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Los resultados del tratamiento quir&#250;rgico en manos expertas igualan los del tratamiento endovascular y especialmente en los aneurismas de circulaci&#243;n anterior&#44; aunque su invasividad es mayor&#46; El precio de los materiales de embolizaci&#243;n es elevado y el desarrollo de nuevos dispositivos como los stents y los diversores de flujo lo han incrementado&#44; mientras que el precio de la cirug&#237;a es moderado&#44; por lo que el tratamiento quir&#250;rgico de los aneurismas podr&#237;a ser rentable desde un punto de vista econ&#243;mico&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo de este art&#237;culo es comparar 2 series de pacientes con aneurismas incidentales tratados endovascularmente &#40;EV&#41; y quir&#250;rgicamente &#40;SC&#41; desde el punto de vista de resultados cl&#237;nicos y angiogr&#225;ficos as&#237; como econ&#243;mico&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material y m&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Se revisa a pacientes tratados de aneurismas incidentales tratados de EV y SC y se analizan datos demogr&#225;ficos &#40;edad y sexo&#41;&#44; las caracter&#237;sticas anat&#243;micas del aneurisma &#40;localizaci&#243;n y tama&#241;o&#41;&#44; as&#237; como los resultados &#40;GOS a los 6 meses&#41; de ambas series&#46; Se registra estancia hospitalaria &#40;Unidad de Cuidados Intensivos y planta&#41;&#44; los costes derivados del tratamiento y los retratamientos &#40;n&#250;mero de coils&#44; stents&#44; cat&#233;teres gu&#237;a&#44; balones&#44; craneotom&#237;a&#44; pinzas&#44; etc&#46;&#41;&#44; y los costes relacionados con el seguimiento de estos pacientes &#40;arteriograf&#237;as de control&#44; angio-RM&#41;&#46; Los costes de estancias&#44; procedimientos y materiales se obtienen de fuentes hospitalarias &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Se realiza un estudio descriptivo de ambas series y se comparan en t&#233;rminos de edad&#44; sexo y caracter&#237;sticas cl&#237;nicas y radiol&#243;gicas&#46; Para el c&#225;lculo de costes se excluye a aquellos en los que no se realiz&#243; un seguimiento de forma adecuada&#46; El seguimiento de los pacientes intervenidos difiere del de los embolizados&#46; Aquellos pacientes intervenidos de aneurisma cerebral son sometidos a una arteriograf&#237;a de control generalmente durante el primer ingreso&#44; no precisando de otras pruebas de imagen de control estandarizadas&#46; Los pacientes embolizados se someten a una arteriograf&#237;a a los 6 y otra a los 12 meses&#44; continuando despu&#233;s con angio-RM anuales en caso de considerarse estable el tratamiento&#44; por un periodo no inferior a 5 a&#241;os&#46; En caso de observarse un aumento del resto permeable&#44; se programan para nuevo tratamiento&#44; reinici&#225;ndose el ciclo de arteriograf&#237;as y angio-RM&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Para comparar la edad entre los grupos se ha utilizado el test t de Student&#44; Mann-Whitney para el tama&#241;o del aneurisma&#44; ya que no cumple la hip&#243;tesis de normalidad y para el sexo se ha utilizado el test de la chi al cuadrado de Pearson&#46; 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de los aneurismas fueron menores de 5 mm&#44; un 58&#44;4&#37; midieron entre 5 y 10 mm y un 18&#37; fueron mayores de 10 mm&#46; Los aneurismas embolizados fueron discretamente m&#225;s grandes que los intervenidos &#40;7&#44;8 mm frente a 7 mm de media&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">No hay diferencias estad&#237;sticamente significativas entre ambas series en lo que a edad&#44; sexo o tama&#241;o del aneurisma se refiere&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Los resultados cl&#237;nicos y angiogr&#225;ficos se resumen en la <a class="elsevierStyleCrossRef" href="#tbl0020">tabla 4</a>&#46; En cuanto a los resultados cl&#237;nicos a los 6 meses&#44; medidos en relaci&#243;n con la escala de GOS&#44; un 90&#37; de los pacientes presentaban un GOS 5&#44; un 6&#37; un GOS 4 y un 4&#37; un GOS 3&#46; Los resultados fueron muy similares en ambos grupos&#46; No hubo mortalidad relacionada con el tratamiento&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">En cuanto a los resultados angiogr&#225;ficos del tratamiento se dispone de arteriograf&#237;a de control en el 100&#37; de los casos&#46; Se consigui&#243; el cierre completo del aneurisma en el primer tratamiento en el 65&#37; de los pacientes&#44; quedando un resto de cuello en el resto&#46; Esta oclusi&#243;n completa fue notablemente superior en el grupo SC &#40;96&#37; versus 55&#37;&#41;&#46; De los casos tratados EV&#44; un 24&#37; precis&#243; de retratamiento &#40;una cuarta parte de ellos en dos ocasiones&#41;&#44; Las tasas de retratamiento de los aneurismas de circulaci&#243;n anterior fue superior &#40;27&#37;&#41; a los de circulaci&#243;n posterior &#40;10&#37;&#41;&#46; Un 50&#37; de los aneurismas de comunicante posterior&#44; un 36&#44;5&#37; de los de ACM y un 25&#37; de los de comunicante anterior tratados EV precisaron de retratamiento&#46; El tama&#241;o medio de los aneurismas retratados es tambi&#233;n superior a la media &#40;9 mm frente a los 7&#44;6 mm de la media&#41;&#44; de manera que un 38&#44;5&#37; de los aneurismas mayores de 10 mm necesitaron retratamiento&#46; La media de coils utilizados por paciente en el primer tratamiento fue de 5 y en los retratamientos de 6&#46; De igual forma&#44; el uso de stent y diversores de flujo fue m&#225;s frecuente en los retratamientos&#46; Existen 4 complicaciones relacionadas con el tratamiento EV&#44; ninguna de ellas con secuelas posteriores&#58; 2 vasoespasmos angiogr&#225;ficos&#44; una disecci&#243;n de car&#243;tida interna y una reacci&#243;n anafil&#225;ctica&#44; lo que constituye un 6&#37;&#46; Una paciente present&#243;&#44; un a&#241;o despu&#233;s de la colocaci&#243;n de un diversor de flujo en un aneurisma de car&#243;tida interna complejo&#44; una oclusi&#243;n completa del mismo tras una colecistectom&#237;a&#44; con resultado de defunci&#243;n&#46; Las complicaciones relacionadas con la cirug&#237;a fueron una infecci&#243;n de herida &#40;4&#44;5&#37;&#41; y un seudomeningocele &#40;4&#44;5&#37;&#41;&#44; ambos resueltos con tratamiento m&#233;dico y sin secuelas&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Respecto a las estancias&#44; el tiempo medio de hospitalizaci&#243;n en pacientes fue de 7&#44;7 d&#237;as&#46; Los pacientes embolizados tuvieron una estancia media de 6 d&#237;as&#44; en tanto que en los quir&#250;rgicos fue de m&#225;s del doble &#40;12&#44;7 d&#237;as&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Dado que ambos grupos presentan un protocolo de seguimiento diferente&#44; los pacientes tratados mediante embolizaci&#243;n tras hemorragia subaracnoidea &#40;HSA&#41;&#44; tienen una media de 2&#44;5 arteriograf&#237;as por paciente frente a la &#250;nica arteriograf&#237;a de control de los pacientes intervenidos&#46; La media de angio-RM es de 2&#44;1 por paciente &#40;2&#44;5 en grupo EV y 1 en SC&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">El gasto total generado por estos pacientes fue de 1&#46;848&#46;300 &#8364;&#44; de los cuales el 83&#37; corresponde al grupo EV&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En tanto que en el grupo SC el 88&#37; del gasto se genera en el primer ingreso&#44; en el grupo EV este porcentaje es del 62&#37;&#46; Los retratamientos constituyen un 18&#37; del gasto del grupo EV&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Considerando solo el primer ingreso&#44; y a pesar de que el gasto de hospitalizaci&#243;n es m&#225;s del doble en el grupo SC&#44; el tratamiento endovascular es un 14&#37; m&#225;s caro que el quir&#250;rgico al alta&#44; debido al precio de los materiales de embolizaci&#243;n utilizados&#44; que generan el 60&#37; del gasto al alta&#46; Cerca de la mitad de los gastos en material de embolizaci&#243;n se deben a coils&#44; siendo tambi&#233;n importante el gasto en diversores de flujo &#40;un cuarto del total&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Solo el gasto invertido en los materiales de embolizaci&#243;n supone un 46&#37; del gasto total del grupo EV&#46; La diferencia en costes aumenta cuando se incluyen los gastos de seguimiento y de retratamiento que hacen que el tratamiento endovascular sea un 31&#37; y un 61&#37; m&#225;s caro que el quir&#250;rgico&#44; respectivamente&#44; ascendiendo finalmente a 22&#46;908 &#8364; por paciente frente a los 14&#46;264 &#8364; del tratamiento quir&#250;rgico &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">Los aneurismas incidentales pueden descubrirse de forma casual en el curso de exploraciones radiol&#243;gicas o en el contexto de una HSA&#44; acompa&#241;ando a un aneurisma roto&#46; Su hallazgo es relativamente frecuente y su incidencia ha aumentado en los &#250;ltimos a&#241;os debido a la mejora y la generalizaci&#243;n del uso de las t&#233;cnicas de imagen&#46; Son m&#225;s frecuentes en mujeres y a partir de los 30 a&#241;os<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; y existe una serie de factores de riesgo que predisponen al desarrollo de aneurismas cerebrales&#44; unos no modificables &#40;gen&#233;ticos&#41; y otros modificables &#40;h&#225;bito tab&#225;quico&#44; hipertensi&#243;n y exceso de alcohol&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Con estos datos&#44; la incidencia de aneurismas incidentales en una poblaci&#243;n mayor de 50 a&#241;os sin factores de riesgo se estima en un 3&#44;2&#37;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La indicaci&#243;n de tratamiento se basa en el riesgo de rotura&#44; as&#237; como en la edad del paciente y las caracter&#237;sticas del aneurisma&#46; Algunos estudios&#44; como el ISUIA&#44; han evidenciado un riesgo de rotura del 0&#44;5&#37; al a&#241;o&#44; siendo mayor en aneurismas grandes &#40;&#62; 10 mm&#41; y de circulaci&#243;n posterior&#46; El estudio UCAS sobre pacientes japoneses evidenci&#243; un riesgo de rotura ligeramente mayor &#40;0&#44;95&#37;&#41;&#44; estando relacionado asimismo con el tama&#241;o del aneurisma y la localizaci&#243;n&#44; y adem&#225;s con la presencia de irregularidades en el saco<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Desde el estudio ISAT ha habido un aumento progresivo de las indicaciones de tratamiento endovascular frente al quir&#250;rgico de manera que hoy en d&#237;a el primero ha sobrepasado al segundo tanto en aneurismas rotos como incidentales&#46; Esta generalizaci&#243;n de los tratamientos endovasculares ha generado un significativo aumento de las indicaciones de tratamiento &#40;y del gasto generado&#41; en los aneurismas incidentales<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Cada modalidad de tratamiento tiene sus ventajas e inconvenientes&#46; A favor del tratamiento endovascular estar&#237;a su menor agresividad teniendo como desventaja una menor estabilidad que el quir&#250;rgico&#44; lo que hace que los &#237;ndices de oclusi&#243;n incompleta<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;7</span></a>&#44; recanalizaciones&#44; retratamientos<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> y resangrados<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;9&#44;11</span></a> sean mucho mayores que en el quir&#250;rgico&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Si se excluyen los aneurismas sintom&#225;ticos y rotos&#44; el tratamiento ofrece en general resultados con baja morbimortalidad con ambos tratamientos &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">tabla 5</a>&#41;&#46; En los estudios con mayor poblaci&#243;n publicados hasta la fecha&#44; la mortalidad quir&#250;rgica relacionada con este procedimiento oscila entre el 0&#44;6 y el 2&#44;6&#37;&#44; con una morbilidad que se sit&#250;a entre el 4&#44;1 y el 10&#44;9&#37;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;21</span></a>&#46; Las morbimortalidad ha ido disminuyendo debido a la mejora de la t&#233;cnica quir&#250;rgica y la introducci&#243;n de ayudas como la ICG&#44; y existen largas series con morbimortalidad del 0&#37;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a>&#46; No obstante&#44; el tratamiento endovascular tiene en general una menor mortalidad &#40;entre el 0&#44;5 y el 1&#44;7&#37;&#41; y morbilidad &#40;entre el 1 y el 7&#44;5&#37;&#41;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18&#44;24</span></a>&#46; El &#250;nico estudio prospectivo sobre los resultados del tratamiento endovascular en aneurismas incidentales es el publicado por Pierot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> sobre 649 pacientes y 1&#46;100 aneurismas tratados en 27 centros&#46; En este estudio se evidenci&#243; un 0&#44;9&#37; de mortalidad y un 15&#44;4&#37; de acontecimientos adversos relacionados con el tratamiento&#44; con una mortalidad del 1&#44;4&#37; y una morbilidad global del 1&#44;7&#37; al mes del tratamiento&#46; Hubo un 5&#44;4&#37; de embolismos cerebrales sintom&#225;ticos de los cuales un 2&#44;6&#37; fueron permanentes y un 0&#44;9&#37; causaron la muerte&#46; Tres de las muertes fueron debidas a una rotura intraoperatoria del aneurisma&#44; fen&#243;meno que aconteci&#243; en el 16&#44;7&#37;&#44; siendo la mitad de ellas asintom&#225;ticas&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">El tratamiento endovascular tiene menor &#237;ndice de oclusiones completas&#44; llegando en algunas series&#44; como la de Naggara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> al 86&#37; &#40;en la serie de Pierot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> es del 59&#37; y en el metaan&#225;lisis de Ruan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> del 82&#37;&#41;&#44; en tanto que los porcentajes de oclusi&#243;n completa en las series quir&#250;rgicas de aneurismas incidentales est&#225;n por encima del 90&#37;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;20&#44;21&#44;26</span></a>&#46; Aunque la posibilidad de recanalizaci&#243;n es mayor en los aneurismas rotos que en los incidentales<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a>&#44; en estos &#250;ltimos sigue siendo alta y los retratamientos son necesarios en un 10&#37; de los pacientes<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Determinados factores influyen en el resultado del tratamiento quir&#250;rgico de los aneurismas incidentales&#58; localizaci&#243;n en circulaci&#243;n posterior&#44; tama&#241;o mayor de 12 mm y edad superior a 50 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;25</span></a>&#46; El hecho de que la recanalizaci&#243;n ocurra con cierta frecuencia hace que algunos autores se decanten por el tratamiento quir&#250;rgico en los aneurismas de circulaci&#243;n anterior&#44; especialmente en menores de 40 a&#241;os<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;28&#44;29</span></a>&#46; Otro factor que influye en el resultado es el volumen de aneurismas tratados por centro<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> y por cirujano<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En la literatura existen diversos trabajos que comparan los resultados del tratamiento endovascular y quir&#250;rgico desde un punto de vista econ&#243;mico<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">32&#8211;39</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">tabla 6</a>&#41;&#46; La mayor&#237;a de ellos no incluyen los gastos de seguimiento ni los retratamientos&#44; por lo que los costes del tratamiento endovascular est&#225;n infravalorados&#46; Pr&#225;cticamente&#44; en todos los estudios el tratamiento endovascular es m&#225;s caro que el quir&#250;rgico&#46; Aunque la estancia media es en general superior en los pacientes intervenidos quir&#250;rgicamente&#44; el gasto que generan los materiales de embolizaci&#243;n supera el ahorro en estancia hospitalaria del tratamiento endovascular ya en el primer ingreso&#46; Este factor es m&#225;s evidente en el trabajo de Familarli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a> basado en aneurismas gigantes&#44; en los que con m&#225;s frecuencia es preciso utilizar stent o diversores de flujo&#44; por lo que el tratamiento endovascular es un 153&#37; m&#225;s caro que el quir&#250;rgico&#46; Es interesante destacar que ambas t&#233;cnicas tienen estancias medias similares&#44; a pesar de que el 94&#37; de los pacientes intervenidos precisaron de complejas t&#233;cnicas de revascularizaci&#243;n&#46; Este hecho apunta en la direcci&#243;n de que este tipo de cirug&#237;as deber&#237;an ser realizadas solo en centros con larga experiencia y elevado n&#250;mero de casos&#46; Similares conclusiones pueden sacarse del trabajo de Zweifel<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#44; donde la adecuada t&#233;cnica quir&#250;rgica se traduce en una estancia media solo un d&#237;a superior en el grupo quir&#250;rgico y unos resultados cl&#237;nicos y angiogr&#225;ficos superiores en el grupo quir&#250;rgico &#40;67&#37; de oclusi&#243;n en el grupo EV frente al 97&#37; del grupo SC&#41;&#46; En esta serie&#44; el gasto del grupo endovascular es m&#225;s del doble del quir&#250;rgico&#44; sin incluir seguimiento ni retratamientos&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">El &#250;nico estudio que incluye seguimiento y retratamientos<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">34</span></a> evidencia que los gastos del primer ingreso son muy similares entre ambos tratamientos&#44; pero el seguimiento y los retratamientos endovasculares &#40;que en este trabajo llegan al 16&#44;7&#37;&#41; encarecen el precio final del tratamiento&#44; siendo el endovascular un 8&#37; m&#225;s caro que el quir&#250;rgico&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">El estudio de Duan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a>&#44; demuestra que el tratamiento endovascular es ya un 28&#37; m&#225;s caro que el quir&#250;rgico sin incluir seguimiento ni retratamientos&#44; y lo es especialmente en pacientes menores de 60 a&#241;os&#44; aneurismas de circulaci&#243;n anterior y de tama&#241;o superior a 7 mm&#46; Si al ahorro econ&#243;mico sumamos que los resultados cl&#237;nicos del tratamiento de los aneurismas en este subgrupo poblacional son en general mejores&#44; existir&#237;an criterios de peso para indicar la cirug&#237;a en lugar de tratamiento endovascular&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">De la serie actual se pueden deducir las siguientes conclusiones&#58; <span class="elsevierStyleItalic">1&#41;</span> los resultados cl&#237;nicos de una y otra t&#233;cnica son comparables&#59; <span class="elsevierStyleItalic">2&#41;</span> los resultados angiogr&#225;ficos son superiores con el pinzamiento quir&#250;rgico&#59; <span class="elsevierStyleItalic">3&#41;</span> la estabilidad del tratamiento es mayor en los aneurismas pinzados&#59; <span class="elsevierStyleItalic">4&#41;</span> los retratamientos son m&#225;s frecuentes en los aneurismas de circulaci&#243;n anterior y en los de mayor tama&#241;o&#59; <span class="elsevierStyleItalic">5&#41;</span> la estancia hospitalaria es mayor con el tratamiento quir&#250;rgico pero el gasto que genera la embolizaci&#243;n compensa el ahorro en hospitalizaci&#243;n&#44; y <span class="elsevierStyleItalic">6&#41;</span> el coste del procedimiento endovascular es m&#225;s caro que el quir&#250;rgico ya al alta &#40;un 14&#37; superior debido al precio de los materiales de embolizaci&#243;n&#41;&#44; y de forma m&#225;s notable con el transcurso del tiempo&#44; debido a los costes derivados del seguimiento y los retratamientos que suelen requerir &#40;un 61&#37; m&#225;s caro finalmente&#41;&#46; Estos resultados se ven corroborados por la mayor&#237;a de los trabajos publicados&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">En aneurismas incidentales grandes de circulaci&#243;n anterior en pacientes j&#243;venes que precisan ser tratados&#44; la cirug&#237;a deber&#237;a ser la primera opci&#243;n debido a los buenos resultados cl&#237;nicos y angiogr&#225;ficos que suelen obtenerse&#44; y al ahorro generado&#46; No obstante&#44; es preciso se&#241;alar que dicho tratamiento deber&#237;a ser llevado a cabo por neurocirujanos experimentados y en centros de alto volumen&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">La serie presentada tiene limitaciones&#46; La primera es que se trata de una serie corta&#46; La segunda es que es un estudio retrospectivo y las estimaciones del gasto se han realizado utilizando diversas fuentes y en ocasiones m&#233;todos indirectos&#46; La tercera es que no eval&#250;a las diferencias que pudieran existir entre uno y otro tratamiento en cuanto a tasa de reincorporaci&#243;n laboral&#44; el llamado lucro cesante&#44; que podr&#237;a influir en el ahorro generado por una u otra t&#233;cnica y que seg&#250;n alg&#250;n estudio ser&#237;a favorable al tratamiento endovascular<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a>&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusiones</span><p id="par0145" class="elsevierStylePara elsevierViewall">En la serie presentada&#44; los resultados en cuanto a morbimortalidad obtenidos mediante tratamiento quir&#250;rgico o embolizador son similares&#44; siendo los resultados angiogr&#225;ficos y de estabilidad del tratamiento quir&#250;rgico superiores al endovascular&#44; con mayores tasas de oclusi&#243;n completa y menor necesidad de retratamiento&#46; Aunque el tratamiento endovascular tiene una menor estancia hospitalaria que el quir&#250;rgico&#44; el gasto medio total es sensiblemente mayor debido sobre todo al precio de los materiales de embolizaci&#243;n&#44; a la tasa de retratamientos y al seguimiento que precisan&#46; Una adecuada selecci&#243;n de los pacientes candidatos a tratamiento endovascular o quir&#250;rgico podr&#237;a mejorar los resultados angiogr&#225;ficos&#44; la tasa de retratamientos y ahorrar costes sin modificar las tasas de morbimortalidad&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicto de intereses</span><p id="par0150" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "palabras" => array:4 [
            0 => "Subarachnoid hemorrhage"
            1 => "Cost effectiveness"
            2 => "Coil"
            3 => "Brain aneurysm"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objetivo</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluar los resultados cl&#237;nicos y angiogr&#225;ficos&#44; as&#237; como los costes del tratamiento quir&#250;rgico frente al endovascular&#44; en el tratamiento de los aneurismas incidentales&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material y m&#233;todos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de una serie consecutiva de 89 pacientes de un solo centro tratados endovascularmente &#40;EV&#41; y quir&#250;rgicamente &#40;SC&#41;&#46; Se realiza estudio descriptivo de aspectos demogr&#225;ficos &#40;edad&#44; sexo&#41; y de las caracter&#237;sticas de los aneurismas as&#237; como se eval&#250;an resultados cl&#237;nicos &#40;GOS a 6 meses&#41;&#44; angiogr&#225;ficos &#40;grado de oclusi&#243;n&#41; y de costes econ&#243;micos tanto globalmente como de cada uno de los grupos&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ochenta y nueve pacientes tratados entre 2010 y 2015&#46; Un 74&#37; de los pacientes recibieron tratamiento endovascular y un 26&#37; quir&#250;rgico&#46; No hubo diferencias significativas en cuanto a edad o sexo entre los grupos EV y SC&#46; Un 89&#37; de los pacientes presentaron GOS a los 6 meses favorable &#40;4-5&#41;&#44; sin diferencias entre ambos grupos&#46; La oclusi&#243;n completa del aneurisma fue mayor en el grupo SC &#40;96&#37; versus 55&#37;&#41;&#44; as&#237; como la estabilidad del tratamiento &#40;24&#37; de retratamientos en el grupo EV versus 0&#37; en el grupo SC&#41;&#46; Los retratamientos son m&#225;s frecuentes en aneurismas de circulaci&#243;n anterior &#40;27&#37;&#41; y de mayor tama&#241;o &#40;un 38&#44;5&#37; de los mayores de 10 mm&#41;&#46; El gasto en el grupo SC viene derivado fundamentalmente de la estancia hospitalaria en tanto que en grupo EV tiene m&#225;s importancia el coste de los materiales de embolizaci&#243;n&#46; Las estancias medias son notablemente superiores en el grupo SC pero el coste medio del primer ingreso es un 14&#37; superior en el grupo EV debido al precio de los materiales de embolizaci&#243;n&#46; El gasto total es notablemente superior en el grupo EV &#40;un 61&#37;&#41; debido a los gastos derivados del seguimiento y de los retratamientos&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los resultados cl&#237;nicos de ambos tipo de tratamiento son comparables&#46; El grado de oclusi&#243;n aneurism&#225;tica del grupo SC es superior al del EV&#44; as&#237; como la estabilidad del tratamiento&#44; precisando menos retratamientos&#46; A pesar de que el tratamiento quir&#250;rgico genera estancias m&#225;s largas&#44; los costes del grupo EV son notablemente superiores a los del grupo SC debido al precio de los materiales de embolizaci&#243;n&#44; el seguimiento que precisan y la tasa de retratamientos&#46; Una adecuada selecci&#243;n de los casos candidatos a coiling o pinzamiento podr&#237;a mejorar los resultados angiogr&#225;ficos&#44; reducir la tasa de retratamientos y ahorrar costes&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly &#40;EV&#41; and surgically &#40;SC&#41;&#46; A descriptive study of demographic &#40;age&#44; sex&#41; charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out&#46; Clinical results &#40;GOS at 6 months&#41;&#44; angiographic data &#40;occlusion classification&#41; and economic costs have been evaluated in both globally&#44; and in each of the groups&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">89 patients treated between 2010 and 2015 were reviewed&#46; Most of them were treated endovascularly &#40;74&#37;&#41;&#46; There were no statiscally significant differences between EV and SC groups&#46; 89&#37; of the patients presented favourable GOS &#40;4-5&#41; at six months&#44; being this percentage similar in both groups&#46; Complete occlusion was much higher in SC group &#40;96&#37;&#41; than in EV &#40;55&#37;&#41;&#46; Retreatment rate was 24&#37; in EV group and 0&#37; in SC group&#46; The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms &#40;&#62; 10 mm&#41;&#46; The expenses in the SC group come mainly from hospital stay&#44; meanwhile in the EV group is due to embolisation materials&#46; The average length of stay &#40;ALOS&#41; are higher in SC group but costs of first admission are higher in EV group &#40;14&#37; more&#41;&#46; When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical &#40;61&#37; more expensive&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">results of both types of treatment are comparable&#46; The grade of aneurysmal occlusion of the SC group was higher than the EV&#44; as well as the stability of the treatment&#44; requiring fewer retreatments&#46; Althoug the ALOS in SC group were longer&#44; the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials&#44; follow up that they need and the rate of retreatment&#46; Adequate selection of candidates for endovascular coiling could improve angiographic outcomes&#44; reduce retraction rates&#44; and save costs&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objective"
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            "identificador" => "abst0030"
            "titulo" => "Material and methods"
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            "identificador" => "abst0035"
            "titulo" => "Results"
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            "identificador" => "abst0040"
            "titulo" => "Conclusions"
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          "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribuci&#243;n del coste de los materiales endovasculares&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#205;tem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Precio &#40;&#8364;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&#237;a UCI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&#237;a planta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">650&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Craneotom&#237;a<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;600&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Embolizaci&#243;n<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angiograf&#237;a cerebral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">700&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Angio-RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">600&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pinza&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">900&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cat&#233;ter gu&#237;a&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bal&#243;n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;300&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diversos flujo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            ]
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              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Embolizaci&#243;n incluye los gastos de la arteriograf&#237;a&#44; la anestesia y los recursos humanos&#46;</p>"
            ]
          ]
        ]
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          "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Gu&#237;a de costes</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Edad</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#44;5 &#40;22-75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#44;5 &#40;22-75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54 &#40;34-70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sexo &#40;M&#59; H&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#59; 4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#59; 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#59; 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Seguimiento &#40;meses&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;7-72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38 &#40;7-72&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32 &#40;6-67&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Localizaci&#243;n aneurisma</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Circ&#46; ant&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">88&#44;8&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Circ&#46; post&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;2&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#160;&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Tama&#241;o</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#60; 5 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5-10 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62; 10 mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas y angiogr&#225;ficas de la serie</p>"
        ]
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ACA&#58; cerebral anterior&#59; ACS&#58; cerebelosa superior&#59; ACM&#58; arteria cerebral media&#59; ACP&#58; cerebral posterior&#59; AICA&#58; cerebelosa anteroinferior&#59; ChoA&#58; coroidea anterior&#59; CI&#58; car&#243;tida interna&#59; CoA&#58; comunicante anterior&#59; CoP&#58; comunicante posterior&#59; MCA&#58; cerebral media&#59; PICA&#58; cerebelosa posteroinferior&#59; VB&#58; vertebrobasilar&#59;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CoP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CoA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ChoA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Circulaci&#243;n posterior</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>VB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PICA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Localizaci&#243;n de los aneurismas</p>"
        ]
      ]
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Tot&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Estancia media &#40;d&#237;as&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">GOS 6 meses</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Angiograf&#237;a</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Oclusi&#243;n completa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Resto cuello&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        ]
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Estudio&#44; a&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">n casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mortalidad &#40;&#37;&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Morbilidad &#40;&#37;&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">King<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; 1994<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">733&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Johnston<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">40</span></a>&#44; 1999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;412&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Raymakers<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#44; 1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;460&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Barker<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; 2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;929&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ISUIA<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#44; 2003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;368&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lanterna<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#44; 2004<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;379&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Higashida<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; 2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;535&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#44;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#44;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pierot<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; 2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alskhlee<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#44; 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;738&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brinjikii<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#44; 2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;940&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">McDonald<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#44; 2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;899&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#44;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kotowski<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#44; 2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;845&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duan<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#44;3<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ruan<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&#44; 2015<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;135&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zweifel<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#44;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#44;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Estudio actual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Morbilidad a los 2 meses&#46; La morbilidad inicial fue de 18&#44;8&#37; en SC y 9&#44;8&#37; en EV&#46;</p>"
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">EV&#58; endovascular&#59; incr&#58; incremento&#59; R&#58; aneurisma roto&#59; Retto&#58; retraimiento&#59; Seguim&#46;&#58; seguimiento&#59; SC&#58; quir&#250;rgico&#59; UR&#58; aneurisma no roto&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Autor&#44; a&#241;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">N&#46;&#176; casos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Tipo aneurisma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">M&#225;s caro&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; incr&#46; coste&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Seguim&#46; incluido&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Retto&#46; incluido&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Halkes<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">33</span></a>&#44; 2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R y UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hoh<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">34</span></a>&#44; 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">565&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R y UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#37;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hoh<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">35</span></a>&#44; 2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;347&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R y UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#37;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lad<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">38</span></a>&#44; 2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;504&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#37;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duan<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">39</span></a>&#44; 2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kim<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">36</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">410&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Familiarli<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">32</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">153&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zweifel<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>&#44; 2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">209&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">114&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chang<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">37</span></a>&#44; 2016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Estudio actual&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">UR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                      "titulo" => "Prevalence of unruptured intracranial aneurysms&#44; with emphasis on sex&#44; age&#44; comorbidity&#44; country and time period&#58; a systematic review and meta-analysis"
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                        0 => array:2 [
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                          "autores" => array:4 [
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                      "doi" => "10.1016/S1474-4422(11)70109-0"
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                          "etal" => true
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                          "etal" => false
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                            0 => "N&#46; Andaluz"
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                      "titulo" => "Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms&#58; The cerebral aneurysm rerupture after treatment &#40;CARAT&#41; study"
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                            3 => "M&#46;T&#46; Lawton"
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                            5 => "D&#46;R&#46; Gress"
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                      "titulo" => "Guglielmi detachable coil embolization of cerebral aneurysms&#58; 11 years&#8217; experience"
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                      "doi" => "10.3171/jns.2003.98.5.0959"
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                      "titulo" => "Sixteen-year single-surgeon experience with coil embolization for ruptured intracranial aneurysms&#58; Recurrence rates and incidence of late rebleeding&#46; clinical article"
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                          "autores" => array:4 [
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                      "titulo" => "Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment"
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
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                            3 => "N&#46; Ramzi"
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                      "titulo" => "Risk of recurrent subarachnoid haemorrhage&#44; death&#44; or dependence and standardised mortality ratios after clipping or coiling of an intracranial aneurysm in the international subarachnoid aneurysm trial &#40;ISAT&#41;&#58; Long-term follow-up"
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                            4 => "J&#46; Yarnold"
                            5 => "M&#46; Sneade"
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                        "paginaInicial" => "427"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Sluzewski"
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                            2 => "G&#46;N&#46; Beute"
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                  ]
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            11 => array:3 [
              "identificador" => "bib0060"
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Vol. 29. Núm. 6.
Páginas 267-274 (noviembre - diciembre 2018)
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Vol. 29. Núm. 6.
Páginas 267-274 (noviembre - diciembre 2018)
Investigación clínica
Resultados clínicos y de costes del tratamiento endovascular frente al quirúrgico en aneurismas incidentales
Clinical results and costs of endovascular treatment in comparison with surgery in non ruptured aneurysms
Visitas
82
Angel Horcajadas
Autor para correspondencia
angel.horcajadas@gmail.com

Autor para correspondencia.
, Isabel Ortiz, Ana M. Jorques, Majed J. Katati
Neurocirugía, Hospital Virgen de las Nieves, Granada, España
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Estadísticas
Figuras (2)
Tablas (6)
Tabla 1. Guía de costes
Tabla 2. Características clínicas y angiográficas de la serie
Tabla 3. Localización de los aneurismas
Tabla 4. Resultados estancia media, clínicos y angiográficos
Tabla 5. Morbimortalidad del tratamiento de los aneurismas incidentales
Tabla 6. Resumen de los trabajos publicados sobre costes del tratamiento de aneurismas incidentales
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Resumen
Objetivo

Evaluar los resultados clínicos y angiográficos, así como los costes del tratamiento quirúrgico frente al endovascular, en el tratamiento de los aneurismas incidentales.

Material y métodos

Estudio retrospectivo de una serie consecutiva de 89 pacientes de un solo centro tratados endovascularmente (EV) y quirúrgicamente (SC). Se realiza estudio descriptivo de aspectos demográficos (edad, sexo) y de las características de los aneurismas así como se evalúan resultados clínicos (GOS a 6 meses), angiográficos (grado de oclusión) y de costes económicos tanto globalmente como de cada uno de los grupos.

Resultados

Ochenta y nueve pacientes tratados entre 2010 y 2015. Un 74% de los pacientes recibieron tratamiento endovascular y un 26% quirúrgico. No hubo diferencias significativas en cuanto a edad o sexo entre los grupos EV y SC. Un 89% de los pacientes presentaron GOS a los 6 meses favorable (4-5), sin diferencias entre ambos grupos. La oclusión completa del aneurisma fue mayor en el grupo SC (96% versus 55%), así como la estabilidad del tratamiento (24% de retratamientos en el grupo EV versus 0% en el grupo SC). Los retratamientos son más frecuentes en aneurismas de circulación anterior (27%) y de mayor tamaño (un 38,5% de los mayores de 10 mm). El gasto en el grupo SC viene derivado fundamentalmente de la estancia hospitalaria en tanto que en grupo EV tiene más importancia el coste de los materiales de embolización. Las estancias medias son notablemente superiores en el grupo SC pero el coste medio del primer ingreso es un 14% superior en el grupo EV debido al precio de los materiales de embolización. El gasto total es notablemente superior en el grupo EV (un 61%) debido a los gastos derivados del seguimiento y de los retratamientos.

Conclusiones

Los resultados clínicos de ambos tipo de tratamiento son comparables. El grado de oclusión aneurismática del grupo SC es superior al del EV, así como la estabilidad del tratamiento, precisando menos retratamientos. A pesar de que el tratamiento quirúrgico genera estancias más largas, los costes del grupo EV son notablemente superiores a los del grupo SC debido al precio de los materiales de embolización, el seguimiento que precisan y la tasa de retratamientos. Una adecuada selección de los casos candidatos a coiling o pinzamiento podría mejorar los resultados angiográficos, reducir la tasa de retratamientos y ahorrar costes.

Palabras clave:
Hemorragia subaracnoidea
Efectividad-coste
Coil
Aneurisma cerebral
Abstract
Objective

to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms.

Material and methods

retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups.

Results

89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive).

Conclusions

results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs.

Keywords:
Subarachnoid hemorrhage
Cost effectiveness
Coil
Brain aneurysm

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