What is coil embolization (endovascular coiling procedure)?

From the Guidelines

Coil embolization is now recommended over clipping for the treatment of ruptured aneurysms when both options are feasible, due to improved 1-year patient outcomes. This recommendation is based on the results of the ISAT and BRAT trials, as highlighted in the 2023 guidelines for the management of patients with aneurysmal subarachnoid hemorrhage 1. The procedure involves inserting a catheter through an artery and guiding it to the treatment site, where tiny platinum coils are deployed to trigger blood clot formation and seal off the aneurysm.

Key considerations for coil embolization include:

• Aneurysm location and morphology, with coiling being preferred for aneurysms that are amenable to this approach
• The use of stent-assisted coiling or flow diversion for patients with wide-neck aneurysms that are not amenable to clipping or coiling
• The importance of aneurysm obliteration within 24 hours of subarachnoid hemorrhage, as delayed treatment may be associated with poorer outcomes
• The need for multidisciplinary discussion and consideration of both surgical and endovascular approaches when aneurysms are not amenable to coiling or when there is equipoise

In terms of patient management, coil embolization is typically performed under general anesthesia or conscious sedation, with patients usually staying in the hospital for 1-2 days afterward. Recovery involves bed rest for 6-8 hours post-procedure, avoiding strenuous activities for 1-2 weeks, and taking prescribed antiplatelet medications to prevent clot formation around the coils. Follow-up imaging is typically scheduled at 6 months and then annually to ensure the treatment remains effective, as recommended in the 2023 guidelines 1.

From the Research

Coil Embolization Overview

• Coil embolization is a procedure used to treat cerebral aneurysms by filling the aneurysm with coils to prevent blood flow and reduce the risk of rupture 2, 3, 4, 5, 6
• The procedure can be performed using various techniques, including single catheter technique, adjunctive techniques, and stent-assisted coil embolization 3, 5

Complications and Risks

• Thromboembolic events are a common complication of coil embolization, and can be reduced with the use of antiplatelet therapy 2, 6
• Intraoperative cerebral aneurysm re-rupture and symptomatic cerebral embolism are also potential complications of coil embolization 3, 5
• Systemic anticoagulation after coil embolization may carry a significant risk of rebleeding, particularly in patients with ruptured aneurysms 4
• Stent-assisted coil embolization may be associated with a higher rate of complications, including thromboembolism, stent occlusion, and re-bleeding 5

Treatment Outcomes

• Complete obliteration of the aneurysm can be achieved in a significant proportion of cases, with rates ranging from 32% to 100% 2, 3, 5
• The use of antiplatelet therapy, including dual and triple antiplatelet regimens, can help prevent thromboembolic complications and improve treatment outcomes 2, 6
• The choice of procedure and technique may depend on various factors, including the location and size of the aneurysm, as well as the patient's overall health and medical history 3, 5

Antiplatelet Therapy

• Antiplatelet therapy, including aspirin and clopidogrel, is commonly used to prevent thromboembolic complications after coil embolization 2, 6
• The addition of cilostazol to dual antiplatelet therapy may not provide additional benefit in preventing thromboembolic events, particularly in patients undergoing Y-stent-assisted coil embolization 6
• The optimal duration and dosage of antiplatelet therapy after coil embolization are not well established and may require further study 2, 6