Long-Term Durability of Open Surgical versus Endovascular Repair of Intracranial Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVE: The long-term durability of different modalities of intracranial aneurysm repair remains unclear. The aim of this study was to conduct a meta-analysis comparing long-term rates of intracranial aneurysm recurrence, retreatment, and rebleeding after surgical clipping or endovascular treatment (EVT). METHODS: A systematic review of PubMed and Embase was performed in accordance with the PRISMA guidelines and a meta-analysis was conducted. Cohort studies and randomized controlled trials (RCTs) with a surgical and an endovascular arm of 10 patients each and a median follow-up of 3 years were included. Pooled-effect estimates for reported outcomes were calculated using the random-effects model; sensitivity analysis was performed using the fixed-effects model. RESULTS: Of 4876 articles, 11 studies including 3 RCTs comprising 4517 patients were analyzed. Coiling was the modality of EVT in all included studies. In the randomeffects model, coiling was associated with an increased relative risk of 8.1 for recurrence (95% confidence interval [CI], 3.8-17.2), 4.5 for retreatment (95% CI, 3.4-5.9), and 2.1 for rebleeding (95% CI, 1.3-3.5); the fixed-effects model yielded similar results. Meta-regression by study design, length of follow-up, age, aneurysm size, ruptured versus unruptured aneurysms, or posterior versus anterior location did not yield significant results (all P interactions >0.05). No significant publication bias was identified. CONCLUSIONS: These results indicate better long-term durability of clipping compared with coiling-based EVT. The relatively high incidence of recurrence and retreatment after coiling should be considered when determining treatment strategy.