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Grand Rounds-Misadventures During Aneurysm Surgery: How to Manage Them

Dan Barrow

August 10, 2012


- Ladies and gentlemen, thank you for joining us for the second session about management of intraoperative complications, during aneurysm surgery, Dr. Dan Baril, from Emory university. He has a set of spectacular, and amazing videos of how to manage some of the most difficult moments in surgery. And I really appreciate his expert opinion and comments. Dan, please take it away.

- Thanks Aaron, I appreciate all of you joining us this evening, the second part of this talk, we'll pick up where we left off, earlier in the first session we spoke about avoiding and managing a number of complications that can occur in the management of intracranial aneurysms. And a lot of these principles apply to, although that's the model that I'm using, the next slide demonstrates what I think is the worst a nightmare that can occur during aneurysm surgery and the complication of intraoperative rupture. This is a complication, like all complications, that's better avoided than managed, but if you do enough aneurysm surgery, they're going to be situations where you have to manage an intraoperative complication such as this. So we're gonna talk about avoiding it as well as managing it. So if we could go to the slides, please, one of the first steps towards avoiding intraoperative rupture is to obtain proximal control. And in some situations that's relatively easy, in others it's more challenging, for middle cerebral artery aneurysms. Oftentimes when opening the Sylvian fissure, you will come down on the aneurysm before you come down on the proximal artery or the M1 segment. One trick is to look at the aneurysm as it's shown in this top bank of slides and actually identify the M1... Underneath the aneurysm, beneath the bifurcation as is shown here, applying the temporary clip from the backside rather than the front side, and then clipping the aneurysm before removing the temporary clip. Likewise, the basilar artery oftentimes getting proximal control can be very difficult. These series of photographs in the bottom bank show a left sided approach to a basilar tip aneurysm. Here's the Basilar trunk, here is the posterior cerebral artery, and the application that the temporary clip to the basilar trunk in this particular case, if the bifurcation is high, this is relatively straightforward. If it's low, one may actually have to drill off the posterior clinoid processes in order to attain that proximal control or another trick is to use intraoperative balloon occlusion with the assistance of your endovascular experts for a basilar aneurysms, for carotid aneurysms, particularly those that are very proximal. The best bet is to prep and drape. If not prophylactically open the cervical carotid and expose it. So that one has proximal control for the carotid artery. This also allows one to perform a maneuver that was popularized by Hunt Bakker, many years ago, where one can trap a proximal carotid aneurysm, and suction decompress a lesion, particularly when it's large or giant. And this requires proximal control in the cervical region. One of the other things to do to prevent intraoperative rupture besides obtaining proximal control is to avoid blunt dissection. Virtually every series that has been published on intraoperative ruptured aneurysms would indicate that more often an intraoperative rupture occurs during blunt dissection rather than sharp dissection. As illustrated in this video, here is a distal anterior cerebral artery aneurysm being bluntly dissected, and you know exactly what's going to happen. The blunt dissection transmits more pressure to the aneurysm and in this case, the aneurysm ruptured at the prior rupture site leading to this massive intraoperative hemorrhage, unfortunately was able to be controlled because we had the aneurysm exposed. Please go back to the slides. So, if you do obtain an intraoperative rupture, if you can't avoid it, and it's not always avoidable, the surgeon is faced with two challenges. One is you've got to control the bleeding and the second is need to repair the aneurysm. And those can both be challenging and complicated. to control the bleeding. There are a number of tricks that have been used to use a large bore suction to control the bleeding, to have your assistant use a second assumption to tapping on very gently the bleeding site with a cottonoid or a piece of cotton, proximal temporary occlusion, or trapping of the aneurysm can control the bleeding, carotid compression, which we mentioned in the first session. One can try to coagulate the rent on the aneurysm dome. Although that's rarely successful. One can sometimes apply a clip to the rent. If it's on the dome of the aneurysm and obtain a temporary occlusion without occluding the parent vessel induced hypotension has been used in the past, but it's very ineffective and actually puts the patient at greater risk of an ischemic injury. And then also there's the option, that we'll go into more detailed with the transient cardiac arrest. This is just the video that went with the last slide, just illustrating an intraoperative hemorrhage that needs to be controlled using those adjuncts. Let's move back to the slides please. So, if the aneurysm ruptures intraoperatively, after you've exposed the aneurysm, generally speaking that's not a serious problem and can be managed quite readily by the surgeon is illustrated in this video. This is a middle cerebral artery aneurysm. You can see it's being exposed through the right Sylvian fissure, it's a ruptured aneurysm. As you can tell from the subarachnoid blood we've already opened the Sylvian fissure, and you can see that the aneurysm is now ruptured and is bleeding at the site where it originally bled. It's a very simple maneuver now to put a piece of cotton to tampa knotting, but a temporary clip on the M1, because we had proximal control and now sharply dissect the rest of the aneurysm away from the M2 segments, and identify the neck of the aneurysm. We now place a temporary clip on the dome of the aneurysm and remove the temporary clip. So we've minimized the ischemic time. Now we see the the M2 segments, and beneath the temporary clip, we place a permanent clip to reconstruct the M1, M2 junction in a perfect manner before removing the temporary clip. That's on the dome of the aneurysm that temporary clip has removed. And now we've got the aneurysm reconstructed, let's go back to the slides please, as was illustrated in that last case. And I'll illustrate again in this case, another option, if the aneurysm ruptures on the dome of the aneurysm, one can put a clip onto the dome, the rent, and do it in such a way that the parent vessel is wide open and the surgeon can then leisurely clip the aneurysm. And this next video demonstrates that this is an anterior communicating artery aneurysm that's being approached from the left side. And you can see that it's ruptured at the time that the camera was started. This small piece of cotton is tampa knotting bleeding side, right on the dome of the aneurysm, the aneurysms pointing anteriorly, and this temporary clip is placed right on the bleeding side. Now, I know I don't have the aneurysm clipped, but the temporary clip, rather than putting it on the a one segment and potentially causing ischemia allows me to clip the dome, dissect out the neck of the aneurysm. And in this case placed the permanent clip across the net, of the intercommunicating aneurysm, and then remove the temporary clip, which was causing no ischemia whatsoever. Once that clip is removed, we see that the aneurysm is completely obliterated and now using sharp dissection, we're going to be sure, that the aneurysm is completely obliterated as it was. And here's the intraoperative angiogram demonstrating reconstruction of the entry communicating complex and the aneurysm completely gone. Now, if an intraoperative rupture occurs before you've exposed it, that can be an absolute disaster as shown in this case, here is an aneurysm that has ruptured and bled intraoperatively with massive bleeding that is very difficult to control. And we're gonna talk about some examples, of how one can manage that. We go to the next slide here, excuse me. This is a patient who presented with a subarachnoids hemorrhage. You can see has this a proximal carotid aneurysm, but plus you're communicating artery aneurysm. And before we go to the video, let me set the stage here. This aneurysm was being approached from the right side throughout a frontal temporal approach. And before we had completely open the Sylvian fissure I had not seen the aneurysm, but literally had just opened the Sylvian fissure, the aneurysm ruptured and bled as you'll see on the video. So what I did initially, and I'll set the stage here, here's the right temporal lobe and right frontal lobe. The first thing that I did is put this self retraining attractor alongside the temporal lobe. Very gently prior to this, we had no retractors in place, but once the bleeding began, we started the video and I put this retractor and you'll see the reason for it. The next step is a piece of cotton is placed into the depths of the wound and the suction is placed on top of the cotton ball. Here's the cotton. You can see how absorbent that is. Now, the retractor is gently placed on top of the cotton bowl. One must be careful not to force and push that retractor, but simply very lightly set of on top of the cotton. And essentially I'm using the retractor as a third hand, so that the retractor on the cotton, which is on the bleeding site, completely tapping nods it, this frees up my hands to identify the proximal carotid artery on which I put a temporary clip, the distal carotid upon which I put a second temporary clip to trap the aneurysm, now we can remove the retractor, lifted up, remove the piece of cotton and expose the aneurysm and the rent in it, which you can see. There's a little bit of trickle a back leaning from the posterior communicating artery, but I can carefully resect the aneurysm from the free edge of the tentorium, place a permanent clip, remove the two temporary clips with literally a few minutes of temporary occlusion, and now place a final clip to completely obliterate the aneurysm. Now I'm looking at the reconstructed carotid bifurcation, looking at the enter coronary posterior communicating arteries. Here's the enter coronary artery right here, posterior communicator there, we can see that the aneurysm is completely obliterated using that retractor as a third hand, on a tiny piece of cotton intraoperative angiogram showing the fetal post, your communicator is paint. This is another case and before we go to this video, let me set the stage here. This is a patient with an aneurysm, and I wanna illustrate with this category, the section shown in the upper corner here. This is the optic nerve. Here is the dural ring, enter coronary process has been removed to expose the carotid segment of the carotid and the super carotid segment, and the bifurcation, this particular aneurysm is right at the dural ring, and it ruptured before I actually had it fully exposed. So what I have to do in this case is tampa knotting, the leading with a piece of cotton, very absorbent, free cotton, and a suction. With my other hand, I'll open the dural ring. So let's go to the video. This also is from the right side here you can see the attractor. You can see the substantial bleeding from the aneurysm that's ruptured right at the dural ring. I have had begun removing the enter coronary process, but it not opened the dural ring yet. So in this case, we control the bleeding with a large bore suction, small piece of cotton is place, and notice how absorbent the cotton is. It allows us to gently tampa knot if we push too hard, we can actually extend the rent and the aneurism. So keeping my left hand in this case, that retractor didn't work, keeping my left hand on the section. Here's where the enter coronary process has been removed. And we're now opening the dural ring with micro scissors. My assistant is carefully suctioning to clear the field for me, while I'm keeping pressure on the aneurysm to keep it from bleeding, or progressively removing the dural ring. Here's where the coronary has already been removed. And gradually by opening the dural ring on top of the carotid artery. And on top of the optic nerve, we will expose the carotid segment, and expose the neck of the aneurysm, which is partially below and partially above the dural ring, here we're getting close to the neck of the aneurysm as we progressingly and cautiously opened the dural ring. We're laterally, here's the coronary segment of the carotid. And at this point now I've got the aneurysm clipped. There's the coronary segment. The dural ring is completely open, in a second clip is used, a little more approximately to obliterate the remaining portion of the aneurysm and obliterated completely. Please go back to the slides, the next case, before we go to the video, demonstrates the preoperative imaging on another patient in whom there was a massive, even more massive intraoperative rupture before we had even come close to seeing the aneurysm, this patient presented with an intercerebral hemorrhage. And we didn't even take time to do an arteriogram. We did a CTA that shows this middle cerebral artery aneurysm, which you can see in these two CT angiograms. And we took him to surgery and expose the aneurysm through a right frontal temporal craniotomy. So in this particular case, as we were literally opening the dura and beginning to open the Sylvian fissure, we had massive intraoperative hemorrhage that I could not control with two large bore suctions. And this is the instance where we used intravenous adenosine. This is a case where it's nice to have a good anesthesiologist, particularly one that has some experience in cardiac anesthesia, but the intravenous use of adenosine will cause a transient circulatory arrest that is illustrated on the video. If we go to that now, you can see that the adenosine has been given and the bleeding will rapidly slow down in there, it stops as the heart stops for just a few moments long enough that we could put a temporary clip on. I then place a temporary clip on the dome, remove the temporary clip from the M1, and the heart begins spontaneously. And now with a temporary clip on the dome, we can leisurely remove the blood from the Sylvian fissure, clip the aneurysm. Now you can see the reconstructed middle cerebral artery aneurysm, and the ICG video angiogram demonstrating the M1, the two M2 segments and notice that it's a completely obliterated and this patient had a stormy postoperative course, but did extremely well. Here is his intraoperative angiogram, and this is a postoperative CT angiogram. I saw this patient back in the office a few months after his course, and he had made a very rewarding recovery. Clearly, in my opinion, saved because of the intravenous identity.

- If I may ask then the details of identity and for our viewers. Number one, do you need for short cardiac pacers ahead of time, if you suspect you're gonna use adenosine.

- Well, if you think you're gonna use it, that's always a great idea. Oftentimes the use of adenosine is in situations like this, where you don't really anticipate it. And in this case, we did not have that. And fortunately, in the overwhelming majority of cases, the heart will resume spontaneously, but not always. And that's why it's extremely important and advantageous to have a very experienced anesthesiologist particularly one that has some experience in cardiac anesthesia, where this used more often.

- And the dosing you use for, you use 40 milligram. And that gives you about 40 seconds to a minute of cardiac arrest or 60 milligrams, if you desire to have more time.

- We typically start with the low dose, but give it, you can give it up to two or even three times. In this particular case, we gave two doses. The first one slowed things down, but didn't provide an arrest. The second dose completely arrested the heart. I was a little busy focusing on the aneurysm. I had an eczema anesthesiologist, and I believe in that case, two doses were given.

- Thank you.

- These cases up to this point. What I've illustrated are intraoperative ruptures that occurred before and after the aneurysm has been exposed. Then in all of these cases, the rupture was on the dome of the aneurysm. The mother-in-law of all intraoperative complications and aneurysm surgery, unfortunately is when there is a tear at the neck, this is an extremely difficult problem to deal with. Some of the options for dealing with it would be to microsutures that effect, which virtually never works. Obviously the vessel is diseased or there wouldn't be an aneurysm on it. And typically the tissue to simply will not hold a microsutures but it's something that I have tried, but I don't think I've ever been successful in doing that. Another option is illustrated in this cartoon in the upper right, is the Sundt clip graft created by Dr. Thoralf Sundt. It is a tool that I have used on several occasions to bail myself out of otherwise disastrous complications, oftentimes with excellent results. The problem with the sundt clip graft, is that there are only a few locations where you can use it, where this in circling clip that has, is reinforced with this, kind of cotton material can reconstruct the lumen of the vessel, and I'll show an example of that. And the other option traditionally has been to just trap the aneurysm with, or without some type of a bypass to provide a revascularization of the brain. This is an example, the arrows are pointing to a so-called blister aneurysms that occurred right on the coronary segment and had ruptured and bled. And this is an example of an aneurysms where this sundt clip graft in-circles the aneurysm actually in-circles the entire parent artery, and compresses the aneurysm can be very useful. And I have a video that shows the sundt clip graft being used in this particular case. After the enter coronary process had been completely removed here, you can see the carotid has been removed. Here's the optic nerve, here's the carotid artery. I'm taking a tiny piece of cotton and placing it over the blister aneurysm. And then what we'll do with a carotid segment exposed after opening the dural ring, the sundt clip graft, you can see being placed around the carotid. So the carotid runs through this clip graft, the ICG video angiogram demonstrating that the carotid remains patent. And if we go back to the slides, you can see this is the intraoperative angiogram demonstrating patency through that clip graft with the patency of the ophthalmic artery. Another trick I wanna share with the audience is something that Robert Spencer and I, published sometime within the last year or two. It's a trick that both of us realized we had independently used at various times in our practice. And we were talking about this and decided that it was a technique that probably was worth, the technique, if there is a tear of an aneurysm at the neck or below the neck, placing a clip across the neck of the aneurysm, obviously does not get rid of the aneurysm rent, and does not stop the bleeding. If one puts the clip more proximately, obviously you run the high risk of occluding or compromising the parent vessel. So the technique is to take a small piece of free cotton. And I keep these on my operating room, a stands multiple different sizes and shapes of free cotton that are fluffy, and soaking, and sailing. The first benefit of the cotton is if you place it over the bleeding site and place your suction on top of it, it's very absorbent and immediately clears the field. So you can see what you're doing. If the surgeon then places the clip in exactly the same place that it was placed in panel A, the cotton increases the surface area and tampa knots the bleeding side as is illustrated on these cross sectional cartoons. Let me show you some examples of real life cases, where this has been successfully used to treat. What would otherwise be a disastrous intraoperative complication. This patient has a left sided, middle cerebral artery aneurysm, on the three-dimensional angiogram. You can see the M1 segment and the M2 segment bifurcating with the aneurysm between those two. If we go to the video, this is a left sided approach. The Sylvian fissure has been opened, and we're looking at, the left middle cerebral artery aneurysm. A temporary clip was on the M1. Here is the one M2, the other M2 here. And I'm looking at the neck of the aneurysm. So if we begin the video again, here's one M2 and one temporarily clipped, and a fenestrated clip is being placed across the neck of the aneurysm to in-circle this M1, and a portion of the neck of the aneurysm, being sure we obliterate the distal part of the neck. Temporary clip is removed after a short period of temporary occlusion. You see the M1 passing through the fenestration and using the tandem clipping technique. The second clip is used a straight clip used to clip that portion of the aneurysm, passing through the fenestration and the aneurysm is now obliterated, but my effort to be sure that I've done everything perfectly I want to explore the distal M2 segment, and in doing so you can see that I tear the neck of the aneurysm right at the M2 origin. So what we do is put a temporary clip back on a small piece of cotton I put in place. And then with the temporary clip in place, I open the original fenestrated clip and put it exactly back where it was, cottonelle increasing the surface area and tampa knotting. The small tear that was in the neck, had I put this clip more approximately it would have occluded the M2 segment. Now temporary clip has removed. The aneurysm has been completely reconstructed and the cotton stays there indefinitely. This is a posterior communicating artery aneurysm. You can see on this standard in three-dimensional arteriogram, start the video, please. This is also a right sided approach. Here's the carotid artery. Here's the posterior communicating aneurysm optic nerve. And you can see that this is a fairly straightforward aneurysm. A side angle clip is being used to reconstruct the neck of this aneurysm, but notice this very thin area on the neck and in clipping it, I fail to completely include this portion of the neck of the aneurysm. And that becomes important. I've seen the anterior coronal, seeing the posterior communicator looks like the aneurysms obliterated, but when I really inspected carefully, and I find the puts your communicator here, I see the anterior carotid artery, but I noticed that this weak area is not included in the clip. So many clip is now being used to pinch that little, very thin walled area, seemingly to get rid of the aneurysm completely, but as I clip that aneurysm, I noticed that I actually started bleeding proximal to the clip. So literally right on the wall of carotid artery, that's unacceptable. You know, I have to do something about it. So I choose to remove the mini clip and identify the bleeding site, which indeed is right at the neck of the aneurysm, right here. So in this case, I take, as it's bleeding, pulling the bleeding with my suction, I take a small piece of free cotton that I had prepared and place it right over the bleeding site, and this residual dog ear of the aneurysm, and then take the same mini clip that I put on previously, put it in exactly the same place as it was originally, but the cotton by increasing the surface area, tampa knot the bleeding site, even though the clip is placed more distally and where the actual bleeding site is. So as not to compromise the internal carotid artery or the inter coronal which is originating right underneath here, we then inspect the clip placement. The cotton is clipped into place, and you can see that the inter coronary artery fills quite well right here, the aneurysms completely obliterated, and there's no bleeding at the site of the cotton. We go back to the slides, please. Here's another a posterior communicating artery aneurysm. This one seemingly a pretty simple and straightforward. Here's a three-dimensional angiogram showing that straightforward, a posterior communicating artery aneurysm, the origin of the inter coronary coming up off the neck of the aneurysm at the time of this operation, this particular video is also a right sided approach. You can see that we've clipped the aneurysm and we're just inspecting it, we think we're all finished, but as we move this clip over, and begin to look notice there's actually we tear the neck right here approximately, any attempt to put another clip proximal here, we were concerned would compromise the carotid artery. And so in this particular case, we remove the second clip that had been put on to obliterate the aneurysm here. We even see the bleeding site right at the neck of the aneurysm. This dog ear is what we were actually attempting to get rid of. Now, we take a small piece of free cotton, which was available and we'll place it right over this bleeding site, much as we did in the last case, there's the tear and the neck, right at that point, you can see the bleeding, the inter coronary is coming off right at that neck. And so putting it any more proximately would have carried grave risk of compromising the inter coronary artery. So, we now replace the clip a little bit smaller one using the clip to clip the cotton onto the bleeding site and completely obliterate the aneurysm, and then inspected carefully. In this case, ICG video angiography demonstrates the enter coronary right here, which we can see very well knowing that we have not compromised it by putting that clip too close to the carotid artery. Let's go back to the slides, please. Here is a little more complicated case. This is another a posterior communicating artery aneurysm. That's a little bit larger and more complicated. We'll start the video please. Another illustration of the same technique, just a little different situation, here we have on the left side, here's the carotid artery. We're putting a temporary clip on here. Here's the left optic nerve, left temporal lobe. Here, we have this large posterior communicating artery aneurysm, and even with a temporary clip, you can see that, it's still a fairly full. And at this point we are decepting off the intracranial artery, which we can see right here and peeling it away from the neck of the dome of the aneurysm, it's quite adherent. And as we carefully, you're peeling away inter coronal perforators off the posterior communicating artery, we try a number of different clip strategies. And this initial attempt, we're using a fenestrated clip to try to reconstruct the lumen of the carotid artery and get rid of the aneurysm. And that seems to provide us with a partial obliteration, a second finished rated clip they put in tandem, try to again reconstruct the lumen of the carotid artery while we have it temporarily occluded all the while being careful not to compromise the Inter coronary and the perforators coming off of the posterior communicating artery on this medial side of the large aneurysm. Now a side angle clip being used to obliterate that portion of the aneurysm, still passing through the fenestrations here. Now we can see that the aneurysm has begun to bleed right here with the original proximal clip was put on right at the neck of the aneurysm, despite the fact that the clip appears to be across that it's actually bleeding proximal to the clip. And as we try to correct it, it just bleeds more and more. So a piece of cotton is now placed right over the bleeding site. And my left hand, I'm holding that in place with the suction and notice again how the cotton is so absorbent. Now I open the original clip, the fenestrated clip, and to simply place it on top of the cotton. So the cotton acts as it tampa knot, to tampa knot the bleeding site, and it immediately stops the bleeding. The fenestrated clips have reconstructed the lumen of the internal carotid artery. And we now at this point perform an ICG video angiogram showing that the carotid remains are patent and the aneurysm remains completely obliterated, this new dog here that was left, showed up on the ICG. And we clipped that with a little mini clip to make the results even more perfect. We go back to the slides, please. Here's an example of a similar technique used for an anterior coronary artery aneurysm in which we got an intraoperative misadventure. In this case, if you start the video, I'll orient you, it's a right sided coronary craniotomy in this case, the patient has both a small posterior communicating aneurysm. Here's the carotid, here's the right optic nerve. There is a retractor demonstrating the middle cerebral and anterior circles at the carotid bifurcation. But this here is a large intercranial artery aneurism is a pointing a posteriorly. So can dissecting the small posterior communicating aneurysm adjacent to the larger intercrural. You'll see, what's the neck right here, that my instrument tears, the neck of the intercranial aneurysm, right at the neck and right at the site where the carotid artery is the fittest. So using a small piece of cotton to cover up very gently the bleeding site to control the bleeding and with a left-hand on the suction on the cotton, on the bleeding side, it's controlled, here's the small posterior communicating aneurysm, which would go ahead, and clip with a little mini clip to get it out of the way. That's the easy part. Here's now the carotid and the carotid bifurcation back here and a tear right at the neck of the aneurysm. And I haven't even exposed the inter coronary artery yet, which goes way back into the proximal part of the Sylvian fissure. So at this point, I put a piece of cotton over the bleeding site and tampa knotting, put a temporary clip on the carotid so that the bleeding site is tampa knotted. Here's the carotid bifurcation, here is the large inter carotid aneurysm. And here's the anterior carotid artery. We're seeing back here on the backside of the bifurcation fenestrated clip is then used to reconstruct the lumen of the M1 and the blades are clipping the cotton onto the bleeding site, which has been tampa nod it by the cotton here. So the fenestration going around the M1, here's the inter coronary artery free here, and aneurysm obliterated, the temporary clip now removed. And the cotton has been used as a bolster to obliterate, not only the aneurysm, but also the bleeding site and saving what otherwise uncertain would have been a complete disaster. This case illustrates a little different use of cotton. This is a carotid bifurcation aneurysm on the left, complex aneurysm that was turned out to be extremely atherosclerotic and partially thrombotic. So if we could go to the 3D video view here, you can see the complexity of the aneurysm and get the sense that there's some thrombus and atherosclerosis. Can you start the video, please. In this case, we're operating from the left side, frontal temporal craniotomy, and here is the carotid A1 and M1, retractor is put on the frontal lobe to protect it. Here's the A1 again, and looking at the distal portion of the neck of the aneurysm and the approximate portion here is the distal carotid artery and a temporary clip. This is important to note where this temporary clip is put, because this part of the carotid is very diseased. I made multiple attempts to use a fenestrated side angled clips to reconstruct this aneurysm but the thrombotic, an atherosclerotic characteristics caused the clip to slide down onto the carotid artery each time. So I would put a tandem clip beyond that, trying to get it to stay where I put it, remove the proximal clip, but each time it appeared that the clip I put would slide back down and compromise the A1, M1 junction and you can see that despite multiple attempts with these clips, try to walk them more distantly. I constantly felt I was compromising the carotid, at this point, as I'm attempting to do this yet, again, quite persistent in my efforts to try to get rid of this aneurysm, notice that the carotid, not the aneurysm, but the carotid ruptures, where the temporary clip was, and notice the spurt of arterial blood. This is not on the aneurysm, it's not on the neck, but it's actually on the native carotid artery. I use some gel foam, I used some cotton, thrombotic materials with some gentle pressure, but you'll notice that despite all my efforts, this rent in the carotid continues to enlarge. And I consider trying to put a stitch in, that I'm well aware of the fact that is simply not going to hold a suture. So this is another attempt with, on the approximate carotid with some gel foam. So at this point, knowing that I can't stop the bleeding, I put a temporary clip on the carotid artery approximately, to slow down the bleeding. I take a long strip of cotton. Here's the bleeding side here. You can still bleeding, here's the inter coronary artery here. I take a long strip of free cotton, and place it underneath the carotid artery. Here's the cotton medial to the carotid, here it is the internal carotid, and I'm pulling it up between the inter carotid and the internal carotid artery. And I essentially will use this long piece of free cotton to wrap circumferentially around the carotid artery. Here's one end of it here, here's the other end, I stitch them together, hold them tight enough that they tampa nod the bleeding site but not so tight that they compromise the carotid. And then using a small aneurysm clip, clip the two ends together. So I have cinched the cotton circumferentially around the carotid artery, temporary clip is removed. Now you can see the cotton cinch that is Tampa nodding, the bleeding site. And at this point we do an ICG video angiogram to document, and I reconstructed the carotid in such a way that remains patent, here's the color of cotton around it. Let me demonstrate another case. This one quite complicated. This is a patient who had undergone surgery in the very distant past. You can not date this surgery from the old Drake clip that this patient had been carrying around for many years and presented with a new hemorrhage from either a De novo set of aneurysms, a posterior communicating aneurysm, a middle cerebral aneurysm, and neither a De novo aneurysm or a recurrence of this carotid aneurysm that apparently had undergone clipping in the past. Here is a three-dimensional picture showing some of that, a complex aneurysm that appears to recurred through this old clip. You started the video orient you to this left sided, frontal temporal craniotomy, a real elevation of that, a craniotomy and here you see the old Drake clip. This is a new clip that I've placed on the posterior communicating artery aneurysm. And here is the middle cerebral aneurysm that showed up on the Enneagram. So a very complicated situation where the old clip is seems to be embedded into the aneurysm. Here is aneurysm protruding posteriorly between the A1 and M1, and notice that I tear the aneurysm, and trying to expose the undersurface of it. So here's the carotid. Here's the M1, here's the aneurysm, in this case, I try to put just a straight clip across the neck of the aneurysm, but the tear appears to be more approximal, despite my efforts to try to completely eliminate the bleeding. The straight clip simply does not do the job. It slows down the bleeding. So now I can see the residual aneurysm. In this case, a fenestrated clip is placed around the M1 using the blades to obliterate the part of the aneurysm where I tore the neck, this clip largely, but not completely stopping the clip the bleeding. So I've made a complicated situation, even more complicated by adding now three new clips to an already complex situation. That clip is closed, and it completely stops that bleeding, and I reconstructed that carotid bifurcation or M1 segment aneurysm. Now I make what could have proven to be a fatal error. I try to remove the old clip. And as you can see, as I try to remove it, I tear the, the recurrent aneurysm realizing that removal of that clip that had been there for a decade and a half probably was not a wise idea, at this point the important thing is to keep wits, and I go down and identify exactly where the bleeding site is. And I can actually see the tear where I tried to remove this old clip. I tap it on it with a piece of cotton, and you can see the absorbency that it immediately clears the field. So I know exactly where the tear is on the carotid artery. Temporary clip is placed on the carotid. I then I'm able to identify exactly where the tear is, right where the aneurysm clip is embedded into the carotid. There's the tear. I put a small piece of cotton onto a cumbersome clip, and literally clip that to the existing aneurysm clip, to hold it in place and use the cotton as a bolster. So the clip is clipped the cotton to the old clip. A temporary clip is removed, and now I can eliminate that remaining part of the aneurysm that's beneath the carotid artery with yet one additional curved clip placed underneath the carotid bifurcation. I know this is a complex video and believe me at the time of surgery was equally as complex. Fortunately, we go back to the slides. We did an intraoperative arteriogram since the constellation of the clips precluded a good visualization under the operating microscope. If we can go back to the slide, here's the intraoperative arteriogram demonstrating complete obliteration of all three of the aneurysms, including the recurrent one, and excellent filling of the intercranial vasculature. This is an example of using cotton for a posterior circulation aneurysm. This is a large basilar trunk aneurysm rising between the origin of the superior cerebellar and the posterior cerebral arteries. And you can see the aneurysm on the standard and the three-dimensional angiograms. If you start the video. You can see that the aneurysm is exposed from the left side. This is left side, here is the aneurysm in the interpeduncular fossa. And here's the superior cerebellar artery. If you notice here's the basilar trunk right here, here's the carotid and the carotid bifurcation. So we're looking at the aneurysm below the posterior cerebral, lateral to the basilar trunk. And in this case, I'm putting a clip on the neck of the aneurysm. This is the basilar trunk, and notice that as the clip is slid in it, tears the neck, right between the neck and the posterior cerebral artery through this very small window. This is a potential disaster. Here's the carotid again right here, temporary clip is placed on the Basilar trunk. And importantly, very importantly, I knew preoperatively the patient had an adequate posterior communicating artery. So in this case, here's the tear right at the neck piece of cotton is placed on the tear right there, right on the basilar trunk. This is not on the neck of the aneurysm, actually the base itself. So a piece of cotton is used to Tampa nod, and we actually clip the cotton right onto the basilar artery since the tear was large enough that the clip alone would not have obliterated it. So we've now occluded the basilar artery here are the superior cerebellar arteries. The temporary clip is removed. We're now depending upon the baseline artery to fill up to, and including the superior cerebellar, the cotton is tampa knotting, the ramped in the basilar artery. And if you go back to the slides, the intraoperative arteriogram, that is on the next slide shows that indeed the superior cerebellar spill bump from below here's the clip with a cotton tampa knotting the tear of the basilar artery. And you notice that the posterior communicating artery fills the wasps role-basilar, and the posterior cerebral artery, and the segment that was occluded was a non perforator bearing segment. The patient made an excellent recovery from what could have been an absolute disaster. So in conclusion, I think there remains of bright future for neurovascular surgery, including the surgical treatment of aneurysms, as aneurysms are more and more often treated by endovascular techniques. Those aneurysms coming to surgery will increasingly challenge the skills and the creativity, and the ingenuity of the cerebrovascular surgeon. And I think only through strict adherence to surgical principles, doing everything we humanly can to avoid complications and then be able to manage those that we get ourselves into. Only in those situations, will we be able to provide the very best care for our patients. So our goal with surgery should be able, to have two scans and have difficulty determining which one is the pre-operative and which one's the postoperative scan. That's a great goal for the cerebral vascular surgeon. Thank you very much.

- Thank you very much Dan, for other spectacular talk. I just wanted to stress something that you so eloquently mentioned, and that's really the use of the piece of cotton, I think that gets us out of trouble 95% of the time, the moment that huge gush of blood comes in, it's very easy to panic, get nervous, lose your temper and wish you, there was a way you would have not done this surgery and sort of lose your sense of thought process. I think that piece of content putting it there, taking a breath, taking time and putting your plans together. It's so important. I think the method of reconstruction of the next two eloquently mentioned by you and Robert Spatular, has been life-saving at least for my patients in a few times, if I can ask you to put three basic principles together that are most important for an aneurysm surgeon, what would be those three? Would you mind sharing those with us please?

- Well, I think first and foremost, an aneurysm surgeon needs to be part of an interdisciplinary team. It takes a village to take care of these very critically ill patients. It requires skills in microsurgery. It requires skills in endovascular therapy, and it requires skills in neurocritical care. Importantly, neurosurgeons are qualified to do all of those in many instances, but it's rare that a neurosurgeon will be an expert in all three of those areas. Certainly modern cerebral, vascular neurosurgeons, not dinosaurs like myself are well-trained in both endovascular and microsurgical techniques. But I think the key is to work in an interdisciplinary program where you can offer the patient what's best for them and their individual aneurysm. Secondly, I think that the selection of patients for surgery is very important. I tried to make that point in the first half of this talk, that there are many patients that just simply are not ideal candidates for aneurysm surgery. Likewise, there are many patients that are not ideal candidates for endovascular therapy. And that second principle of choosing patients properly fits hand in hand with that first principle of working in an interdisciplinary program where you can discuss what the best option is for that particular patient and that particular aneurysm. And the third thing I think that is very important is for the surgeon to be creative, not to go into an operation with the idea that come hell or high water, I'm goNNA use a straight clip, or I'm gonna use a side angled fenestrated clip, or I'm going to wrap this aneurysm. I think that the surgeon who keeps all of his or her options open, who prepares themselves for the possibility they might need proximal control of the neck, they might need a bypass, that thinks ahead, and thinks about the complications that might occur, that hopefully won't, but that might occur and prepares themselves to manage those complications if they should occur is going to have better results for their patients.

- And as you said it very well prepared for the worst and hope for the best, again, Dan, thanks very much for your time.

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