January 20, 2016
Let's discuss some of the technical nuances for Clip Ligation of Partially Coiled Aneurysms, and also describe the techniques to avoid and manage complications. This is a 62 year old female who underwent partial coiling off her Poster Communicating artery aneurysms associated with a fetal PCA. This case demonstrates why partial coiling of part of the lobe of the aneurysm can actually add significant difficulty and risk to the clipping procedure. And therefore partial coiling with a plan to do clip ligation has to be carefully planned. Preoperative 3D angiogram demonstrates coiling of one of the lobes of the PCoA aneurysm. You can see the origin of the fetal PCoA from the neck of aneurysm. The live loop of the aneurysm is located slightly more laterally. She underwent a left frontotemporal craniotomy. The Sylvian fissure was widely dissected. The ICA was exposed at the level of the skull base and was noted to be highly atherosclerotic. Here you can see the ICA, some of the perforating vessels were carefully dissected. The anterior collateral artery was protected. Here's the distal neck of the aneurysm, the dome of the aneurysm that is live. Despite placement of a temporary clip at the level of the ICA at the skull base, the aneurism remained very tense. I attempted to place a temporary clip on the PCoA, which was fetal, but this maneuver was not very beneficial. Next I gently attempted to mobilize the neck of the coil aneurysm to create more space for placement of the fenestrated clip. Obviously the neck of the aneurism should not be significantly manipulated as the domes and any traction on them can lead to a neck tear. In this case, I selected a fenestrated clip to close the residual portion of the aneurysm while placing the coiled lobe of the aneurysm within the fenestration. Obviously the origin of the fetal PCoA has to be protected and the third nerve should not be placed at risk. The first set of clip blades were gently approximated. The origin of the PCoA appears intact. Intraoperative angiography demonstrated, continued filling of the aneurysm. I suspected that the clip blades are not closing effectively. Therefore, a second fenestrated clip was placed just distal to the first one. And the third nerve was inspected to make sure it remains intact. The second intraoperative angiogram demonstrated complete exclusion of the aneurysm with with patency of the origin of the PCA. Therefore in partially coiled aneurysms more innovative and creative ways are necessary to exclude the live portion of the aneurysm, but the best strategies to plan ahead of time and avoid partial coiling of the aneurysms as these coils can significantly complicate placement of the clip during the microsurgical procedure. Thank you.
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