Small Ruptured Anterior Communicating Artery Aneurysms in the Endovascular Right-of-First-Refusal Era:...

Ruptured small anterior communicating artery (ACoA) aneurysms can pose a technical challenge for endovascular therapy. We sought to explore treatment and follow-up results in the modern endovascular right of first refusal era.

Smaller (≤7 mm) ruptured aneurysms of the ACoA undergoing treatment were compared with non-ACoA counterparts and further dichotomized by size (≤3 mm and 3-7 mm). Immediate and 2-year angiographic results, procedural complications, retreatment, and functional results at follow-up were stratified by treatment modalities and compared between aneurysm location and size groups.

Of 449 consecutive small ruptured aneurysms, 35% (n = 155) were ACoA. Endovascular treatment was the first-line option in 68%. While the immediate aneurysm occlusion was more favorable in the ACoA group compared to other aneurysms treated endovascularly (Raymond-Roy I-II, 89% vs. 74%, P = 0.003), the residual and/or recanalization requiring retreatment rate at 2 years was higher (27% vs. 17%, P = 0.04). ACoA aneurysms were associated with a 2-fold higher risk of retreatment (odds ratio [OR] 2.08, P = 0.02) in multivariate analyses of the endovascular cohort. The incidence of intraprocedural rupture was numerically higher for coiled ≤3 mm ACoA aneurysms (12.5% vs. 2.2%, P = 0.11), corresponding to a higher major complication rate (12.5% vs. 1.1%, P = 0.06) in this subgroup. Endovascularly treated ≤3 mm ACoA aneurysms were associated with a 4-fold higher risk of recanalization (OR 4.4, P = 0.01) and retreatment (OR 3.8, P = 0.03).

While the immediate efficacy is satisfactory for endovascularly treated small ruptured ACoA aneurysms, there are increasing needs for retreatment and non-negligible risks for coiling ACoA aneurysms ≤3 mm.