Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video

2021 ◽  
Author(s):  
Fabio A Frisoli ◽  
Joshua S Catapano ◽  
S Harrison Farber ◽  
Jacob F Baranoski ◽  
Rohin Singh ◽  
...  

Abstract Giant basilar apex aneurysms are associated with significant therapeutic challenges.1–6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7–9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

1997 ◽  
Vol 87 (6) ◽  
pp. 836-842 ◽  
Author(s):  
Gary J. Redekop ◽  
Felix A. Durity ◽  
W. Barrie Woodhurst

✓ A series of 49 consecutively treated patients with 52 aneurysms of the upper basilar artery (BA) is presented. Thirtynine aneurysms arose at the BA bifurcation, 11 at the origin of the superior cerebellar artery (SCA), and two from the upper BA trunk just below the SCA. The patient population consisted of 36 women and 13 men, with a mean age of 50 years (range 23–74 years). Of the 35 patients presenting with subarachnoid hemorrhage, 10 were Grade I, 10 were Grade II, 11 were Grade III, and four were Grade IV according to the Hunt and Hess scale. Treatment consisted of aneurysm neck clipping in 28, proximal occlusion of the BA in three, and endovascular therapy with coils in four patients. The remaining 14 patients with unruptured aneurysms underwent direct neck clipping. Postoperatively, 38 patients developed diplopia in at least one direction of gaze but this had resolved in 31 of them at the last follow-up evaluation. There were four deaths (8.2%): two as a result of rebleeding following coil compaction at 8 days and 9 months posttreatment, respectively; one as a result of vasospasm; and one as a result of brainstem infarction after proximal occlusion of the BA in a giant bifurcation aneurysm. Of the surviving patients, 33 (67.3%) made an excellent recovery, seven (14.3%) made a good recovery, and five (10.2%) were in poor condition at the last follow-up review. Direct microsurgical clipping of most aneurysms of the BA apex region can be performed with acceptable rates of morbidity. These data from an unselected series of patients in a general hospital provide a basis for comparison with developing alternative techniques.


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Ninomiya ◽  
M Ishida ◽  
K Tosaka ◽  
N Kanehama ◽  
Y Ishikawa ◽  
...  

Abstract Background Although rapid ventricular pacing (RVP) is commonly performed for preparation of transcatheter aortic valve implantation (TAVI). It has been reported that multiple and / or prolonged RVP is associated with adverse clinical outcomes of TAVI. Retrograde Inoue-Balloon was designed for balloon aortic valvuloplasty (BAV) without RVP to prevent slip of balloon by way of central waist during biphasic inflation. Purpose The purpose of this study was to evaluate safety and feasibility of Retrograde Inoue-Balloon for TAVI preparation. Methods From December 2013 to December 2019, 427 consecutive patients who performed TAVI for severe aortic valve stenosis, were retrospectively enrolled in Iwate Medical University. Of them, 227 (53%) patients (mean age 83±5 years, male 41%), underwent retrograde BAV before prosthetic valve implantation, comprised this study population. Retrograde BAV procedures were divided into two groups; patients used Inoue-Balloon without RVP and those did conventional balloon with RVP. The primary endpoint was defined as combined adverse events of 30-day mortality, cerebral infarction, and critical complications after BAV (aortic dissection, aortic rupture and cardiopulmonary arrest). The secondary endpoint was set as prolonged hypotension after BAV. Result Inoue-Balloon (IB) and conventional balloon (CB) were used for 73 patients (32%) and 154 (68%) patients, respectively. Both balloons were succeeded to through and expand of aortic valve in all cases. In the CB group, cardiopulmonary arrest occurred in 2.0% after BAV, cerebral infarction was observed in 3.9%, and 30-day death in 3.3%. On the other hand, no major complications were observed except one aortic dissection in the IB group. In logistic regression analysis adjusted by sex and age, the incidence of combined adverse events was significantly lower in the IB group (OR 0.17, 95% CI 0.009–0.917, P=0.037). Furthermore, the IB group had significantly a lower incidence of prolonged hypotension following BAV compared with CB group (4.1% vs 19.5%, p=0.002). Conclusion Balloon aortic valvuloplasty using retrograde Inoue-balloon without rapid ventricular pacing is safe and feasible, and may improve clinical outcomes of TAVI. Funding Acknowledgement Type of funding source: None


2011 ◽  
Vol 9 (01) ◽  
pp. 34-38
Author(s):  
Christodoulos Stefanadis ◽  
John Dernellis ◽  
Eleftherios Tsiamis ◽  
Costas Stratos ◽  
Leonidas Diamantopoulos ◽  
...  

2005 ◽  
Vol 56 (suppl_4) ◽  
pp. ONS-E442-ONS-E442 ◽  
Author(s):  
Hans-Jakob Steiger ◽  
Farias Lins ◽  
Thomas Mayer ◽  
Robert Schmid-Elsaesser ◽  
Walter Stummer ◽  
...  

Abstract OBJECTIVE: Giant paraclinoid carotid artery aneurysms frequently require the temporary interruption of local circulation to facilitate safe clip occlusion. Owing to the brisk retrograde blood flow through the ophthalmic artery and cavernous branches, the simple trapping of the aneurysm by cervical internal carotid artery clamping and intracranial distal clipping may not adequately soften the lesion. Retrograde suction decompression aspiration of this collateral supply by a catheter introduced into the cervical internal carotid artery is a popular method to achieve aneurysm deflation. With a large collateral supply, the method is not effective enough. The advent of relatively long and maneuverable soft balloons allows temporary occlusion of the aneurysm orifice. METHODS: We applied this method in two instances of giant carotid ophthalmic aneurysms. In both instances, a 15- to 20-mm-long and 4-mm-wide occlusion balloon was inserted in the internal carotid artery at the level of the aneurysm before craniotomy. After craniotomy and dissection of the aneurysm neck, the balloon was inflated under intraoperative angiographic control. RESULTS: The aneurysm became soft enough in both cases without tapping and aspiration to allow safe clip occlusion. In the first case, the postoperative course was uneventful and visual acuity improved. A known additional infraclinoid part of the aneurysm was eliminated endovascularly 5 months later using balloon-protected injection of vinyl alcohol copolymer (Onyx; Micro Therapeutics, Inc., Irvine, CA). In the second case, a postoperative symptomatic vasospasm developed 15 hours after surgery. Hypertensive therapy resulted in the disappearance of symptoms and an otherwise uneventful course with improvement of vision. CONCLUSION: This preliminary experience suggests that this new method is a feasible alternative to retrograde suction decompression.


2009 ◽  
Vol 110 (1) ◽  
pp. 7-13 ◽  
Author(s):  
Eric S. Nussbaum ◽  
Michael T. Madison ◽  
James K. Goddard ◽  
Jeffrey P. Lassig ◽  
Leslie A. Nussbaum

Object The authors report the management and outcomes of 55 patients with 60 intracranial aneurysms arising distal to the major branch points of the circle of Willis and vertebrobasilar system. Methods Between July 1997 and December 2006, the authors' neurovascular service treated 2021 intracranial aneurysms in 1850 patients. The database was reviewed retrospectively to identify peripherally located intracranial aneurysms. Aneurysms that were mycotic and aneurysms that were associated with either an arteriovenous malformation or an atrial myxoma were excluded from review. Results The authors encountered 60 peripheral intracranial aneurysms in 55 patients. There were 42 small, 7 large, and 11 giant lesions. Forty-one (68%) were unruptured, and 19 (32%) had bled. Fifty-three aneurysms were treated surgically by using direct clip reconstruction in 26, trapping or proximal occlusion with distal revascularization in 21, excision with end-to-end anastomosis in 3, and circumferential wrap/clip reconstruction in 3. Coils were used to treat 6 aneurysms, and 1 was treated by endovascular parent artery occlusion. Overall, 49 patients had good outcomes, 4 were left with new neurological deficits, and 2 died. Conclusions Peripherally situated intracranial aneurysms are rare lesions that present unique management challenges. Despite the fact that in the authors' experience these lesions were rarely treatable with simple clipping of the aneurysm neck or endovascular coil occlusion, preservation of the parent artery was possible in most cases, and the majority of patients had a good outcome.


1993 ◽  
Vol 265 (5) ◽  
pp. R1132-R1140 ◽  
Author(s):  
N. B. Olivier ◽  
R. B. Stephenson

Open-loop baroreflex responses were evaluated in eight conscious dogs before and during congestive heart failure to determine the effects of failure on baroreflex control of blood pressure, heart rate, cardiac output, and total peripheral resistance. Heart failure was induced by rapid ventricular pacing. Baroreflex function was determined by calculation of the range and gain of the open-loop stimulus-response relationships for the effect of carotid sinus pressure on blood pressure, heart rate, cardiac output, and total peripheral resistance. The range and gain of blood pressure responses were substantially reduced as early as 3 days after induction of heart failure (161 +/- 6 to 99 +/- 8 mmHg and -2.7 +/- 0.3 to -1.5 +/- 0.1, respectively) and remained depressed for the 21 days of heart failure. This depression in baroreflex control of blood pressure was associated with similar depressions in reflex range and gain for heart rate (125 +/- 9 to 78 +/- 11 beats/min and -2.05 +/- 0.2 to -1.16 +/- 0.2 beats/min, respectively) and cardiac output (1.74 +/- 0.2 to 0.46 +/- 0.2 l/min and -0.81 +/- 0.02 to -0.027 +/- 0.008 l/min, respectively). The group-averaged range and gain for reflex control of vascular resistance were not altered by heart failure. In three dogs, discontinuation of rapid ventricular pacing led to resolution of heart failure within 7 days and partial restoration of the range and gain of reflex control of blood pressure. We conclude that heart failure reversibly depresses baroreflex control of blood pressure principally through a concurrent reduction in reflex control of cardiac output, whereas reflex control of vascular resistance is not consistently affected.


2019 ◽  
Vol 10 ◽  
pp. 205
Author(s):  
Seiei Torazawa ◽  
Hideaki Ono ◽  
Tomohiro Inoue ◽  
Takeo Tanishima ◽  
Akira Tamura ◽  
...  

Background: Very large and giant aneurysms (≥20 mm) of the internal carotid artery (ICA) bifurcation (ICAbif) are definitely rare, and optimal treatment is not established. Endovascular treatments are reported as suboptimal due to difficulties of complete occlusion and tendencies to recanalization. Therefore, direct surgery remains an effective strategy if the clipping can be performed safely and reliably, although very difficult. Case Description: Two cases of ICAbif aneurysms (>20 mm) were treated. Prior assistant superficial temporal artery (STA)-middle cerebral artery (MCA) bypass was performed to avoid ischemic complications during prolonged temporary occlusion of the arteries in both cases. In Case 1 (22-mm aneurysm), the dome was inadvertently torn in applying the clip because trapping had resulted in insufficient decompression. Therefore, in Case 2 (28-mm aneurysm), almost complete trapping of the aneurysm and subsequent dome puncture was performed, and the aneurysm was totally deflated by suction from the incision. This complete aneurysm decompression allowed safe dissection and successful clipping. Conclusion: Trapping, deliberate aneurysm dome puncture, and suction decompression from the incision in conjunction with assistant STA-MCA bypass can achieve complete aneurysm deflation, and these techniques enable safe dissection of the aneurysm and direct clipping of the aneurysm neck. Direct clipping with this technique for very large and giant ICAbif aneurysms may be the optimal treatment choice with the acceptable outcome if endovascular treatment remains suboptimal.


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