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Decision Making for Endovascular versus Microsurgical Treatment of Aneurysms

Jan Burkhardt

July 26, 2021


- Ladies and gentlemen, thank you for joining us for another session of the Virtual Operating Room, our guest today's Dr. Jon Burkhardt from UPenn. He's an endovascular and open neurosurgeon. Today, he's going to talk to us about decision-making process for managing aneurysms via endovascular versus open clipping routes. This is obviously something very complicated and very dynamic topic, but an extremely important one. And I'm so honored Jon to have you today, and I'm very much looking forward to hearing about your perspective and learning from you. So with that, let's go ahead and jump it.

- Thank you so much. Thank you so much for having me. It's a, great honor to present here in The Neurosurgical Atlas Virtual OR sessions. And I really enjoyed watching the previous speakers and it's great discussion. My subject today is talking about decision-making for endovascular and microsurgical treatment of aneurysms. And it's a pretty broad spectrum of, aspects we can discuss. And I want to first focus a little bit about introduction, what is known in the literature about decision-making and also about trans and aneurysm treatment. And then I'm on a follow with some aneurysm treatment examples. How I approach these patients and how I come up to a decision if I want to treat them open or endovascular. First of all, I want to mention that open microsurgical and endovascular treatment are going hand in hand, and it's really important to understand that both techniques are helping each other and it's not either or so for me, they are really a combination. And if you look back into history, you can really see that open microsurgical techniques for vascular. As you can see here, the first clipping from Walter Dandy in 1938 and also introduction of microscope from Dr.Yasargil And also the introduction of bypasses into vascular neurosurgery went then hand in hand with also the new upcoming endovascular techniques starting in the '90s. But also go hand in hand with diagnostic imaging modalities, like the introduction of angiogram, CT MRI. and then also just recently the introduction of IC-Green and flouricine into the ORs as well as an exo scope. So all of these techniques go hand in hand and they are not exclusively either or. In the first, in the next upcoming slides. I want to talk a little bit about trends and my research fellow Mohammed's Salem helped me with these slides. And you can see here just an overview and you can see it starting in the 2000s there was a trend now when coiling was introduced into treating aneurysms, that most of the aneurysms were then treated with coiling or increasingly with coiling. And the curve came down a little bit on the clipping in these early results, in this study. In this trends where, these authors looked into a pre and post ISAT, you can see also in patients that for ruptured and unruptured aneurysms, the coiling increased compared to pre and post 2002. The same applies to the discharges of hospitals. And also you can see here how the increase of endovascular took place starting in 2000 and 1999. And the clipping volume stayed pretty much similar for this charges and the overall costs increased for both open and endovascular. And here, this is a more updated studies of ruptured aneurysm between 2004 and 2014. You can see that continuing the endovascular therapy over the last couple of years and the decreasing of open microsurgical clipping for ruptured aneurysms. Interestingly, if you look at unruptured aneurysms, the curve is pretty stable since 2004 The clipping of aneurysms and the endovascular increased, but fluid plateaued over the last couple of years as well. Interesting on this slide is that the diagnosis of an aneurysm is increasing over time. As you can see here on the left, but the treatment stayed kind of stable. So that kind of shows us that probably the imaging modality innovation increased and the sensitivity of MRI really showed us that we can now find more aneurysms in screening, but it doesn't lead to more treatment of patients. Here, this is another summary of treated aneurysms by modality, and you can see that endovascular treatment became more dominant for unruptured aneurysms around 2004. And for ruptured aneurysms in 2006. Here, this graph shows the outcome of patients treated either with endovascular or open microsurgical treatment. And you can see that the outcome mobility and mortality is more favorable with endovascular treatment. Than open microsurgical, clipping over time for unruptured aneurysms, which also makes sense since most of the microsurgical clipped entrances are more challenging aneurysms and they're referred most likely to surgery and explained most likely the trend for better outcomes for endovascular. The same applies to ruptured aneurysms. As you can see in this graph. Thus these changes affect our training for our residents? Obviously it does. And as you can see here, this was really nice study looking at trends and exposure for residents for clipping and endovascular treatment. And you can really see that clip aneurysms are less common nowadays and really declining for residents over time. But on the other side, endovascular treatment is increasing over time. And that is also interesting to keep in mind. And you should make sure that if you go into vascular neurosurgery, that fellowship training after residency is a very important thing. And so for me, although I was trained in a very busy open vascular program in Zurich, in Switzerland, in the hospital actually it was professor for a long time. I decided to do an open vascular fellowship at UCSF with Michael Lawton, just to also make sure that very, open complex treatment that I'm well-trained in, especially in bypass and ADM and complex aneurysm surgery. And then also I spent another year for an endovascular fellowship at NYU to be really up to date with the most common endovascular treatment modalities. This is a very nice slide, which Christopher shared with me. This is a very, shows kind of like our thinking nowadays, the debate between clipping and coiling and what patients should be clipped and coiled. But what I want to show over the next remaining talk is how to challenge this graph and how it changed over the last couple of years. And it's also, you have to keep in mind that it's not only clipping and coiling. That's just the tip of the iceberg because we have so many different options in, especially in endovascular with flow diverter, intracellular devices, stent coiling, balloon coiling, and other upcoming newer devices. And also for open microsurgery is not only necessary clipping. You can do trapping, you can do complex clip occlusions depending on the situation. This is a study which looked actually into this decision-making and trained neurosurgeon from And you can see here his thinking of how to treat aneurysms open versus endovascular. And you can see that over time his the larger aneurysms he treated were endovascular. And if you look at the location, you can see that ICA aneurysms are more treated endovascular in his practice and MCA more open as expected. And that kind of echoes also this graph, which is a very interesting collaboration we built up in Switzerland. So we have, in Switzerland, it's a very small country, and there are only a few hospitals treating patients with subarachnoid hemorrhages. So we have this prospective database of all SAH patients in Switzerland, where I was PI when I was in Zurich. And so here this, in this study, we, we looked at different treatment modalities and incidents in Switzerland. And you can see based on location that most of the aneurysms in the basilar artery and posterior circulation and ICA were nowadays treated endovascular and microsurgically MCA and distal ACA. And then there are areas around the anterior cerebral artery, ACOMM complex, and also PICA were both treatment modalities were used. Okay, let me go now to switch gears to treatment examples. And here, I want to go back to this graph and I'm going to use that graph now for the remaining talk. I want to start with the posterior circulation when I have a red circle, that means it means I want, I'm going to challenge the thinking that endovascular treatment should be applied for posterior circulation. If it's a green circle, I'm presenting an example of which goes along with this treatment modality. Yeah, this is a interesting patient. She's 47 year old, she's neuro intact, this an incidental findings which led to a diagnostic angiogram. And there are two findings, one ICA Terminus, or A1 aneurysm. As you can see here irregular shape around 4 to 4.5 millimeters, and then a very small list of like aneurysm at the basal apex as you can see here. Around two millimeter 1.5 to 2 millimeter aneurysm. If you look at the classic, some unruptured aneurysms, if you look at the classic scores, how to predict potential hemorrhage, and there's one score, which is called PHASES score, most of us are familiar with this. You can see that the risk of the ICA aneurysm and the basal aneurysm are fairly low over the next five years. But there are different factors, she was a previous smoker, has a family history and has multiple aneurysms which are not captured by the PHASES score. And I want to introduce also this score, which I really like, but it's not very practical in your practice because it includes a lot of factors. But the advantage of this score is that it includes factors, both favoring treatment, which was on the left side and favor favoring conservative treatment. And then you summarize all these factors. And if the number is larger here on that side, that would favor treatment overall. And you can see on this score, both aneurysms actually favor treatment. And the patient also would like to proceed with treatment. So my decision making here was she has two aneurysms. The ICA Terminus aneurysm is more irregular and larger. So you could argue with two treatment strategies here. You could say, I just focus on the ICA Terminus aneurysm. You could either clip or coil aneurysm and observe the basal aneurysm. On the other hand, the basal aneurysm looks fairly nasty. It's a blister aneurysm. And I don't think there's a good endovascular option for this basal aneurysm. You could do flow diversion but she doesn't have any PCOM. So you will jail one of the PCA segments, so and coiling or stand assistant coiling. It's too small for this, you could try, but in this really specific situation, I decided to, offer an open approach to clip the ICA Terminus aneurysm. And also since we're, it's on the right side, which would be a favorite approach also for the baseline apex to inspect and possibly also clip this aneurysm on the baseline apex. So here the strategy was to do an orbitozygomatic craniotomy Sylvian fissure split, and then in a first step clipping the ICA Terminus aneurysm. Usually I clip when I cut multiple aneurysms first the one which is at the bottom, and then go up, but here, since it's a different triangle for approach, I decided first to do the ICF Terminus aneurysm, and then open up the carotid-occulomotor triangle exposure to the basilar vascular apex with possible posterior clinoid process removal for control, and then clipping off the end result. So let me show you this video. So this is a classic Terryana approach, a little bit longer, the incision, as you can see here, radio loosened headframes I always do an intraoperative angio 2D and 3D. I usually use a sub facial dissection for an overdramatic approach. But interfacial will be also fine. If you can see the first overview picture with a zygoma exposed and the temporalis muscle. I like to use it two-piece full OZ for basilar apex aneurysms. And here you can see a first pterional craniotomy. And then I do the craniectomy orbitotomy similar to Lawton in these steps with the seven cups, as you can see here. And I leave a little bit more sphenoid bone for cup five and six, as you can see are illustrated in a seven aneurysm book. After that, after the two pieces done, I usually take up a little bit of the orbital fat, as you can see here, especially if when you a little injury, just to make sure that it's very flat when you bring up the dura. This is now after I opened the dura you can see the sylvian fissure. And then as with any case, I first go down to open up the arachnoid over the optic nerve. As you can see here, I like to use a sharp dissection as you can see here, I'm opening up the arachnoid over the optic nerve. Under my section on the left, you can see olfactory nerve here and then the frontal lobe. And then I've worked my way back more lateral towards the carotid artery opening up the arachnoid here. The beauty of these scissors is they're coming, they're either Kamiyama scissors or also the scissors from Lawton, which I'm using here that you can dissect and cut at the same time. So you can use it a little bit of dissection, and then dissect. You saw, I was just over the third nerve, and then in the next step I split the sylvian fissure. I skipped that for the sake of time in this video, and now I'm exposing the ICA Terminus, or basically the A1 aneurysm here. You can see there's a large perforator on that side, but you have to preserve. And now looking more lateral along the carotid artery, you see the anticorodal artery and also the a little bit for the proximal. Since for the approach to the basilar apex, you need to dissect this area as well. So that's why I'm exposing here already. And just to make sure for the clip blades for the other aneurysms that I'm not reaching towards that direction. Here the final dissection before clipping to make sure you have really all the perforator moved away. I use a retractor sometimes if, especially in the situation after I split the fisher. Here, I decided to do temporary clipping and I used a curved clip, mini clip looking up and slowly bringing the clip over the aneurysm. I like non-locking clip appliers just that I can really move the clip up close it and open in the situation as needed. Here we're moving the temporary clip and I'll find that section to make sure the clip is not caught in any perforator, as you can see here and here we could even see the clip leads closing on the other side. And here I'm using the fluorescein yellow 560, because I just use the IC-Green right before. And then sometimes the signal is too weak for another IC-green, but actually fluorescein is really good for the small perforator. As you can see here, they're all open intermedially this was the larger perforator, as you remember, it's also open here. So first aneurysm is clipped so now we're going back to the third nerve. As you can see here, running along the tent and loosening up the temporal lobe from the nerve and I'll slowly walk in my way back, opening up the Liliequist membrane, walking along the posterior communicating artery, going down towards the P1, P2 junction here, more arachnoid, more Liliequist membrane. Can see some blood run down into the vascular apex here. Here are some more steps going further back. And it's also good to really open up the arachnoid along the anterior choroidal to really open up this triangle all the way. Sometimes also useful to really mobilize the temporal lobe in the front here in the situation that was not needed. And this is the overview see, here now, looking over the third nerve on the other side, the SCA and contralateral PCA. And here already the aneurysm comes into view, as you can see here. So now you look to the other side here and then divide structure here. Here you can see is the posterior choroid process, pretty close to to the apex. And here are more lateral, you see the ipsilateral SCA and PCA. So I decided to remove a little bit of the PCA just to allow a possible temporary clipping of the base-level Apex. And so I'm I'm using a knife to open that with an 11 blade, and then I use a diamond drill here. It's a three millimeter diamond drill just to drill, drill this clinoid. It's very important, especially for the residents who are watching. If you stop, don't move the drill before it completely stops because it still, when you get off the paddle, it sometimes still moves. So you want to really make sure you hold still before you move up, especially when you, drill between the carotid artery and these deeper structures. I obviously use fibrin glue for for bleeding in the anterior or posterior kind of processes as you can see here. And this is the final dissection. I'm just testing a temporary clip here, possibly between the SCA and PCA. But here in this situation, I decided to to not use temporary clipping. You can really see the, nasty looking aneurysm final dissection, it was actually a pressure on a vessel coming off, like right there behind the aneurysm. So I'm want to make sure that this is really dissected off here with a rotor on 60 dissector. final dissection before the clip application. And now here I decided to a curve mini clip, opening up the clip blades and, slowly taking my time to, really make sure that the clip laid on the top is really sliding under the aneurysm neck and it's not compromising this perforator and then slowly closing the clip over the aneurysm. So that concludes the clipping. The perforator is open. So now I'm using, I think I'm going to do another IC-Green here, just to make sure that everything looks open. First you see the filling of the carotid on the top, and then on the bottom you see the basilar and the most important thing is to make sure the perforator is open here. That's the final picture of the two clips and that's the final view for the Slyvian Fissure. Okay. So I also did an intraoperative angiogram, as you can see here, the choroidgram shows a complete occlusion of the 3D and 2D angiogram, and as well as the Basiler artery complete occlusion. I also want to quickly show you a video, they're integrated videos, I think I can play them. But so she had right after surgery because of the approach. She had a ptosis and had a significant swelling, but I actually saw her back on the floor. She's a nurse in our hospital and she fully recovered and has no issues with the eye in all six months post-op. So let me show you another aneurysm in the posterior circulation, which is more amendable for endovascular. This is a 41 year old female patient. She presented with headaches and migraines, and over a couple of years already, and the migraine got worse over the last couple of months. So she got an MRI, and they found this lesion here, potentially in the bag basil of apex, this aneurysm. And then the angiogram actually showed fusiform aneurysm in about 14 to 15 millimeters in the P1, P2 segment on the left side. Here I think just looking at this, I don't think there's a good surgical option for this, just knowing the endovascular options we have nowadays. Because this is really a good case for a flow diverter in this short segment for a small flow diverter and due to the size I decided. So my plan was to place a flow diverter and add some coils in the aneurysm. And let me show you the second video For the posterior circulation aneurysms we nowadays most likely go from radio. So there's the radio access with the sheet. And then I just use the single intermediate catheter. That's a Sofia catheter and then two microcatheter for the, flow diverter and the coil. So this is the micro, this is the Sophia tip here, and the subclavian artery. And you can see how I navigate easily now, very favorable anatomy into the vertebral artery all the way up. And you can either place this in the V3 segment or here in the B3 four segment junction. And then based from here, you have already a pretty good access to the aneurysm. This actually a previous one because my catheter is already up here. Off the aneurysm, and you can see how slowly actually the PCA is filling because all the contrast is taken up by the aneurysm. And then, so the most challenging thing here is really to cross the aneurysm, to get out into the PCA with your wire. And it took me quite a while. And sometimes you have to do tricks where you loop through the aneurysm, but here at some point, I got the wire all the way out and the microcatheter to be ready for, the flow diverter. As you can see here, the tip of the microcatheter, what do you have to keep in mind is when you place a flow diverter you can't cross the flow diverter leader, so you have to jail another catheter in the aneurysm before you deploy the device. You can see here and I'm starting deploying the flow diverter. Here in this situation, I used the Fred Jr which is just a small, a smaller diameter catheter in space stable. And you can place it very precisely and especially the smaller vessels. And you see, my other tip of the catheter is in the aneurysm. So because after I deployed the device, I want to make sure that I can still call the aneurysm Here the most challenging thing is to really land the device. I don't want to jail the other sites. I really want to land in the P1 segment with the Fred. And so that's what I'm going to do here, just to make sure that that I'm good and I don't have to reposition the device. This is a different angle. It's more lateral without roadmaps, just the native to show you how the device opens. And the float over the device, the combination has a standard portion, which you usually see here and a float overloading portion. So now the device is deployed. So you can see here with your catheter still in the aneurysm. And then you're ready to place coils. I was starting with like one large coil just to fill and decrease a little bit the flow and also help thrombosing with the aneurysm early on. And I actually left the, just with one coil, and this has already, it's a big jump. This is the six month followup of the flow diverter. And you can see how it remodeled the vessel completely. And now also the flow and the PCAs is going back to normal, as you can see here. And that's the 3D reconstruction with the coil. So very nice result in this patient and also her headaches and migraines went away. So it must have been some effect. So let's go back to the slides. Here these are interoperative pictures. So this was before I placed the coil, you could see they're still, filling in the aneurysm. So here I decided to, place the coils and after I placed the coils, you could see how the flow was significantly slower already here on the PCA. So I decided not to place more coils than this, and I was a little bit actually worried that maybe this PCA would go down over time, which could have been happened and would be also fine. But I just wanted to make sure I'm not getting an acute occlusion, and this is the follow up also the MRI, the remodel. Okay, let me switch gears again. Let's look at ruptured aneurysm. So most of the ruptured aneurysms, I treat in my practice now with endovascular coiling, but there's still a few endorsements which are not favorable for coiling or web or where I'm not favored to do an early flow diversion. And that's one of these cases. He's 44 year old patient, Hampton has three fissure three, as you can see here on the CT scan. And he has like these two aneurysms we're coming off from a common neck, pretty far pretty, pretty wide neck. And these two aneurysms are between 1.5 and 2.5 in diameters, is fairly small. I mean you could argue to try to stand coil or coil, but it's, again, it's a rupture case. You want to get a good result also in young patient. So here my strategy was really to do clipping off the aneurysms a Pterional craniotomy. Usually I go the dominant side. So here on the left A1, the Sylvian fissure split be ready for temporary clipping off the A1 and aneurysm flipping. Okay, let me show you this video. So here are a standard Pterenional on the left side. As you can see here, obviously, a different picture than the case before, but this arachnoid blood, but still the same concept. You're opening up the arachnoid over the carotid artery, especially in these ruptured cases to get early on proximal control of the ICA, just in case something happens. He in this situation it's swollen. You really want to do a Sylvian fissure split. It's not a case where you try not to split the fissure and retract only. So here I'm doing now a Sylvian fissure split with combination of sharp dissection twix scissors and bipolars dissection, as you can see here. And then I've walked slowly my way down to the Sylvian fissure and really, really opened up the temporal and frontal lobe as you can see here, and then you, have really beautiful view down the M1 segment, all the way up to the ICA Terminus, as you can see here. And that gives you a view to the A1 segment. And then you really have time to, now open up the arachnoid over the optic nerve and make sure that you have a good proximal control now, along the A1. This just testing a temporary clip. I usually like to use this, a curve clip a little bit here that you're not in the way or with clipping testing out just straight clip along during the dissection, just to be very safe in these ruptured cases. And then you walk your way up along the A1 segment here, again a combination of dissection and sharp dissection, blunt dissection, sharp dissection. And then as you remembered on the 3D, there was barely any A1 from the other side, and this is already the curve from the contralateral A2 as you can see here. I'm doing it, in the ruptured cases I most of the time do Jarvis Vector's resection here, opening up the arachnoid layer, and then just suctioning all the little bit of volume to give you the complete view over the A complex as you can see here, especially in these cases where it's turned away from you. You can really see nicely how, the ipsilateral A1 ends. In the complex here, you can see appreciate already. The beginning of the aneurysm here This is the this is the ACOM and the contralateral A2 taking off here and the ipsilateral A1 going this way. And here I really decided to use a curved clip down. I made sure with the dissector that I have a good neck dissected out because there are perforator in the back obviously. And so now I'm working my way with the clip over, this hill of the aneurysm and keep in mind that one portion of the aneurysm is really far back. So I'm really using the clip. I'm closing it a little bit just to test it. But now I'm, just making a curve, a skip with my hand to really get the back of it and then close it up. And you can see how the clip is now sliding even like a little bit up. And that's intentional because I'm dealing with the approximate portion. Now with the second clip at the bottom. So you can see here now, a mini curved clip just to do a curve up, to meet the other clip, which took care of the portion in the back. So that's the second clip and removal of the temporary clip. And you can really see the overview, how this, the second clip took care of this additional of the second aneurysm. And the first clip really goes all the way in the back. And that's the overview and the final picture. So also here, I did intro with the fissure grams, as you can see here, this picture is maybe not the best, but I just recently, like two days ago, I did also a six month followup on this patient. And you can see that this end result or the clip walked itself around this ACOM and the aneurysm was completely occluded. He recovered well, he's completely intact. So I'm very happy with this result as well. Let me show you another example of a ruptured case. And that's one of the classic aneurysms we usually coil. We'll come in on call separate arachnoid patient 53 year old patient, 3 Fisher 3. She had previously standpoint, basil aneurysms, as you can see here, the old coil masters. And it also had a vertebral artery stand on that side and formed actually a denuval aneurysm because she had follow-ups for this in an outside hospital and came to our ER with this new aneurysm. So here in this situation, this time I went through the drawing because it's on the left side and a pretty challenging vertebral artery. You could have gone probably from the left radial artery as well. And here with, a benchmark six French catheter, this here is the previous stand As you can see here the straight area. but the catheter nicely made its way up here. And then I used also two catheters to cross to the intracranial standridge from here to here. One catheter in the aneurysm, as you can see here, the tip and then I use the Sceptre balloon just as I usually do for ruptured aneurysms, just for two reasons to, get flow arrester in case you cause a rupture and also for neck modulation, if a coil comes out. In this case, it was not a problem because it was a pretty narrow neck. You can see the first filling coil and then here, the filling coils starting to fill the aneurysm with a very great result, fast and great results. So this is more classic type of ruptured aneurysms. If you now look back to more of the clipping cases, a third nerve palsy, I think that's a very good example of a case where I think clipping plays a significant role. Nowadays, we know this was one of the first, the first aneurysm flipped. It was called Internal Carotid Artery, but most likely based on the presentation of the patient was a picalm aneurysm. Walter Dandy clipped in 1938. Obviously technique involved a microscope, but it's the same concept. This is, a patient a recently treated, 65 year old female patient presented with a partial third nerve palsy, mainly ptosis. But also some double vision for the last three days. And has this nasty looking PICALM aneurysm. And for me, it's this elongated PICALM aneurysm. It's kind of like even another injury within previously aneurysm. So it looks like a weak spot and it came to another like pre rupture into the third nerve. And so I treat these patients as they would be a ruptured patient. Although the CT scan was negative for any hemorrhage. You can see here also, she doesn't have any PICALMs, so it's a fetal PCA, which makes it also sometimes challenging for endovascular. And I'm sure you could also coil that aneurysm, but I truly believe if you clip that aneurysm and take the pressure off the third nerve that the patient will recover faster after, from her third nerve palsy. So here, my surgical strategy was to clip this aneurysm. And I always think about the PICALMs because there's a paper we did during fellowship with Micheal in about 20% of the patients, you have to think about and to anterior clinoidectomy if you can't get a proximal control for the PICALM aneurysm. And so I'm always looking a little bit at the distance between the and the aneurysm neck. So always keep that in mind. But I, if that's the case, I usually just do an intro dura, not a full, extra extradural inter clinoidectomy So Pterial craniotomy then preparation for possibly ACP removal partially, and then aneurysm clipping, and then decompression of the third nerve. So let me show you the next video. So similar to the videos before opening up the arachnoid over the optic nerve. You can see, See the optic nerve underneath. And now I'm dissecting over the internal carotid artery. She had a pretty interesting anatomical variant that her carotid artery was very lateral. And as you can see later on to your coronal and fetal PCA, mainly see in nearly between the optic nerve and the third nerve. So here I decided because there was a little bit of a calcification approximately, so you can see here, the yellow structure to take a little bit of the colinoid off just to make sure that a temporary, potential temporary clip can fit in there. And I was hoping to get a little bit more healthy segment because there was really like a pretty tough calcification in the carotid. So I'm opening a little bit the dora and then I'm drilling with a diamond drill this portion off. And then after I drilled, I'm also opening a little bit of the falciform ligament over the optic nerve just to get a little bit more, medial. And now you can see there's a nice window just for a potential template clip there. And this is now distilled to the aneurysm. So I'm trying to look for the anterior carotid. So for it's very important to see the fetal PCA in the front and the back you want to see down to your carotid artery. And I had trouble to see it here. So I went immediately and I found it here. So it's a little bit more challenging for the clipping because you don't really see where anterior carotid is and you have to make sure that clip plates are obviously not there. So I'm detecting a little bit more arachnoid around there. You can appreciate a little bit anterior carotid here. I decided to do a temporary clipping. This would have been also a good case maybe to use some adenosine just because of the . You see a temporary clip is not fully, fully occluding. The carotid artery and a quick finalized section of the neck before just using a straight clip, straight standard clip. It's a little bit out of focus, apologize. And then, just slide this over, remove the temporary clip, and then do the inspection inspection of the anterior carotid as you can see here in the back and the clip plates are not in there. And, here you can see filling off the anterior carotid nicely not filling off the aneurysm laterally, and now dissecting all the way down. Now you see also the fetal PCA, actually medial crossing off and good flow on Doppler, and also did a 3D angiogram to the angiogram inter operatively. And you can see nice, very nice results, but the single clip. And then after that, as you can see here after the angiogram. So now I'm dissecting a little bit along the aneurysm dome, and I'm actually opening up now the dome just to make sure the third nerve is compressed. You can see that the aneurysm changed already color it strumbles off. And here, when I opened this, you can really see how small actually or thin walled the aneurysm was. So, and all the way down was the third nerve. I didn't really inspect much because I don't think it helps much to really expose or manipulate on the third nerve, but it's very important to open up the aneurysm then after clipping. And I think that's the video, yes. And yeah, so these were the, intraoperative angiograms and she really like recovered well, like two days after. One day after she was already a little bit better, two days after she didn't have a ptosis. And then on the third day, she didn't have any double vision and went home on the, I think on the third day. Let me challenge a little bit of the clipping side. So we, the teaching has always associated hematomas are, microsurgical clipping cases. But in this specific situations, I want to show you a 41 year old female patient Hunt and Hess 4, Fisher 4 Had a pretty significant neurological deficit and declined actually on the way to us. With a large hemorrhage here, as you can see here and on the CTA, she had a left sided artery aneurysm. So here, my thinking process was, should I share a clip this directly and take the hematoma out? Or should I first try to secure the aneurysm before I take the hematoma out? Because it's kind of challenging to get down and do an to secure the aneurysm, especially with, a dora supply as you can see on this. So my strategy we're lucky to have here at Penn, 100 OR was to bring the patient into the OR, or do a focus angiogram just on the vessel where we saw the aneurysm, do a quick coiling, if possible, and then a craniotomy and hematoma evacuation, if possible re clipping depending on the calling result. So the video is not loading, but on the video, it actually showed that that I was able to get in with my microcatheter pretty fast. And I was able to coil this aneurysm fairly fast and got a very good result. So I proceeded just with ICA evacuation. So you can see here and then repeated an angiogram a few days later because sometimes the claw mess can also, with a large hematoma, can maybe obscure a residual of an aneurysm, but it looked very stable and she actually recovered fairly well after the surgery. Let me show you another case for a clipping indication. Most of the giant aneurysms are also nowadays treated by flow diversion as well, but a classic giant aneurysm, a distal giant aneurysm. I still believe is a good indication for open surgery. And especially this case, we'll show you why I think that is. It's a 60 year old patient presented with a new seizure and a TIA episode, especially aphasia and weakness on the left side. And you can see here this, mass on the MRI and on the CT angiogram, and also angiogram, you can see there's a filling still in this large thrombosis aneurysm, anti aneurysm. And, I was here because, the outflow of the aneurysm was angular artery. And I truly believe that this was his symptoms coming from this aneurysm and the deficit of, the filling of the aneurysm and slowing down of, this episodes explained his TIAs. So here was my, really my strategy was to revascularize this branch distill out and then trap the aneurysm and really do a thrombatictomy of the aneurysm to decrease the mass effect and the Sylvian fissure. So this is the second step after the bypass, where we're trapped the aneurysm and then a third step taking the volume out of the aneurysm. So let me show you this, video. I decided to do a fairly large slob just because we needed to go away just on the Sylvian fissure. First, I harvested the STA I usually leave it intact, as you could see in the still image. And then opened up the Sylvian fissure, fairly distill. And here you can see the superior division of the M2 and then branching off in the MP3 branch here, filling the aneurysm. So this is this the branch basically going towards the inflow of the aneurysm And so I'm dissecting off here now, this MCA branch. And now this is the technique to really define which branch on the surface is actually the outflow. And this is fluids in flush technique. As you can see here at temporary clip is applied for us in as the green is given. And now when you remove the clip, you can see that this area is filling then after. You can also see that on the flow 800 here's the delayed flow. You can do the exact same thing with fluorescein. As you can see here, the clip is in place. This area is not filling now. I'm removing the clip under the fluorescein signal. And then all of a sudden it starts filling since I removed the clip, then the fluorescein dye is coming into this area. So that allows us to show that this is the branch we need to place our bypass on. So I'm disecting now the M4 segment taking down small, tiny arteries here, placing a standard background behind the artery and creating my zone for the bypass. I like really this little cut patties were very small and not bulky. I like to use them for catmeres or also for bypasses. And then before we further prepare the vessel, I usually pay my attention or focus my attention to the, graph, to the STA branch. This was still intact. I usually wrap that up with Cophedrin over the time I'm doing the rest of the surgery. And now I harvest cause I'm looking at the length. And I was wondering if I can use one of these smaller branches, but the length was not ideal. So I had to use the main trunk, which is fine. So I'm cutting this portion off the frontal branch, the STA dissect the final dissect the final last harvest dissections. And now with Hepanus saline I'm flushing the lumen and really make, this portion very naked and fish mouth, the STA make sure there's good flow, flush again with heparin, and then bring the STA into the field, to the area from my M4 recipient vessel. I like to use a micro section here that you can irrigate during the procedure, and don't have to focus on suction testing irrigation if it works, then marking the vessel, the next step, and unloading the STA here, extending the fish mouth a little bit, depending on the vessel size. I like to do this like right before. Now, I'm loading with two needles, the toe and the heel. And then applying the temporary clips for, that anastomosis. I usually use aneurysm clips, the smallest, a 3 millimeter. You can also use ABM clips. And then I use a needle to poke the vessel. And then these small curve pot scissors to open up the space with Heparinized saline irrigating, the lumen. And I always start with the, heel because the heel will really like nicely sit on there. And then I can work with the toe. And I favor now more than a continuous suture technique after my fellowship with Michael . I used to do just single stitches, but I'm a little bit faster if I can do a running suture line and you can sometimes get also more stitches in the same time than single stitches. But I think it doesn't matter which technique, when I do a running suture, I leave them loose first, do the runnings aside first, always check on the other side that I didn't make a mistake. And then, I slowly tighten them so that they lie in a perfect position, as you can see here. And, then I tied end after an additional stitch, I usually do it one more stitch. Then I tie that one then to the end of the very first stitch. And then you, focus on the, other side. So I'm bringing that needle through there. And this is the most challenging suture, like the first couple of the first one or two in this end. Here I had a lot of slack from the STA, but sometimes that can be very challenging. And then you were on your way all the way back, especially in the first on the, front frontline. And then you tie them, tighten them. And so you can see your last and that concludes the anastomosis here. And I always remove first the clips on the MCA. I use some fibrillar around there because it usually oozes there a little bit and after the MCA clips are off I also remove the STA. Now I'm basically placing a clip in the inflow to the aneurysm before I do my IC-Green run. And you can see that it now feels at the same time with the bypass. Here in the left bottom corner, you see the IC-Green before, and now you can see that it's filling basically at the same time here after the bypass. So now we're good, good in shape with the bypass. So we have now I want to place the permanent clip as close as possible to the inflow. So we're doing this right now here. The chief resident is placing that clip and removing that. And now before I go all the way around the aneurysm, I'm going to take notes on mass effect. So I'm not opening up the aneurysm using a cruiser and just really get the clot out of this, of this thrombos aneurysm. To really get, this mass effect way. And then it's actually favorable and easy to reach to the other side. And we see now that the inflow and outflow and we're placing now there a permanent clip at the outflow. The rest of the aneurysm I usually leave in there because I'm a little bit void to pulling out the whole aneurysm wall because there are perforator on the bottom. And I don't think that actually helps the patients. So this concludes this video and also did an interoperative angiogram. As you can see here on the 3D of the STA it gets in here fills distally, and then also comes back. No, actually this is the disproportionate, here's the proxima going more towards the clip where it takes stops. And here you can see the MCA branch stopping with the proximal occlusion. He did very well. This was the post-op scan right after the surgery and now a follow-up MRI. And he overall improved. He had a little bit more aphasia right after the surgery, but now he is, doing very well. Okay, lastly, a short case for recurrences, I tend to do more endovascular when it was previously microsurgery clips. So for example, if an aneurysm clip and you see a recurrency, I'm very hesitant to go back because I'm through the old scar. So I mainly do a week recalling of an aneurysmal flow diverter version. If it's an aneurysm which was previously coiled and recurrence, then I do either either surgery or another endovascular procedure. Most of the time flow diverter version in that situation, This is an interesting case, 85 year old patient with a previously high-grade kind of as another separate record hemorrhage recovered very well, but loss then lost the follow-up. You can see the pictures from 2019, that was the initial aneurysm, the PICALM aneurysm as well, low coiled. But then she came to the ER and you can see how these coils are just pushed to the side and looked like a giant recurrence. And so I think these cases are really good cases for flow diversion, especially in the internal carotid artery. And we have now three different flow diverters in the market. So it's dealer's choice for which one you want to use. Medtronic just came out with the pipeline shield version of their device. And then the FRED Jr. I showed you before they have also regular FREDs, and then the Surpass Evolve. It's also a flow diverter from Stryker available. So here in this situation, I decided to use a FRED for the reason to land really in the ICA Terminus, because the stem portion allow to anchor really in ICA Terminus. Otherwise in this arachnoid you would have probably needed to jail the Avon segment. You need to start in the M1 segment and she didn't have an ACOM on that side. So I was a little bit worried joining there. So I decided to do a FRED here, and that worked very well for this patient. So let me summarize, I hope I could show you with these cases that, both microsurgical and endovascular techniques are needed nowadays still. Obviously more endovascular, but there are cases where I truly believe open microsurgical, flipping or trap bypasses are a very good options for the patients. For me, it's always important safety for the patient and really the success of the treatment modality is key. And to really achieve this, you have to have a neurovascular team covering both techniques on a high volume. Either, it's like here at Penn where we are doing trained and all of us do both techniques or in other places, especially in Europe, where the neurosurgeons are treating more to open and radiology more than endovascular. It doesn't matter in the end, but you have to have a good team and talk about these cases to really define case selection and really know the knowledge of the limitation of all techniques. And then you reach low morbidity, mortality, and really favorable outcome for your patients. So thank you very much again for the invitation. I'm happy to take questions.

- Beautifully done Jon. Great techniques, very meticulous, really a sensational video presentation. And I really enjoyed them. I really liked the way you handled the tissues very gently, and also the bypass just superb, superb technique. You know, on a surgery is on a significant transformation. In the rate of the aneurysms remaining within the new microsurgical armamentarium have become so much smaller, unfortunately. And the question that everybody asks is how are we gonna maintain those skills? And obviously there's a lot of, you know, different pseudo answers, go into the lab, you know, being in a major center of excellence, but as we know, those are not always definitive as to do or maintain those skills. The lab doesn't give you really those micro of techniques. You have to be able to do it. But the volume is so small that it's very difficult to maintain those skills. So I'm curious about what your perspective is about how we should maintain those higher level microsurgical surgical skills?

- Yeah, thank you for this question. I think that's a very important question and I'm not sure if I have the answer, but I think for me, the solution is that we really have a high volume of open procedures still in a few academic centers where maybe smaller centers would send us patients who are more challenging and that we can maintain a good volume of, open procedures when it's indicated in addition to good fellowships, where we can train vascular interested residents after the residency to make sure that they are involved in these cases and see that volume before they start out.

- I agree, that's in theory, that would be the right answer. The problem is that the business model of small hospitals, is inconsistent. Smaller hospitals are recruiting neurologist, even in rare circumstances, cardiologists are quilling enuresis. And therefore the hospital would not really be favorable for those cases to be sent out because they feel financially that will be a drain on their system. So this is really a complicated problem. It's going to get even more and more complicated next few years. And I really don't think there isn't one answer Jon. I think it's going to be very challenging to know what will be the best in ahead of us. Do you have any other closing comments that you would like to let us know?

- No, I just appreciate the opportunity to really present here.

- Thank you. Jon we're really very impressed with what you have done. I followed your career from the time you came and what you did and being a Baylor and now at UPenn. And I have no doubt. We're going to hear a lot bigger and more important news about your successes. And I think neurovascular surgery is in good hands with your generation of vascular neurosurgeons. Thank you for being with us and look forward to working with you in the future.

- Thank you so much. Thanks for having me.

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