Neurosurgical perspectives: A shift towards endovascular strategies and personalized approaches

How do you think the results of this study will influence the future of aneurysm treatment strategies, especially with regard to patient selection for microsurgical versus endovascular approaches?

Dr. Pascal JABBOUR: "This paper showed the shift from open surgical techniques toward intrasaccular devices after the introduction of the WEB device, especially since the indications to use the WEB are in large part those aneurysms that we used to clip."

In the study, did you observe any specific patient factors (e.g., age, comorbidities, aneurysm size) that consistently favored one treatment modality over the other?

Dr. Pascal JABBOUR: "The post WEB cohort was significantly older compared to the Pre WEB cohort maybe because of the availability of the less invasive endovascular option for those patients who would have been deemed poor candidates for open surgery."

What do you believe are the most critical factors influencing the choice between endovascular and microsurgical approaches for different types of aneurysms?

Dr. Pascal JABBOUR: "There are multiple factors that are important some related to the anatomy of the aneurysm itself,  some related to the general medical condition of the patients, and some related to the socioeconomic condition of the patients where some patients tend to keep on smoking and would not be compliant with follow-up. For example, there’s a size limitation because the largest WEB is 11 mm. There is also tortuous anatomy limitations, and noncompliant patients who would not come for follow-up; in this case, they would benefit from a one-stop clipping."

What advancements in endovascular technology do you anticipate could further reduce the need for microsurgical interventions in aneurysm cases, based on the findings of your research?

Dr. Pascal JABBOUR: "Other possible future advancements that would make the endovascular option even more feasible would be to have more sizes of the device on both ends small and large and being able to deliver larger devices through a lower profile microcatheter."

In your opinion, are there specific anatomical or morphological characteristics of aneurysms that still present significant challenges for endovascular treatment compared to microsurgical approaches?

Dr. Pascal JABBOUR: "There are some specific anatomical or morphological characteristics that would make some aneurysms more appropriate for clipping mainly aneurysms that would incorporate branching vessels coming out, partially thrombosed aneurysms with mass effect, aneurysms presenting with an intraparenchymal  hemorrhage  and mass effect,  fusiform dolichoectatic aneurysms that sometimes would need a deconstructive procedure and a bypass and very small ruptured aneurysms at the bifurcation."

Can you elaborate on how emerging technologies, such as artificial intelligence or machine learning, might impact decision-making in aneurysm treatment in the near future?

Dr. Pascal JABBOUR: "Nowadays, with all the advances in artificial intelligence and machine learning, I can soon see how we could input the imaging from an angiogram in a program, and the program would match the aneurysm with the best technique."

What are your thoughts on the long-term durability of endovascular treatments compared to microsurgical techniques, especially regarding the risk of recurrence or retreatment?

Dr. Pascal JABBOUR: "Historically It was well known that the durability of clipping  is incomparable but more and more with new technology. I think we are getting closer in durability, but not matching it yet, for example with flow diversion. I think the durability is extremely high. We yet have to see an aneurysm recurring after it’s gone at six months follow-up angiogram, but we are still not there with other devices at this point in time."

Today, how does your team select the approach that you recommend first to your patients?

Dr. Pascal JABBOUR: "We try to have a bird eye view of the whole problem taking into consideration the anatomy of the aneurysm, the tortuosity of the vessels to get there, the comorbidities and risk factors of the patient, and the personal choice of the patient to a certain level, patients need to understand that when we offer an endovascular treatment, it’s not just a one-and-done solution. We are offering a full package of endovascular treatment with continuous follow-up,  patients who are not willing to do this maybe would benefit from an open surgery once and done."