January 05, 2016
This is an interesting case, involving clip ligation of a large fusiform MCA aneurysm. This is a 51 year-old female presented with an incidental 1.5 centimeter, and right-sided aneurysm incorporating the lumen of the distal M1. Obviously, the perforating vessels have to be carefully protected during handling of this aneurysm intraoperatively. And you can see the absence of a neck. Here's the positioning of the patient. The Sylvian fissure was widely dissected. Here, you can see the distal M1, one of the perforating vessels. There's no neck available. Placing a clip was unsuccessful, across the neck of the aneurysm without significant deflation of the aneurysm, and the proximal temporary clip on M1 was not beneficial in deflating the aneurysm. Therefore, I felt that the aneurysm had to be trapped, and mechanically deflated by puncturing it. A needle was placed into the sack after the aneurysm was completely trapped, using two clips. And the needle was connected to the suction tubing, so that the sack can be completely deflated as you can see here. Now, the perforating vessels are more apparent. These vessels were dissected away from the neck of the aneurysm, and a longer straight clip was used to reconstruct the lumen of M1 as demonstrated here. Here is the advancement of the clip blades, across the perforating vessels. The clip lights were repositioned to assure that the origin of their lenticular straight arteries is intact. Here's the lumen of the vessel, appears to be well-constructed. Here's a fluorescein angiogram, confirms patency of the vessel, and a perforating artery, ICG confirmed seminal findings. And a post-operative angiogram, demonstrated complete exclusion of the aneurysm. Some evidence of the stenosis of the vessel at the level of the clip reconstruction. However, this amount of stenosis did not lead to any limitation and flow distally, and this patient made an excellent recovery without any sequelae. Thank you.
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