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Large PCoA Aneurysm: Massive Intraop Rupture

February 10, 2016


Let's review some of the technical challenges we face in management of complex and broad base ICA Aneurysms. This is a 62 year old female who presented with acute subarachnoid hemorrhage and was found to harbor a 15 millimeter right-sided posterior communicating artery aneurysm. Imaging demonstrate the broad base of this aneurysm, in addition, calcium was found present along the neck of the aneurysm. The poster communicating artery was noted to be very small. Calcification obviously provides a number of challenges in managing this aneurysm both in obtaining proximal control, in addition, during deployment of the clip lights. Let's go ahead and review these challenges and the management strategies and right-sided frontal temporal craniotomy once completed. The interior limo, of the Sylvian fissure was widely dissected. You can see the neck of the aneurysm, presence of atherosclerosis and calcium along the neck. And the proximal ICA, the anterior coronary artery was dissected along the distal neck and neck was defined as safely as possible. A temporary clip was placed. However, the calcified ICA remained patent. I even attempted a permanent clip and remained unsuccessful in collapsing the ICA. Therefore, proximal control was not available intracranially. I asked my endovascular colleagues to place a balloon within this cervical ICA to provide proximal control and also provide an opportunity for retrograde suction decompression technique. Here's the anterior Choroidal artery around the superior pole of the aneurysm. The midsection of the aneurysm was dissected so that the clip plates can be placed without significant resistance. Due to the broad base of the aneurysm, I placed two or three angled fenestrated clips, the suction decompression techniques was used. You can see the placement of the temporary clip, just distal to the aneurysm. The balloon remained inflated within the cervical ICA and suctioned decompression technique was used to decompress the aneurysm. However, as you will see, in a moment, the balloon did not provide an adequate seal and the suction decompression technique was not very effective. The clips continue to slide toward the lumen of the ICA due to the tense condition of the aneurysm. These clips led to some stenosis within the ICA, as evident on intraoperative angiogram. My next strategy involved penetrating sack with a 25 gauge needle in order to deflate the aneurysm sack. So the clip lights can be applied effectively and do not place the Lumina of the ICA at significant risk. This strategy provided some additional deflation. You can see suction decompression is in progress. The clips were now reapplied. However, as you will see in a moment, the small opening in the sack by the needle is being expanded by a piece of calcium. Just around the area of the opening within the sack here, you can see the piece of calcium broke through the sack and led to torrential bleeding. This seal around the balloon in this cervical ICA was lost, unfortunately at the same time. I remained compost. You can see that I left the clip around the ICA, did not inadvertently pull the clip away leading to injury to the lumen of the ICA. Now the aneurysm is more decompressed. The clips can be applied without any significant stenosis of the ICA, a straight fenestrated clip also closed the more proximal portion of the neck of the aneurysm. Here's the final construct. Postoperative angiogram demonstrated adequate exclusion of the aneurysm without any restriction of flow within the ICA. In addition, postoperative CT excluded any evidence of Ischemia and this patient recovered from her surgery uneventfully. There are two important lessons noted by this experience during this surgery. Number one is presence of calcium on imaging, significantly complicates, securing proximal control, and deployment of the clip blades around the neck of the aneurysm. Therefore contingency plans should be available for both achieving proximal control and placing clips across the neck of the aneurysm. Secondly, surgeon should remain really composed during torrential bleeding. As you can see during the sudden gush of blood, I kept the eclipse blades around the neck of the aneurysm and ICA, I did not blindly move the clip away so that the lumen of the ICA cannot be, or will not be placed at any risk of injury. Large or suction can quickly clear the field and immediately prepared decisive maneuvers can prevent undesirable sequela from the torrential bleeding. Thank you.

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