Most surgeons prefer to avoid a second surgical attempt to treat residual or recurrent aneurysms after surgical clipping. Intraoperative angiography provides the benefit of visualizing residual aneurysm or unintended occlusion of parent vessels, thus allowing adjustment of the clip during the same operation. Although 88% of aneurysms treated by surgical clipping achieved complete aneurysmal closure in a study of patients with ruptured and unruptured aneurysms, ruptured, posterior circulation, and large/giant aneurysms were prone to incomplete clipping (121). The authors suggested that these aneurysms should receive either postoperative or intraoperative angiographic evaluation. At the same time, unexpected failures have been associated with clipping of numerous anterior circulation aneurysms, implying that intraoperative angiogra-phy could be beneficial (121). Findings on intraoperative angiography prompted reexploration and clip readjustment in 11% of clipped aneurysms in one study (122 ) . False-negative and false-positive results were found in 12.5% of intraoperative angiograms, although only 2.6% of patients suffered complications (123). The benefits of intraoperative angiography must be weighed against the complications associated with repeated angiography and prolonged vascular access, in addition to possible false negatives and positives, but it appears that routine intraoperative angiography is safe and helpful in a significant number of cases.
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