ACoA aneurysm: Principles for Clip Ligation
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This video describes the operative principles for a clip ligation of small ACoA aneurysms. This is a 45 year-old female who presented with an incidental six-millimeter ACoA aneurysm. On Angiogram, the aneurism is projecting essentially straight anteriorly. The morphology of the neck relative to the A2 branches is also demonstrated. In this patient, both A2s and both A1s were relatively co-dominant. The aneurysm was approached from a left side due to slight increased dominance of the left A1. This video is one of my older videos where we used fixer tractors. As you can see, the fixer retractor blade is used to gently elevate the posterior sub-frontal area so that the arachnoid bands over the sphenoidal segment of the Sylvian fissure are placed under gentle tension. These arachnoid bands under tension are subsequently dissected. Furthermore, the sub-frontal area is released from the optic apparatus via dissection of the arachnoid bands in the area. The carotid arteries immediately apparent posterially. Gentle elevation of the frontal lobe, identifies the origin of A1. Small part of the gyrus rectus is removed. The artery of Huebner is carefully protected during this maneuver. Now you can see the morphology of the aneurysm better in this area. Here is the Contralateral A2, Ipsilateral A2, Contralateral A1, Ipsilateral A1, and artery of Huebner. The whole complex is apparent with the ACoA, being located there. I placed a temporary clip on the Contralateral A1, since in the case of an intraoperative rupture placement of the temporary clip, contralateral can be more difficult. Straight fenestrae clip was placed across the aneurysm neck while the Ipsilateral A2 was incorporated into the first duration. Here's the artery of Huebner, intraoperative ICG angiogram demonstrated further filling of the aneurysm which I expected since the straight fenestrated clip closed them or this stall section of the neck or the aneurysm. However, the more proximal part of the aneurysm neck joining their Ipsilateral A2 is still failing. The strategy for closure of this part of the neck of the aneurysm would be to use a straight or slightly curved clip to close the proximal neck of aneurysm while the clip is placed just anterior to the ipsilateral A2 intraoperative ICG in this case demonstrated complete exclusion of the endosome disliked filling is related to the initial injection. All the branching vessels are patent arterial of Huebner is healthy and postoperative angiogram demonstrated complete exclusion of aneurysm without any complicating feature. The filling defect located here is related to the shadow of the cliplites. Thank you.
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