December 05, 2018
This video describes alternative clipping strategies for anterior communicating artery aneurysms that harbor or carry blister aneurysms around their neck. This is a young patient who presented with 12 millimeter ruptured ACoA aneurysm. Preoperative 3D reconstruction angiogram demonstrated multiple blister aneurysms on the neck of the aneurysm, making clip ligation quite challenging, and potentially coiling. Not a very effective strategy. Here in another view you can appreciate these blisters and how close they are to the level of the ACoA. Let's go ahead and review the intraoperative findings. A left frontotemporal craniotomy was conducted, since the left A1 was dominant. Here's the aneurysm. You can see left A1, and here is the A2 branch. Here is the left A2, just close to the suction. I try to use a fenestrated clip to reconstruct the ACoA, but as you can see, I didn't feel that the clip would catch the entire blister formation. And if I bring the clip too much closer to the ACoA, I may have occluded the ACoA. Therefore I use the piece of cotton in order to increase the width of the clip just slightly so that I can preserve the ACoA while removing this blister as you can see at the neck of the aneurysm. Here you can see the gentle motion required to place the clip just at the right location that these blisters at the tip of my arrow, as you can see here, are excluded. Clip repositioning the contralateral A2 is apparent at the tip of the clip. Here is the cotton being manipulated to make sure just the right spot is found. Here you can see a small amount of cotton over the ACoA, so essentially the cotton is bolstering the clip over the ACoA without unnecessarily occluding it. Here you can see all the vessels are patent. Here's the ICG and fluorescein angiography reveals patency of all branching vessels and postoperative angiogram. Again, 3D arteriogram reveals complete exclusion of the blister aneurysms as well as patency of the ACoA without any complicating features. Postoperative CT reveals no complicating features, and this patient recovered very nicely after surgery. Again, this is a nice strategy for clip occluding of blister aneurysms at the neck of the aneurysm, while keeping the parent vessels patent. The cotton essentially covers the dome of the blister aneurysm, and with inflammation and scarring and tamponade over the dome of the aneurysm, decreases the future risk of hemorrhage. Thank you.
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