A Molyneux

Aelwyn Soepboer

Anjob N. de Gast

Guus N. Beute

M Mejdoubi

M Sluzewski

Menno Sluzewski

MJ Slob

T Hirai

Willem Jan van Rooij

WJ Rooij van

English

PubMed

Springer - Publisher Connector

How long does it take to coil an intracranial aneurysm?

INTERVENTIONAL NEURORADIOLOGY
How long does it take to coil an intracranial aneurysm?
Anjob N. de Gast & Aelwyn Soepboer &
Menno Sluzewski & Willem Jan van Rooij &
Guus N. Beute
Received: 8 June 2007 /Accepted: 8 August 2007 / Published online: 22 September 2007
# Springer-Verlag 2007
Abstract
Introduction The change in the treatment of choice for
intracranial aneurysms from clipping to coiling has been
associated with an important change in logistics. The time
needed for coiling is variable and depends on many factors.
In this study, we assessed the procedural time for the
coiling of 642 aneurysms and tried to identify predictors of
a long procedural time.
Methods The procedural time for coiling was defined as the
number of minutes between the first diagnostic angiographic
run and the last angiographic run after embolization. Thus,
induction of general anesthesia and catheterization of the
first vessel were not included in the procedural time. A long
procedural time was defined as the upper quartile of
procedural times (70–158 min). Logistic regression analysis
was performed for several variables.
Results The mean procedural time was 57.3 min (median
52 min, range 15–158 min). More than half of the coiling
procedures lasted between 30 and 60 min. Multiple logistic
regression analysis identified the use of a supportive device
(OR 5.4), procedural morbidity (OR 4.5) and large
aneurysm size (OR 3.0) as independent predictors of a
long procedural time. A poor clinical condition of the
patient, the rupture status of the aneurysm, gender, the
occurrence of procedural rupture, and aneurysm location
were not related to a long procedural time. The mean time
for the first 321 coiling procedures was not statistically
significantly different from mean time for the last 321
procedures.
Conclusion With optimal logistics, coiling of most intracra-
nial aneurysms can be performed in one to two hours,
including patient handling before and after the actual coiling
procedure.
Keywords Intracranial aneurysms . Coiling .
Procedural time
Introduction
Coiling of intracranial aneurysms has become the treatment
of choice and has partly replaced neurosurgical clipping in
most neurosurgical centers [1–3]. This change in treatment
modality has been associated with an important change in
logistics: patients are no longer treated in the operating
room but in the radiology department. Coiling of intracra-
nial aneurysms has to fit into the program of the
angiography suite and an anesthetic team has to leave the
operating room complex to assist in coiling. Since many
aneurysms are treated acutely after subarachnoid hemor-
rhage (SAH), planning may be difficult. The time slot
needed for coiling is variable and depends on many factors
such as complexity of the aneurysm, the number of
aneurysms that should be treated, the experience and skills
of the treating endovascular team and local preferences. In
this study, we assessed the procedural time for coiling of
642 aneurysms and tried to identify predictors of a long
procedural time.
Neuroradiology (2008) 50:53–56
DOI 10.1007/s00234-007-0301-6
A. N. de Gast :A. Soepboer :M. Sluzewski :W. J. van Rooij (*)
Department of Radiology, St. Elisabeth Ziekenhuis,
Hilvarenbeekseweg 60,
5022 GC Tilburg, The Netherlands
e-mail: radiol@knmg.nl
G. N. Beute
Department of Neurosurgery, St. Elisabeth Ziekenhuis,
Tilburg, The Netherlands
Patients and methods
Patients
From January 1998 to September 2005, 817 aneurysms
were coiled. The starting point of the study was chosen
because of installation of a new biplane angiographic unit
(Integris 3000 BN Neuro, Philips Medical Systems, Best,
The Netherlands) at the end of 1997.
We excluded 65 patients (with 146 aneurysms) with more
than one aneurysm coiled in the same session. Of the
remaining 671 aneurysms, 642 had complete imaging data
available for review. The time of each angiographic run was
printed on the images automatically. The procedural time for
coiling was defined as the number of minutes between the first
diagnostic angiographic run and the last angiographic run after
embolization. Thus, induction of general anesthesia and
catheterization of the first vessel were not included in the
procedural time. In the vast majority of patients, 3-D rotational
angiography (3DRA) of the vessel harboring the aneurysm
was performed [4]. Many patients with acute SAH confirmed
on CT scan were immediately transferred to the angiography
suite and underwent complete diagnostic angiography and
coiling of the aneurysm under general anesthesia. Only in
patients with unruptured aneurysms, was diagnostic angi-
ography usually available before coiling, and in these patients
only 3DRA was performed during the process of coiling.
Of the 642 patients, 178 were men and 464 were women
with a mean age of 52.9 years (median 52 years, range 19–
83 years). Of the 642 aneurysms, 523 had ruptured and 119
had not. Among the 523 patients with a ruptured aneurysm
at the time of treatment, clinical condition was Hunt and
Hess (HH) I/II in 337, HH IV/V in 68, and HH III in 118.
The mean aneurysm size was 8.0 mm (range 2–55 mm).
The aneurysm was located in the posterior circulation in
154, in the anterior cerebral artery in 246, in the middle
cerebral artery in 46, and in the carotid artery in 196
patients. The type of coil used was mostly Guglielmi
detachable coils (GDC; Boston Scientific, Fremont, Calif.),
followed by TruFill/Orbit coils (Cordis Neurovascular,
Miami Lakes, Fl.) and straight coils 50 cm long (Cook
Detach, Cook, Copenhagen, Denmark) for large and giant
aneurysms [5]. A supportive device was used during coiling
in 60 aneurysms, a supportive balloon in 55, a TriSpan in 4,
and a stent in 1 aneurysm [6]. In 26 aneurysms a procedural
rupture occurred. Complications leading to permanent
neurological deficit or death occurred in 40 patients [7, 8].
Statistical analysis
To assess possible predictors of a long procedural time, we
defined a long procedural time as the upper quartile of the
procedural times (70–158 min) and performed logistic
regression analysis for the following variables: male
gender, age greater than the median age of 52 years,
ruptured aneurysm, aneurysm size in the upper quartile
(10–55 mm), occurrence of procedural rupture, HH grade
III–V, occurrence of procedural morbidity defined as
complications leading to death or permanent neurological
deficit [7, 8], use of a supportive device, location on the
anterior cerebral artery, carotid artery or middle cerebral
artery, and location in the posterior circulation. Subsequently,
to identify independent predictors, multiple logistic regres-
sion analysis was performed for all significant predictors.
To assess whether recent technical developments had
influenced procedural time, we compared the mean proce-
dural time of the first 321 aneurysms with the mean
procedural time of the last 321 aneurysms using a t-test. In
addition, we assessed whether the implementation of 3DRA
in October 2000 had influenced procedural time.
Results
The mean procedural time was 57.3 min (median 52 min,
range 15–158 min). More than half of the coiling procedures
lasted between 30 and 60 min (Fig. 1), 49 procedures (7.6%)
lasted less than 30 min, and 68 procedures (10.6%) lasted
more than 90 min.
Median and mean procedural times with ranges and
standard deviations for aneurysm coiling procedures in
relation to patient and aneurysm characteristics are summa-
rized in Table 1. The predictors of a long procedural time
are displayed in Table 2. The use of a supportive device
was the strongest predictor of a long procedural time (OR
5.4), followed by the occurrence of procedural morbidity
(OR 4.5), a large aneurysm size (OR 3.0), and patient age
(OR 1.5). A poor clinical condition of the patient, rupture
status of the aneurysm, gender, occurrence of procedural
Fig. 1 Procedural times in minutes for 642 coiling procedures
displayed as number of procedures in 15-min time periods
54 Neuroradiology (2008) 50:53–56
rupture, aneurysm location, and implementation of 3DRA
had no influence on procedural time. Multiple logistic
regression analysis identified the use of a supportive device,
occurrence of procedural morbidity, and large aneurysm
size as independent predictors of a long procedural time.
The mean procedural time for the first 321 coil procedures
was 56.5 min (median 51 min, range 18–158 min) and for the
last 321 this was 58.1 min (median 54 min, range 15–
124 min). This difference was not significant (t-test, P=0.40)
Discussion
In this study, the mean procedural time for coiling was
57 min. Most procedures were performed within 1 h.
Procedural time was defined as the time between the first
and the last angiographic run, since this time period could
easily be assessed from time prints on the images. The time
for patient preparation, anesthetic care, insertion of angi-
ographic sheet and catheterization of the first vessel were
not included in the procedural time. In our department, this
additional time is usually between 30 and 45 min. This
means that the typical time needed for coiling of an
intracranial aneurysm is around one and a half hours,
varying from one to two hours.
A long procedural time was associated with the use of a
supportive device, occurrence of procedural morbidity and
large aneurysm size. Although coiling of middle cerebral
artery aneurysms tended to take more time and coiling of
carotid artery aneurysms tended to take less time, these
differences were just not statistically significant. The
strongest predictor of a long procedural time was the use
of a supportive device, mostly a supportive balloon [6].
When the use of a supportive device is not anticipated from
the beginning of the procedure, an additional guiding
catheter must be placed in the groin and navigated to the
vessel harboring the aneurysm, or the guiding catheter has
to be changed for a catheter with larger inner lumen. In
addition, the balloon catheter has to be prepared and
navigated across the neck of the aneurysm and this may
be time consuming since 0.010-inch guidewires are usually
difficult to steer. Another predictor of a long procedural
time was large aneurysm size. In larger aneurysms a higher
number of coils can usually be inserted and the accumulated
electrolytic detachment time thus increases. The last predic-
tor of a long procedural time was the occurrence of
morbidity (not the occurrence of procedural rupture). Most
morbidity is caused by thromboembolic complications.
Several actions may be undertaken when such a complica-
tion occurs, such as mechanical thrombus fragmentation and
Table 2 Odds ratios with 95% confidence intervals for different
variables for the upper quartile of procedural times (70–158 min)
Variable Odds ratio 95% CI
Use of supportive device 5.40 3.11–9.34
Procedural morbidity 4.49 2.33–8.64
Aneurysm size in upper quartile (10–55 mm) 3.03 2.06–4.45
Age more than median age 1.47 1.02–2.10
Hunt and Hess grade III–V 1.32 0.88–1.97
Ruptured aneurysm 1.41 0.87–2.30
Male gender 0.79 0.54–1.16
Procedural rupture 0.73 0.27–1.98
Aneurysm location
Middle cerebral artery 1.81 0.97–3.40
Posterior circulation 1.30 0.87–1.95
Anterior cerebral artery 0.93 0.65–1.35
Carotid artery 0.68 0.46–1.02
Implementation of 3D angiography 1.11 0.74–1.66
Table 1 Procedural times for all 642 aneurysms in relation to patient
and aneurysm characteristics
Variable No. of
aneurysms
Procedural time (min)
Median Mean Range Standard
deviation
Aall
aneurysms
642 57.3 52.0 15–158 24.1
Use of
supportive
device
60 80.5 80.2 35–150 30.7
Procedural
morbidity
40 72.5 75.6 28–158 30.7
Aneurysm
size in
upper quartile
(10–55 mm)
163 64 70.5 25–158 26.4
Age more
than median
52 years
321 55 60.7 17–158 25.0
Hunt and Hess
grade III–V
186 54 59.2 18–122 22.6
Ruptured
aneurysm
523 52 58.1 16–158 24.6
Male gender 182 55 60.4 17–131 23.8
Procedural
rupture
26 50 53.8 16–107 21.3
Aneurysm location
Middle cerebral
artery
46 53 61.8 19–131 26.8
Posterior
circulation
154 54 61.7 22–146 27.1
Anterior
cerebral artery
246 53.5 57.1 16–112 21.2
Carotid artery 196 48 53.1 15–158 23.9
Implementation of 3-D angiography
Before 167 52 58.6 18–158 25.5
After 475 52 56.9 15–146 23.7
Neuroradiology (2008) 50:53–56 55
selective injection of thrombolytic drugs, which both lead to
a longer procedural time.
It is of note that no difference in procedural time was
found between the earlier and later procedures, despite the
technical advances in microcatheters and guidewires and
increased experience. In both groups, there was no
difference in mean aneurysm size (8.7 versus 7.2 mm),
use of a supportive device (both 30) or occurrence of
morbidity (both 20). We did not include the first 3 years of
coiling in our hospital because the time was not printed on
the images by the angiographic equipment used during that
period. The mean procedural time may have been longer on
the steep side of the learning curve during those first
3 years.
In our high-volume department, logistics have been
optimized. In patients scheduled for coiling, an intravenous
line and urinary catheter are placed on the ward, the treating
endovascular team is experienced, a biplane angiographic
unit with 3DRA is available, all catheters and devices
needed are available in the angiography room, micro-
catheters and guidewires are prepared by technicians, and in
recent years the puncture site is closed with a dedicated
device. For coiling of large and giant aneurysms, we use for
the most part mechanically detachable coils 50 cm long. All
anesthetists involved in coil procedures were experienced,
with no residents in training. Our time slot for anesthesia is
in the afternoon from 1300 to 1600 hours with a “deadline”
at 16.30, after which time an anesthetist on call has to be
notified to take over care. With these logistics we normally
plan two patients, and regularly treat three patients within
this time slot.
Both of the senior authors (M.S. and W.J.v.R) have
performed many coil procedures in four other hospitals in
The Netherlands. The procedural time may differ greatly
between centers, depending on many factors such as
availability of single- or biplane angiographic equipment
and 3DRA, the experience of the operator, supporting
technicians and anesthetic team, and local preferences such
as liberal or restricted use of supportive devices.
Conclusion
With optimal logistics, coiling of most intracranial aneurysms
can be performed in one to two hours, including patient
handling before and after the actual coiling procedure.
Conflict of interest statement We declare that we have no conflict
of interest.
References
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56 Neuroradiology (2008) 50:53–56


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