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Straight Fenestrated Clips in Surgical Management of Internal Carotid Artery Aneurysms: Technical Note
Technical Note
Straight Fenestrated Clips in Surgical Management of Internal Carotid Artery Aneurysms: Technical Note Sotaro Oshida, Hiroshi Kashimura, Taro Suzuki, Kenta Aso, Yosuke Akamatsu
BACKGROUND: Using angled fenestrated clips for posteromedially projecting internal carotid artery (ICA) aneurysms may allow the surgeon to simultaneously obliterate the aneurysmal neck and preserve the branching artery by applying the blade of the clip parallel to the ICA. However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm.
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CASE DESCRIPTION: A 52-year-old woman developed a subarachnoid hemorrhage. Three-dimensional computed tomography angiography showed a saccular aneurysm arising from the left ICALposterior communicating artery (PCoA) bifurcation. The aneurysmal fundus projected posteromedially, and the PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Tandem straight fenestrated clips were applied across the ICA, followed by reconstruction of the ICA wall with preservation of the PCoA and obliteration of the aneurysm.
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CONCLUSION: When using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, using multiple straight fenestrated clips may be a useful alternative.
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INTRODUCTION
A
Key words Aneurysm - Fenestrated clip - Internal carotid artery - Subarachnoid hemorrhage Abbreviations and Acronyms CT: Computed tomography ICA: Internal carotid artery PCoA: Posterior communicating artery
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CASE ILLUSTRATION History and Examination A 52-year-old woman presented with severe headache and subsequent loss of consciousness and was admitted to our hospital. No focal neurologic abnormality was noted. Initial computed tomography (CT) showed the typical findings of subarachnoid hemorrhage in the basal cistern and communicating hydrocephalus. Three-dimensional CT angiography showed a saccular aneurysm arising from the left ICA-PCoA bifurcation (Figure 1). The ICA was tortuous laterally, and the aneurysmal fundus projected posteromedially. The PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Spinal drainage for the acute hydrocephalus was placed on the day of admission.
Operation
neurysms arising from the internal carotid artery (ICA) are common.1 Because of their variations in the direction of the aneurysmal fundus and regional microvasculature, surgical clip ligation of ICA aneurysms can challenge even
-
experienced cerebrovascular surgeons. For the posteromedially projecting aneurysm, the parent vessel frequently impedes clip placement across the aneurysm neck.2-4 In such cases, angled fenestrated clips may allow the surgeon to simultaneously obliterate the aneurysm neck and preserve the branching artery by applying the blade of the clip parallel to the ICA.5 However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm. A case of a ruptured, posteromedially projecting ICA aneurysm treated using tandem straight fenestrated clips, which facilitated clip ligation of the aneurysm without a remnant aneurysmal neck and preservation of the posterior communicating artery (PCoA), is reported. Our operative experience involving the application of this device in the surgical treatment of ICA aneurysms is reported.
Left frontotemporal craniotomy was performed. After the proximal sylvian cistern was opened toward the ICA bifurcation, the artery proximal to the lesion was exposed for proximal control. The origin and course of the PCoA, branches of the PCoA, and
Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan To whom correspondence should be addressed: Hiroshi Kashimura, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 116:230-233. https://doi.org/10.1016/j.wneu.2018.05.135 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.05.135
TECHNICAL NOTE
Figure 1. Preoperative 3-dimensional computed tomography angiogram, superoinferior view, showing a saccular aneurysm (arrow) arising from the left internal carotid artery (ICA) posterior communicating artery (PCoA) bifurcation in which the aneurysm fundus projects posteromedially and the origin of the PCoA is visible (dotted arrow) (A). Oblique view, showing that
Figure 2. Intraoperative photographs showing the aneurysm (arrow) and its relationships to the left optic nerve, left internal carotid artery (ICA), and posterior communicating artery (PCoA) origin (dotted arrow) (A). The initial straight fenestrated clip is applied perpendicular to the long axis of the ICA. The heel of the clip blade is fitted to the distal aneurysmal neck (white arrow), and the dome is partially obliterated by its clip blades (B). A subsequent straight fenestrated clip is applied to the proximal position of the initial
WORLD NEUROSURGERY 116: 230-233, AUGUST 2018
the greater part of the aneurysm (arrow) is hidden behind the ICA (B). Inferolateral view, showing an aneurysmal neck involving the PCoA origin (C). ACA, anterior cerebral artery; AN, aneurysm; BA, basilar artery; ICA, internal carotid artery; Lt, left; MCA, middle cerebral artery; PCoA, posterior communicating artery.
placed clip, and the heel of the clip blade is fitted to the envisioned proximal aneurysm neck (white arrow). The aneurysm is occluded by a tandem straight fenestrated clip placed with the aperture around the left ICA, preserving the PCoA (black dotted arrow) (C). Intraoperative indocyanine green angiogram showing patency of the ICA, PCoA (white dotted arrow), the anterior choroidal artery (white arrow), and disappearance of the aneurysm (D). CN, cranial nerve; ICA, internal carotid artery; Lt, left.
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TECHNICAL NOTE
anterior choroidal artery were confirmed, lateral and medial to the ICA. Although various clip application options were tested, a tandem straight fenestrated clip (Yasargil titanium clip, No FT640T, blade length 6 mm, fenestration diameter 5 mm, Aesculap AG & Co, Tuttlingen, Germany) seemed sufficient to reconstruct the ICA, obliterate the aneurysm, and preserve the patency of the PCoA (Figure 2). First, a single straight fenestrated clip was applied to obliterate the aneurysm. However, the clip was not placed in the optimal position due to slipping of the clip from the sclerotic aneurysmal neck. Therefore a straight fenestrated clip was applied perpendicular to the long axis of the ICA. The heel of the clip blade was fitted to the distal aneurysmal neck, and the dome was partially obliterated by its clip blades. A subsequent straight fenestrated clip was applied proximal to the initially placed clip, and the heel of the clip blade was fitted to the envisioned proximal aneurysmal neck. As a result, the clip blades reconstructed the posterolateral wall of the PCoA and simultaneously obliterated the dome completely. The inferomedial wall of the ICA was reconstructed by aligning the heels of the blades. Complete aneurysm occlusion and patency of the ICA and the anterior choroidal artery were confirmed intraoperatively by indocyanine green angiography.
Postoperative Course Follow-up 3-dimensional CT angiography the day after the operation showed disappearance of the aneurysm (Figure 3). The patient’s postoperative course was uneventful, and the patient was discharged with no neurologic deficits.
Figure 3. Postoperative 3-dimensional computed tomography angiogram, superoinferior view, showing patency of both the internal carotid artery (ICA) and posterior communicating artery, resulting in disappearance of the aneurysm. BA, basilar artery; Lt, left; MCA, middle cerebral artery.
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DISCUSSION When possible, placement of a straight or angled nonfenestrated clip across the aneurysm neck under direct visual observation remains the safest, simplest method of surgical aneurysm ligation. However, due to variations in the direction of ICA aneurysms and the regional microvasculature, placement of a straight clip may be impeded by structures traversing the operative trajectory. Fenestrated clips provide surgeons the ability to preserve adjacent vessels or nerves when capturing then within the fenestration and provide higher closure pressures at the tip of the blades to allow better occlusion.5,6 The surgical clipping of an ICA aneurysm projecting inferomedially is often facilitated by the use of a conventional angled fenestrated clip placed with its aperture around the ICA. However, using this clip for a case with the aneurysm neck involving the branching artery has a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm. In contrast to tandem fenestrated clipping techniques, such as facing toe-to-toe or cross-wise heel-to-heel, that use the blades of multiple clips to reconstruct the aneurysm neck, fenestrated clips that are stacked on top of one another create tubes that can reconstruct efferent branch arteries. Recently, Yang and Lawton7 referred to these tubes built from stacked, straight fenestrated clips as “fenestration tubes” that have 3 variations including the antegrade fenestration tube, retrograde fenestration tube, and dome fenestration tube. Antegrade fenestration tubes are built with stacked, straight fenestrated clips with an open tube transmitting the efferent artery with forward blood flow. In their study, 25 patients had 26 aneurysms treated with fenestration tubes. Antegrade fenestration tubes were used to clip 15 aneurysms; they were used for anterior communicating artery aneurysms, 1 basilar tip aneurysm, and 1 pericallosal aneurysm in all but 2 patients (1 basilar tip aneurysm and 1 pericallosal aneurysm). Although antegrade fenestration tubes were not used with ICA aneurysms in their study, the technique is useful for cases of ICA aneurysms whose neck involves the PCoA. When the most proximal positioned heel of the clip blade is fitted to the envisioned proximal aneurysmal neck, the posterolateral wall of the PCoA can be reconstructed by its clip blades. Stacked, straight fenestrated clips align the heels of the blades to reconstruct the ICA and obliterate the aneurysm neck simultaneously. Technically, the heels of the blades need to completely close the neck without narrowing the ICA, requiring just the right clip application. In the fenestration tube techniques described in Yang’s article, if there is too much aneurysm tissue in the fenestration tube, the aneurysm will continue to fill from the proximal neck; if there is not enough aneurysm tissue in the fenestration tube, the efferent artery will be crimped or occluded.7 Furthermore, if there is severe sclerotic change in the junction between the ICA and PCoA, the risk of PCoA stenosis or occlusion may increase. In the present case, a single straight fenestrated clip was insufficient to obliterate the aneurysm completely due to slipping of the clip from the sclerotic aneurysmal neck. Therefore we placed the first straight fenestrated clip across the distal neck and dome of the aneurysm. Subsequently, a second clip was placed to reconstruct the origin of the PCoA and simultaneously
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.05.135
TECHNICAL NOTE
obliterated the proximal neck remnant and dome completely. We believe that this clip application order is ideal for the following reasons. First, the ruptured point can be secured with dome clipping first in most cases. Second, imperfections of the first clip application can be corrected with a subsequent clip after securing the ruptured point. Third, slip-out of the subsequent clip can be prevented by the first clip. However, because subsequent clip application may be restricted by the first clip, the final clip design should be determined before first clip deployment. After deployment of the clips, patency of the ICA in the
REFERENCES 1. Yasargil MG. Pathological considerations. In: Yasargil MG, Smith RD, Young PH, Teddy PJ, eds. Microneurosurgery I. Microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative Techniques and Pathological Considerations of the Intracranial Aneurysms. Stuttgart, Germany: Georg-Thieme-Verlag; 1984:299-301. 2. Schomer DF, Marks MP, Steinberg GK, Johnstone IM, Boothroyd DB, Ross MR, et al. The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction. N Engl J Med. 1994;330:1565-1570. 3. Velat GJ, Zabramski JM, Nakaji P, Spetzler RF. Surgical management of giant posterior
fenestration tube and branching artery should be assessed with Doppler flow probes or ICG angiography.
CONCLUSION When using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, the surgical procedure presented here may be a useful alternative.
communicating artery aneurysms. Neurosurgery. 2012;71(suppl 1):43-50. 4. Nakano Y, Saito T, Yamamoto J, Takahashi M, Akiba D, Kitagawa T, et al. Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal type posterior communicating artery-two case reports and review of the literature. J UOEH. 2011;33:303-312. 5. Sugita K, Kobayashi S, Kyoshima K, Nakagawa F. Fenestrated clips for unusual aneurysms of the carotid artery. J Neurosurg. 1982;57:240-246.
7. Yang I, Lawton M. Clipping of complex aneurysms with fenestration tubes: application and assessment of three types of clip techniques. Neurosurgery. 2008;62(suppl 2):ONS371-378.
Received 4 April 2018; accepted 18 May 2018 Citation: World Neurosurg. (2018) 116:230-233. https://doi.org/10.1016/j.wneu.2018.05.135 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
6. Sugita K, Kobayashi S, Inoue T, Banno T. New angled fenestrated clips for fusiform vertebral artery aneurysms. J Neurosurg. 1981;54:346-350.
WORLD NEUROSURGERY 116: 230-233, AUGUST 2018
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Straight Fenestrated Clips in Surgical Management of Internal Carotid Artery Aneurysms: Technical Note Sotaro Oshida, Hiroshi Kashimura, Taro Suzuki, Kenta Aso, Yosuke Akamatsu
BACKGROUND: Using angled fenestrated clips for posteromedially projecting internal carotid artery (ICA) aneurysms may allow the surgeon to simultaneously obliterate the aneurysmal neck and preserve the branching artery by applying the blade of the clip parallel to the ICA. However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm.
-
CASE DESCRIPTION: A 52-year-old woman developed a subarachnoid hemorrhage. Three-dimensional computed tomography angiography showed a saccular aneurysm arising from the left ICALposterior communicating artery (PCoA) bifurcation. The aneurysmal fundus projected posteromedially, and the PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Tandem straight fenestrated clips were applied across the ICA, followed by reconstruction of the ICA wall with preservation of the PCoA and obliteration of the aneurysm.
-
CONCLUSION: When using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, using multiple straight fenestrated clips may be a useful alternative.
-
INTRODUCTION
A
Key words Aneurysm - Fenestrated clip - Internal carotid artery - Subarachnoid hemorrhage Abbreviations and Acronyms CT: Computed tomography ICA: Internal carotid artery PCoA: Posterior communicating artery
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CASE ILLUSTRATION History and Examination A 52-year-old woman presented with severe headache and subsequent loss of consciousness and was admitted to our hospital. No focal neurologic abnormality was noted. Initial computed tomography (CT) showed the typical findings of subarachnoid hemorrhage in the basal cistern and communicating hydrocephalus. Three-dimensional CT angiography showed a saccular aneurysm arising from the left ICA-PCoA bifurcation (Figure 1). The ICA was tortuous laterally, and the aneurysmal fundus projected posteromedially. The PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Spinal drainage for the acute hydrocephalus was placed on the day of admission.
Operation
neurysms arising from the internal carotid artery (ICA) are common.1 Because of their variations in the direction of the aneurysmal fundus and regional microvasculature, surgical clip ligation of ICA aneurysms can challenge even
-
experienced cerebrovascular surgeons. For the posteromedially projecting aneurysm, the parent vessel frequently impedes clip placement across the aneurysm neck.2-4 In such cases, angled fenestrated clips may allow the surgeon to simultaneously obliterate the aneurysm neck and preserve the branching artery by applying the blade of the clip parallel to the ICA.5 However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm. A case of a ruptured, posteromedially projecting ICA aneurysm treated using tandem straight fenestrated clips, which facilitated clip ligation of the aneurysm without a remnant aneurysmal neck and preservation of the posterior communicating artery (PCoA), is reported. Our operative experience involving the application of this device in the surgical treatment of ICA aneurysms is reported.
Left frontotemporal craniotomy was performed. After the proximal sylvian cistern was opened toward the ICA bifurcation, the artery proximal to the lesion was exposed for proximal control. The origin and course of the PCoA, branches of the PCoA, and
Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan To whom correspondence should be addressed: Hiroshi Kashimura, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 116:230-233. https://doi.org/10.1016/j.wneu.2018.05.135 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.05.135
TECHNICAL NOTE
Figure 1. Preoperative 3-dimensional computed tomography angiogram, superoinferior view, showing a saccular aneurysm (arrow) arising from the left internal carotid artery (ICA) posterior communicating artery (PCoA) bifurcation in which the aneurysm fundus projects posteromedially and the origin of the PCoA is visible (dotted arrow) (A). Oblique view, showing that
Figure 2. Intraoperative photographs showing the aneurysm (arrow) and its relationships to the left optic nerve, left internal carotid artery (ICA), and posterior communicating artery (PCoA) origin (dotted arrow) (A). The initial straight fenestrated clip is applied perpendicular to the long axis of the ICA. The heel of the clip blade is fitted to the distal aneurysmal neck (white arrow), and the dome is partially obliterated by its clip blades (B). A subsequent straight fenestrated clip is applied to the proximal position of the initial
WORLD NEUROSURGERY 116: 230-233, AUGUST 2018
the greater part of the aneurysm (arrow) is hidden behind the ICA (B). Inferolateral view, showing an aneurysmal neck involving the PCoA origin (C). ACA, anterior cerebral artery; AN, aneurysm; BA, basilar artery; ICA, internal carotid artery; Lt, left; MCA, middle cerebral artery; PCoA, posterior communicating artery.
placed clip, and the heel of the clip blade is fitted to the envisioned proximal aneurysm neck (white arrow). The aneurysm is occluded by a tandem straight fenestrated clip placed with the aperture around the left ICA, preserving the PCoA (black dotted arrow) (C). Intraoperative indocyanine green angiogram showing patency of the ICA, PCoA (white dotted arrow), the anterior choroidal artery (white arrow), and disappearance of the aneurysm (D). CN, cranial nerve; ICA, internal carotid artery; Lt, left.
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TECHNICAL NOTE
anterior choroidal artery were confirmed, lateral and medial to the ICA. Although various clip application options were tested, a tandem straight fenestrated clip (Yasargil titanium clip, No FT640T, blade length 6 mm, fenestration diameter 5 mm, Aesculap AG & Co, Tuttlingen, Germany) seemed sufficient to reconstruct the ICA, obliterate the aneurysm, and preserve the patency of the PCoA (Figure 2). First, a single straight fenestrated clip was applied to obliterate the aneurysm. However, the clip was not placed in the optimal position due to slipping of the clip from the sclerotic aneurysmal neck. Therefore a straight fenestrated clip was applied perpendicular to the long axis of the ICA. The heel of the clip blade was fitted to the distal aneurysmal neck, and the dome was partially obliterated by its clip blades. A subsequent straight fenestrated clip was applied proximal to the initially placed clip, and the heel of the clip blade was fitted to the envisioned proximal aneurysmal neck. As a result, the clip blades reconstructed the posterolateral wall of the PCoA and simultaneously obliterated the dome completely. The inferomedial wall of the ICA was reconstructed by aligning the heels of the blades. Complete aneurysm occlusion and patency of the ICA and the anterior choroidal artery were confirmed intraoperatively by indocyanine green angiography.
Postoperative Course Follow-up 3-dimensional CT angiography the day after the operation showed disappearance of the aneurysm (Figure 3). The patient’s postoperative course was uneventful, and the patient was discharged with no neurologic deficits.
Figure 3. Postoperative 3-dimensional computed tomography angiogram, superoinferior view, showing patency of both the internal carotid artery (ICA) and posterior communicating artery, resulting in disappearance of the aneurysm. BA, basilar artery; Lt, left; MCA, middle cerebral artery.
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DISCUSSION When possible, placement of a straight or angled nonfenestrated clip across the aneurysm neck under direct visual observation remains the safest, simplest method of surgical aneurysm ligation. However, due to variations in the direction of ICA aneurysms and the regional microvasculature, placement of a straight clip may be impeded by structures traversing the operative trajectory. Fenestrated clips provide surgeons the ability to preserve adjacent vessels or nerves when capturing then within the fenestration and provide higher closure pressures at the tip of the blades to allow better occlusion.5,6 The surgical clipping of an ICA aneurysm projecting inferomedially is often facilitated by the use of a conventional angled fenestrated clip placed with its aperture around the ICA. However, using this clip for a case with the aneurysm neck involving the branching artery has a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm. In contrast to tandem fenestrated clipping techniques, such as facing toe-to-toe or cross-wise heel-to-heel, that use the blades of multiple clips to reconstruct the aneurysm neck, fenestrated clips that are stacked on top of one another create tubes that can reconstruct efferent branch arteries. Recently, Yang and Lawton7 referred to these tubes built from stacked, straight fenestrated clips as “fenestration tubes” that have 3 variations including the antegrade fenestration tube, retrograde fenestration tube, and dome fenestration tube. Antegrade fenestration tubes are built with stacked, straight fenestrated clips with an open tube transmitting the efferent artery with forward blood flow. In their study, 25 patients had 26 aneurysms treated with fenestration tubes. Antegrade fenestration tubes were used to clip 15 aneurysms; they were used for anterior communicating artery aneurysms, 1 basilar tip aneurysm, and 1 pericallosal aneurysm in all but 2 patients (1 basilar tip aneurysm and 1 pericallosal aneurysm). Although antegrade fenestration tubes were not used with ICA aneurysms in their study, the technique is useful for cases of ICA aneurysms whose neck involves the PCoA. When the most proximal positioned heel of the clip blade is fitted to the envisioned proximal aneurysmal neck, the posterolateral wall of the PCoA can be reconstructed by its clip blades. Stacked, straight fenestrated clips align the heels of the blades to reconstruct the ICA and obliterate the aneurysm neck simultaneously. Technically, the heels of the blades need to completely close the neck without narrowing the ICA, requiring just the right clip application. In the fenestration tube techniques described in Yang’s article, if there is too much aneurysm tissue in the fenestration tube, the aneurysm will continue to fill from the proximal neck; if there is not enough aneurysm tissue in the fenestration tube, the efferent artery will be crimped or occluded.7 Furthermore, if there is severe sclerotic change in the junction between the ICA and PCoA, the risk of PCoA stenosis or occlusion may increase. In the present case, a single straight fenestrated clip was insufficient to obliterate the aneurysm completely due to slipping of the clip from the sclerotic aneurysmal neck. Therefore we placed the first straight fenestrated clip across the distal neck and dome of the aneurysm. Subsequently, a second clip was placed to reconstruct the origin of the PCoA and simultaneously
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.05.135
TECHNICAL NOTE
obliterated the proximal neck remnant and dome completely. We believe that this clip application order is ideal for the following reasons. First, the ruptured point can be secured with dome clipping first in most cases. Second, imperfections of the first clip application can be corrected with a subsequent clip after securing the ruptured point. Third, slip-out of the subsequent clip can be prevented by the first clip. However, because subsequent clip application may be restricted by the first clip, the final clip design should be determined before first clip deployment. After deployment of the clips, patency of the ICA in the
REFERENCES 1. Yasargil MG. Pathological considerations. In: Yasargil MG, Smith RD, Young PH, Teddy PJ, eds. Microneurosurgery I. Microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative Techniques and Pathological Considerations of the Intracranial Aneurysms. Stuttgart, Germany: Georg-Thieme-Verlag; 1984:299-301. 2. Schomer DF, Marks MP, Steinberg GK, Johnstone IM, Boothroyd DB, Ross MR, et al. The anatomy of the posterior communicating artery as a risk factor for ischemic cerebral infarction. N Engl J Med. 1994;330:1565-1570. 3. Velat GJ, Zabramski JM, Nakaji P, Spetzler RF. Surgical management of giant posterior
fenestration tube and branching artery should be assessed with Doppler flow probes or ICG angiography.
CONCLUSION When using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, the surgical procedure presented here may be a useful alternative.
communicating artery aneurysms. Neurosurgery. 2012;71(suppl 1):43-50. 4. Nakano Y, Saito T, Yamamoto J, Takahashi M, Akiba D, Kitagawa T, et al. Surgical treatment for a ruptured true posterior communicating artery aneurysm arising on the fetal type posterior communicating artery-two case reports and review of the literature. J UOEH. 2011;33:303-312. 5. Sugita K, Kobayashi S, Kyoshima K, Nakagawa F. Fenestrated clips for unusual aneurysms of the carotid artery. J Neurosurg. 1982;57:240-246.
7. Yang I, Lawton M. Clipping of complex aneurysms with fenestration tubes: application and assessment of three types of clip techniques. Neurosurgery. 2008;62(suppl 2):ONS371-378.
Received 4 April 2018; accepted 18 May 2018 Citation: World Neurosurg. (2018) 116:230-233. https://doi.org/10.1016/j.wneu.2018.05.135 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
6. Sugita K, Kobayashi S, Inoue T, Banno T. New angled fenestrated clips for fusiform vertebral artery aneurysms. J Neurosurg. 1981;54:346-350.
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