Clip ligation of broad-based or potentially fusiform PCoA aneurysms can be quite technically challenging. Let's review the operative events for a 52 year-old female who presented with subarachnoid hemorrhage and a nine millimeter right-sided broad-base p-comm aneurysm. The morphology of the aneurysm is apparent on this 3D CT angiogram image. You can see the very broad neck of the aneurysm and the origin of the PCoA very much incorporated into neck of the aneurysm. The morphology of the aneurysm is also apparent on axial and sagittal source CTA images. Patient underwent a right frontotemporal craniotomy, Sylvian fissure was dissected, you can see ample amount of subarachnoid blood caused by the aneurysm. Here's the proximal ICA for vascular control. The medial wall, the ICA was also dissected so that the lumen of the vessel can be better defined. You can see this aneurysm is quite bulbous and fills the space between the ICA and the optic nerve. Next, it's important to find the origin of the anterior choroidal artery, as well as the PCoA. Here's the anterior carotid artery that is released from the neck of the aneurysm. I elected to use an angled fenestrated clip so I can clip the broad-neck parallel to a long axis of the ICA. I think clipping this broad-neck perpendicular to the ICA is fraught with complications; sub-optimal neck closure and a premature rupture. The initial attempt partially stenosed the ICA, the clip slid toward the lumen of the vessel. I had to reposition the clips slightly so that the lumen is more generous. Here you can see the repositioning technique, the broad-neck of the aneurysm. The clip was angled away from the origin of the PCoA by placing it in an oblique fashion. And a postoperative angiogram demonstrated complete exclusion of the aneurysm, minor amount of stenosis of the ICA, which was not flow-limiting. And the patient made an excellent recovery. Thank you.
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