PCoA Aneurysm: Managing Collateral Vascular Injury

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Let's discuss clip ligation of small ruptured, posterior communicating artery aneurysm, and also review techniques for managing inadvertent collateral arterial injuries during the procedure. This is a 42 year old female who presented with spontaneous subarachnoid hemorrhage. CT angiogram demonstrated small left sided PCoA aneurysm. That was responsible the cause of her hemorrhage. Patient underwent a left sided frontotemporal craniotomy, internal carotid artery, temporary clip on. I see at the level of the skull base. Here's the straight clip, however, during movement of the clip applier, an injury to a branch of the anterior temporal artery was noted. In these situations, I use a piece of cotton to cover the defect on the arterial wall. Tamponade is used using a piece of cottonoid and some patience. These maneuvers usually control the bleeding of the small defects. Ultimately the straight clip was used to close the neck of the aneurysm while preserving the origin of the PCoA. Here, you can see the view of the origin of the PCoA. Here's a magnified view of the operative field. Third nerve. I was pretty satisfied with the result of the clipping. Micro-Doppler ultrasound inspection of the vessel that was inadvertently injured, revealed good flow. Here's a final view of the operative field. And the postoperative angiogram revealed complete exclusion of the aneurysm, without any evidence of ischemia in the temporal lobe. Therefore, the use of cotton soaked in thrombin, can be quite effective in controlling very small defects on the walls of the medium vessels. Suturing can be quite challenging and the holes on the wall of the artery that are created by the sutures, can in fact lead to more bleeding. Thank you.

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