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Clip Ligation of an Anteroinferiorly Pointing ACoA Aneurysm Using FLOW800

January 03, 2019


This is another video discussing clip ligation of an anteroinferiorly projecting anterior communicating artery aneurysm. This is a relatively young patient who presented with a severe headache, and small amount of subarachnoid hemorrhage. 3D angiography revealed this relatively complex aneurysm with evidence of a blister aneurysm at the level of its neck. The right A1 is dominant in this case. A right-sided frontotemporal craniotomy was completed. I used a piece of rubber dam to move around the subfrontal space, expose the optic nerve. One of my fellows is operating at this time, and, you can see evidence of less magnification. I usually tend to operate at a higher magnification level. However, this amount of magnification can allow a better appreciation of operative maneuvers necessary to open the anterior limb of the sylvian fissure and continue dissection over the optic chiasm. Dynamic retraction is utilized. Carotid artery is exposed. Here's portion of the aneurysm adherent the optic chiasm. Go ahead and move a little bit more posteriorly, follow A1 for proximal control, after the Sylvian fissure is further dissected. Here's proximal A1. One does not need to expose the carotid bifurcation. Now that temporary , proximal control is secured, we can go ahead and dissect the aneurysm. Here's the area anterior to the dome, where the frontal lobe is being mobilized, away from the optic apparatus. Sharp dissection is used. Here's part of the aneurysm, very much embedded within the chiasm. Here's the area of the neck. Here's that blister, that is the area of the neck of the aneurysm. Go ahead and dissect, now above the neck, here's A2 ipsilaterally just underneath my scissors. Here you can see A1, A2 ipsilaterally, A2 contralaterally, the aneurysm neck, some of the perforators to the hypothalamus are apparent, temporary clip was placed, so the aneurysm is deflated, and the neck can be more readily, dissected. Here's the area of the neck that is while discernible, area of the ACoA. We wanna make sure the ACoA is preserved. Sharp dissection is used to adequately mobilize the part of the aneurysm that, may be placed under traction during closure of the clip blades. Anatomy's nicely apparent. You can see that blister that should be incorporated into the area of the aneurysm that are obliterated by the clips. I can see all the way across, to the other side, to the other A2 origin. So we're just about ready to replace the permanent clip. Here's a straight clip, again reconstructing the ACoA, making sure the outlet of the A2s are preserved, using dynamics retraction, Seeing cross the neck of aneurysm, gradually approximating the clip blades. Next, I conducted a Flow 800, or quantitative fluorescence angiography to assist the flow within the arteries, since these arteries appear slightly narrowed by the clip, the clip is really close to the ACoA, and this maneuver was conducted so that the blister aneurysm at the level of the neck was excluded. So rather than a qualitative measure, I'm doing a quantitative flow evaluation using Flow 800. In this case, you can see that the A2 has a nice flow, very much comparable in its map to the color of the A1. Therefore, I'm not compromising the flow within it. Also the ACoA appears nicely patent, the A2 origin also, contains adequate flow. Post-operative Angiogram demonstrated complete exclusion of the aneurysm as demonstrated here. There was no evidence of infarct on post-operative CT, and this patient made an excellent recovery. Thank you.

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