Large PCoA Aneurysm: Pitfalls for Ligation

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This is another exciting video describing the techniques for clip ligation of large poster communicating artery aneurysms, and more specifically describing the tandem clipping technique. It's a 52 year old female who presented with an incidental aneurysm. You can see the relatively large size of this aneurism, presence of calcium around the carotid artery. Here you can see the morphology of the aneurysm related to a relatively fetal PCoA. Presence of the calcium around the carotid artery signifies the fact that most likely there is fair amount of atherosclerosis at the nick of the aneurysm. A right frontotemporal craniotomy was completed. Sylvian fissure was dissected. Fissure, carotid artery, further opening of the fissure so that the section of the carotid distal to the aneurysm is exposed. Here's carotid artery, most likely origin of choroidal should be in this region. Here we go, relatively large anterior choroidal. A calm MCA. Distal carotid is exposed. Let's go ahead and work around the aneurysm now. Here's the distal part of the aneurism. Here's the proximal part, origin of the PCoA should be here at the nick. Relatively large aneurysm, some atherosclerosis at the neck. Thick walled. I'll go ahead and silicone freshly dissect around the nick. In this thick walled aneurysms, it's critical for the clip blade to be placed parallel to the long axis of the carotid artery. Here's mobilizing the nick from the tentorium. Temporary clip was attempted, but as you can see, the clip is not closing effectively. Go ahead and find the origin of the PCoA. This juncture I'm dissecting the neck from the edge of tentorium. Very adherent there. You can see the PCoA more inferiorly right there or more proximally. The origin is evident here. Here's the distal neck. Relativity good exposure of the neck is available now. Sharp dissection is the best mode of this section. You can see the more poster part of the neck is very readily available for application of the clip. More proximal neck is very well exposed. There shouldn't be any resistance for passage of the clip blades. Dynamic retraction actually provides more space for identification of the structures at the depth of the cavity. Curve clip was used. Again, parallel to the long axis of the carotid, preserving the origin of the PCoA. This clip may be a little bit short, let's see how it sits. Looking at the distal blades right at the tip of my arrow appears that the clip is short. I attempted a longer clip, again preserving the origin of the PCoA there. I like this clip a lot more. I'm all the way across. I knew this aneurysm can potentially continue to fill at least slightly. An ICG can be quite challenging in this thick walled aneurysms to effectively assess the extent of filling. So I went ahead and used the fluorescein video angiogram. Seems like the carotid is filling nicely. Choroidal is filling the aneurism is most likely not filling. However, there was some pulsation within the aneurysm based on micro-doppler ultrasonography. Intraparietal angiogram demonstrated very slight filling within the aneurysm. Most likely this would have thrombosed postoperatively. However, I went ahead and placed a straight fenestrated clip just distal to the initial clip. This is the tandem clipping technique. So the distal blades of the first clip can close more effectively. The aneurysm appears to be now not filling anymore. I'm happy with the following construct. PCoA is filling nicely there. Third nerve is not compromised by the clips or any other manipulation during the operation. And here's the postoperative angiogram demonstrating complete exclusion of the aneurysm. Nice preservation of the fetal PCoA in this case. Postoperative CT demonstrated nowhere there's ischemia, and this patient made an excellent recovery. This video again demonstrates the importance of preserving the origin of the fetal PCoA and application and deployment of the clip blades parallel to the long axis of the carotid artery for thick walled or atherosclerotic aneurysms. And most importantly, using the tandem clipping technique to make sure the aneurism is completely excluded and the surrounding vessels are preserved. Thank you.

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