to reduce clip artifacts on magnetic resonance imaging threefold, compared with commercially available cobalt alloy clips. Because of this important advantage over conventional clips, titanium clips should be considered for routine use in aneurysm surgery.

Adult↗
PubMed2002

The sizer-dissector for aneurysm clip selection: technical note.

OBJECTIVE: Appropriate clip selection frequently becomes a matter of trial and error because of inadequate dissection of the pathway for each clip blade. To facilitate selection of the proper clip size, a series of dissectors have been designed that mimic the exact caliber of each category of Sugita clips. METHODS: Three lines of sizer-dissectors reflecting the wire size of the most commonly used Sugita clips were developed by attaching a single aneurysm clip blade to a rounded microdissector handle. Each sizer-dissector is scaled in millimeters and is available in straight and angled configurations. Once dissection is presumed to be complete, the device is passed through the pathway of the intended aneurysm clip blades, and the clip with the appropriate caliber and length for permanent occlusion is selected. RESULTS: During dissection and clip ligation of 83 aneurysms, the sizer-dissector was used to select the blade length in 16 lesions and the blade caliber in 5 lesions. There were no complications associated with deployment of the device. CONCLUSION: By use of the sizer-dissector before attempting clip placement, clip selection is facilitated, safety is enhanced, and clip wastage is reduced.

Equipment Design↗
PubMed2006

Clinical research of renal vein control using Hem-o-lok clips in laparoscopic nephrectomy.

Control of the renal vein represents a crucial step in laparoscopic nephrectomy. Although endovascular gastrointestinal anastomosis (GIA) staplers have generally been used for renal vein control because of the large diameter of the vessel, Hem-o-lok clips have recently been used for renal artery control. GIA staplers are expensive and can malfunction on rare occasions, resulting in severe complications. We evaluated renal vein control using Hem-o-lok clips (adaptive vascular width 7-16 mm) in laparoscopic nephrectomy. Since April 2004, we have ligated renal arteries using Hem-o-lok clips. From June 2004, this method was applied for renal vein control in 40 laparoscopic nephrectomies. After renal pedicle dissection, renal pedicle ligation was accomplished using extra large (XL) Hem-o-lok clips on both the renal arteries and veins by placing two clips on the patient side and one clip on the specimen side. Ligation times for obtaining renal vein control were compared between XL Hem-o-lok clips and GIA staplers in 40 cases before June 2004. Vascular control using XL Hem-o-lok clips was successful in all 40 cases, without any slipping of clips or uncontrolled bleeding. After renal pedicle dissection, ligation time for achieving renal vein control was 167.0 +/- 48 s (range: 122-295 s) using XL Hem-o-lok clips (mean, three clips) and 68 +/- 24.0 s (range: 54-150 s) using a GIA stapler. XL Hem-o-lok clips allow safe and reliable control of renal veins in laparoscopic nephrectomy. Ligation time is only 100 s longer than using a GIA stapler. In addition, costs are reduced by more than 90% compared to GIA stapling.

Adult↗
PubMed2004

Impact of surgical clipping on survival in unruptured and ruptured cerebral aneurysms: a population-based study.

BACKGROUND AND PURPOSE: The management of aneurysms is controversial because little is known about the impact of clipping on long-term outcome. This study was designed to evaluate long-term survival of patients with aneurysms undergoing clipping in a statewide population. METHODS: We used a retrospective design using an administrative database to identify patients hospitalized with aneurysms (1987 to 2001). Time-to-event analysis was used to determine the risk of death from all causes and from neurological causes. RESULTS: 4619 patients (mean age 54.7+/-15.3, 66.3% female) were hospitalized with cerebral aneurysms. Survival among patients with ruptures was significantly lower compared with patients with unruptured aneurysm (P<0.001) with adjusted hazard ratio (HR) of death after clipping 40% higher (HR: 1.4; 95% CI: 1.2, 1.7) in patients with rupture compared with those that were unruptured. Survival estimates for unruptured patients who underwent clipping were significantly higher than among those unruptured patients who did not undergo clipping (P<0.001), with adjusted HR of death 30% higher in patients with unruptured aneurysm that were not clipped compared with unruptured patients who were clipped (HR: 1.3; 95% CI: 1.1, 1.6). Patients with unruptured aneurysm who underwent clipping and survived beyond the 30-day postoperative period were less likely to die from neurologically related causes (5.6 versus 2.3%, P<0.001). Patients with ruptures and aneurysms who underwent clipping have a higher rate of death compared with the general population in the long-term. CONCLUSIONS: Short-term and long-term mortality after clipping of cerebral aneurysms is higher than previously reported. Patients with unruptured aneurysms who undergo clipping have improved survival compared with those who do not undergo clipping. This study supports the use of early intervention in the management of patients with unruptured aneurysms.

Aneurysm, Ruptured↗