BALLOON-ASSISTED CLIPPING OF A LARGE PARACLINOIDAL ANEURYSM

Neurosurgery ◽  
2009 ◽  
Vol 65 (6) ◽  
pp. E1210-E1211 ◽  
Author(s):  
Mohamed Samy Elhammady ◽  
Peter Nakaji ◽  
Hamad Farhat ◽  
Jacques J. Morcos ◽  
Mohammad Ali Aziz-Sultan
Keyword(s):  
Parent Artery ◽  
Salvage Procedure ◽  
Parent Vessel ◽  
Intraoperative Angiography ◽  
Paraclinoid Aneurysm ◽  
Paraclinoid Aneurysms ◽  
Vessel Stenosis ◽  
Intraoperative Rupture ◽  
Vessel Reconstruction ◽  
Wide Neck

Abstract OBJECTIVE Surgical clipping and parent vessel reconstruction of wide-neck paraclinoid aneurysms can be very challenging. We report a case of a ruptured paraclinoid aneurysm which failed standard clipping techniques. We were able to reconstruct this aneurysm while providing proximal and distal control using an adjuvant endovascular balloon. CLINICAL PRESENTATION We report the case of a 45-year-old woman presenting with a ruptured large paraclinoidal aneurysm, which involved a significant portion of the internal carotid artery wall. INTERVENTION Repeated attempts at fenestrated clip placement resulted in slipping of the clip and occlusion of the parent artery. Ultimately, the aneurysm ruptured at the neck, and, despite trapping and direct aneurysmal suction decompression, significant bleeding was encountered. The bleeding point was packed, and, subsequently, endovascular access was obtained. A balloon was navigated and then inflated across the neck of the aneurysm using C-arm fluoroscopic guidance. The aneurysm was successfully clipped, and intraoperative angiography demonstrated no parent vessel stenosis. CONCLUSION This case demonstrates a salvage procedure in the event of intraoperative rupture and inadequate interruption of local blood flow. Balloon inflation resulted in adequate hemostasis and provided intraluminal support for optimal clip placement while preserving the parent artery.

scholarly journals Endovascular Treatment of Small Ruptured Intracranial Aneurysms (<5 mm)

2019 ◽  
Vol 30 (4) ◽  
pp. 817-826
Author(s):  
Fei Peng ◽  
Xin Feng ◽  
Xin Tong ◽  
Baorui Zhang ◽  
Luyao Wang ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intracranial Aneurysms ◽  
Cox Proportional Hazards ◽  
Parent Artery ◽  
Parent Vessel ◽  
Fisher Grade ◽  
Wide Neck ◽  
Ruptured Intracranial Aneurysms

Abstract Purpose To investigate the long-term clinical and angiographic outcomes and their related predictors in endovascular treatment (EVT) of small (<5 mm) ruptured intracranial aneurysms (SRA). Methods The study retrospectively reviewed patients with SRAs who underwent EVT between September 2011 and December 2016 in two Chinese stroke centers. Medical charts and telephone call follow-up were used to identify the overall unfavorable clinical outcomes (OUCO, modified Rankin score ≤2) and any recanalization or retreatment. The independent predictors of OUCO and recanalization were studied using univariate and multivariate analyses. Multivariate Cox proportional hazards models were used to identify the predictors of retreatment. Results In this study 272 SRAs were included with a median follow-up period of 5.0 years (interquartile range 3.5–6.5 years) and 231 patients with over 1171 aneurysm-years were contacted. Among these, OUCO, recanalization, and retreatment occurred in 20 (7.4%), 24 (12.8%), and 11 (7.1%) patients, respectively. Aneurysms accompanied by parent vessel stenosis (AAPVS), high Hunt-Hess grade, high Fisher grade, and intraoperative thrombogenesis in the parent artery (ITPA) were the independent predictors of OUCO. A wide neck was found to be a predictor of recanalization. The 11 retreatments included 1 case of surgical clipping, 6 cases of coiling, and 4 cases of stent-assisted coiling. A wide neck and AAPVS were the related predictors. Conclusion The present study demonstrated relatively favorable clinical and angiographic outcomes in EVT of SRAs in long-term follow-up of up to 5 years. THE AAPVS, as a morphological indicator of the parent artery for both OUCO and retreatment, needs further validation.

scholarly journals Microsurgical clipping of paraclinoid aneurysms

2020 ◽  
pp. 31-40
Author(s):  
Mugurel Radoi ◽  
Ram Vakilnejad ◽  
Suditu Stefan ◽  
Florin Stefanescu
Keyword(s):  
Endovascular Coiling ◽  
Parent Artery ◽  
Excellent Outcome ◽  
Microsurgical Clipping ◽  
Paraclinoid Aneurysm ◽  
Postoperative Control ◽  
Paraclinoid Aneurysms ◽  
Operative Control ◽  
Ophthalmic Segment Aneurysms

Background. Paraclinoid aneurysm is a nonspecific term that includes ophthalmic segment aneurysms and distal cavernous internal carotid artery (ICA) aneurysms. The literature mostly described the frequency to be in the range of 1.3-5%. and a high incidence of being multiple or having a large size. Methods. A retrospective review of 18 consecutive patients surgically treated for paraclinoid aneurysm was performed. The data of all our consecutive patients were searched to obtain patient and aneurysm characteristics, treatment details, complications and follow up. Clinical outcome was graded according to the modified Rankin scale. The follow-up period varied widely from 3 to 62 months (mean 26 months). Results. Surgical clipping was performed for 15 ruptured paraclinoid aneurysms; only in 3 cases the aneurysm was unruptured. Post-operative control angiography was performed in 10 patients (55.56%), from which we reported a full occlusion of the aneurysm in 9 patients (90%). Best results were obtained in patients who preoperatively were included in 1st and 2nd grade of Hunt & Hess scale. Two months postoperative follow-up was complete for all but one patient who died 12 days after surgery, from cerebral ischemia resulting from severe cerebral vasospasm. There were excellent and good results (mRS 0–2) in 88% of the cases (15 out of 17 patients) at two months follow-up, and 94% (16 out of 17 patients) at six months follow-up. Three patients with slight disabilities, ranked mRS 1-2 at two months follow-up, improved to mRS 0, with no symptoms at all, at 6 months postoperative control. All 3 patients with a surgically treated non-ruptured paraclinoid aneurysm had an excellent outcome (mRS 0). Conclusions. Most appropriate treatment is to occlude aneurysms without compromising patency of the parent artery. Anterior clinoidectomy and microsurgical clipping can still be a standard treatment despite of recent development of endovascular coiling procedures.

scholarly journals Flow Diverters for Intracranial Aneurysms

2014 ◽  
Vol 2014 ◽  
pp. 1-12 ◽  
Author(s):  
Yazan J. Alderazi ◽  
Darshan Shastri ◽  
Tareq Kass-Hout ◽  
Charles J. Prestigiacomo ◽  
Chirag D. Gandhi
Keyword(s):  
Antiplatelet Therapy ◽  
Intracranial Aneurysms ◽  
Evidence Base ◽  
Flow Diverter ◽  
Parent Artery ◽  
Comparative Efficacy ◽  
Parent Vessel ◽  
Wide Neck ◽  
Endovascular Devices ◽  
Flow Diverters

Flow diverters (pipeline embolization device, Silk flow diverter, and Surpass flow diverter) have been developed to treat intracranial aneurysms. These endovascular devices are placed within the parent artery rather than the aneurysm sac. They take advantage of altering hemodynamics at the aneurysm/parent vessel interface, resulting in gradual thrombosis of the aneurysm occurring over time. Subsequent inflammatory response, healing, and endothelial growth shrink the aneurysm and reconstruct the parent artery lumen while preserving perforators and side branches in most cases. Flow diverters have already allowed treatment of previously untreatable wide neck and giant aneurysms. There are risks with flow diverters including in-stent thrombosis, perianeurysmal edema, distant and delayed hemorrhages, and perforator occlusions. Comparative efficacy and safety against other therapies are being studied in ongoing trials. Antiplatelet therapy is mandatory with flow diverters, which has highlighted the need for better evidence for monitoring and tailoring antiplatelet therapy. In this paper we review the devices, their uses, associated complications, evidence base, and ongoing studies.

Novel Use of an Endovascular Embolectomy Device for Retrograde Suction Decompression-Assisted Clip Ligation of a Large Paraclinoid Aneurysm: Technical Case Report

2008 ◽  
Vol 62 (suppl_5) ◽  
pp. ONS412-ONS413 ◽  
Author(s):  
Daniel J. Hoh ◽  
Donald W. Larsen ◽  
James B. Elder ◽  
Paul E. Kim ◽  
Steven L. Giannotta ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Internal Carotid ◽  
Computed Tomographic Angiography ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Intraoperative Angiography ◽  
Paraclinoid Aneurysm ◽  
Surgical Clip ◽  
Paraclinoid Aneurysms

Abstract Objective: Several different methodologies for proximal occlusion and retrograde suction decompression of large paraclinoid aneurysms have been reported previously. In this article, we describe the novel use of an endovascular embolectomy device (F.A.S.T. funnel catheter; Genesis Medical Interventional, Inc., Redwood City, CA) for temporary internal carotid artery occlusion and suction decompression of an intracranial aneurysm to facilitate surgical clip ligation. The combination of atraumatic occlusion technology and large lumen size makes this technique safer and easier. Clinical Presentation: A 53-year-old woman with progressive headaches underwent computed tomographic angiography, which revealed an unruptured large left paraclinoid aneurysm. Cerebral angiography confirmed the diagnosis. The patient did not tolerate a balloon test occlusion for therapeutic Hunterian internal carotid occlusion. The patient was subsequently taken to the operating room for a craniotomy and clip ligation of the aneurysm. Intervention: A standard left pterional craniotomy was performed with opening of the sylvian fissure and exposure of the left paraclinoid aneurysm. Intraoperative angiography with introduction of a new endovascular embolectomy device was performed. The device was deployed to achieve temporary occlusion of the cervical internal carotid artery, and aspiration through the central lumen allowed for retrograde suction decompression of the aneurysm. Collapse of the aneurysm through this technique permitted visualization of the aneurysmal neck with successful clip ligation. Conclusion: A new endovascular embolectomy device can be used to safely perform suction decompression of large paraclinoid aneurysms to facilitate clip ligation.

Balloon-Mounted Stents for Treatment of Refractory Flow Diverting Device Wall Malapposition

2019 ◽  
Vol 19 (1) ◽  
pp. 37-42
Author(s):  
Jacob Cherian ◽  
Mahsa Dabagh ◽  
Visish M Srinivasan ◽  
Stephen Chen ◽  
Jeremiah Johnson ◽  
...  
Keyword(s):  
Blood Flow ◽  
Parent Artery ◽  
Pulsatile Blood Flow ◽  
Parent Vessel ◽  
Stent Deployment ◽  
Stent Occlusion ◽  
Vessel Stenosis ◽  
Blood Flow Modeling ◽  
Wall Apposition

Abstract BACKGROUND As indications for flow diversion (FD) have expanded, new challenges in deployment of flow diverting devices (FDDs) have been encountered. We present 4 cases with aneurysms in which deployment of FDDs were complicated by device malapposition and compromised opening in regions of parent vessel stenosis. In all 4 cases, a balloon-mounted stent was ultimately deployed within the FDD. OBJECTIVE To describe the use of balloon-mounted stents (BMS) within FDDs for correction of flow-limiting stenosis and device malapposition. METHODS Patients undergoing FD for treatment of aneurysms complicated by refractory flow-limiting stenosis were identified through multi-center retrospective review. Those cases requiring use of BMS were identified. Further investigation in one of the cases was performed with a simulated pulsatile blood flow model. RESULTS After attempts to perform balloon angioplasty proved unsuccessful, BMS deployment successfully opened the stenotic parent artery and improved FDD wall apposition in all 4 cases. Simulated pulsatile blood flow modeling confirmed improvements in the distribution of velocity, wall shear stress, oscillatory shear index, and flow pattern structure after stent deployment. One case was complicated by asymptomatic in-stent thrombosis. CONCLUSION In cases of FDD deployment complicated by flow-limiting stenosis refractory to conventional techniques, a BMS deployed within the FD can provide radial support to open both the stenotic device and parent artery. Resulting improvements in device wall apposition may portend greater long-term efficacy of FD. In-stent occlusion can occur and may reflect a thrombogenic interaction between the devices.

Endoscope-assisted Microsurgery for Intracranial Aneurysms

Neurosurgery ◽  
2002 ◽  
Vol 51 (5) ◽  
pp. 1119-1127 ◽  
Author(s):  
Chandrasekar Kalavakonda ◽  
Laligam N. Sekhar ◽  
Pranatartiharan Ramachandran ◽  
Peter Hechl
Keyword(s):  
Intracranial Aneurysms ◽  
Aneurysm Rupture ◽  
Parent Artery ◽  
Major Advance ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Intraoperative Angiography ◽  
Unruptured Aneurysms ◽  
Microsurgical Treatment ◽  
Aneurysm Clipping

Abstract OBJECTIVE We discuss the role of the endoscope in the microsurgical treatment of intracranial aneurysms, analyzing its benefits, risks, and disadvantages. METHODS This was a prospective study of 55 patients with 79 aneurysms, treated between July 1998 and June 2001, for whom the endoscope was used as an adjunct in the microsurgical treatment of their lesions. Seventy-one aneurysms were located in the anterior circulation, and eight were located in the posterior circulation. Thirty-seven patients presented with subarachnoid hemorrhage. Eighteen patients had unruptured aneurysms, of whom 5 presented with mass effect, 2 presented with transient ischemic attacks, and 11 were without symptoms. In all cases, the endoscope was used in addition to microsurgical dissection and clipping (sometimes before clipping, sometimes during clipping, and always after clipping), for observation of the neck anatomic features and perforators and verification of the optimal clip position. Intraoperative angiography was performed for all patients after aneurysm clipping. RESULTS In the majority of cases, the endoscope was very useful for the assessment of regional anatomic features. It allowed better observation of anatomic features, compared with the microscope, for 26 aneurysms; in 15 cases, pertinent anatomic information could be obtained only with the endoscope. The duration of temporary clipping of the parent artery was significantly reduced for two patients. The clip was repositioned because of a residual neck or inclusion of the parent vessel during aneurysm clipping in six cases, and the clip position was readjusted because of compression of the optic nerve in one case. One patient experienced a small aneurysm rupture that was directly related to use of the endoscope, but this was easily controlled, with no sequelae. For many patients, the combination of the neuro-endoscope and the micro-Doppler probe made intraoperative angiography redundant. CONCLUSION “Endoscope-assisted microsurgery” is a major advance in the microsurgical treatment of intracranial aneurysms; the endoscope allows better observation of regional anatomic features because of its magnification, illumination, and ability to “look around corners.”

scholarly journals Experiences of Using Hybrid Operating Rooms in the Treatment of large or giant Carotid-Ophthalmic Aneurysms

2019 ◽  
Author(s):  
Nai Zhang ◽  
Wen-qiang Xin
Keyword(s):  
Operating Room ◽  
Thromboembolic Event ◽  
Postoperative Recovery ◽  
Hybrid Operating Room ◽  
Parent Vessel ◽  
Surgical Clipping ◽  
Vessel Stenosis ◽  
New Ideas ◽  
Technical Features ◽  
Vessel Reconstruction

Abstract Background: A hybrid operating room (Hybrid-OR) was a surgical theatre combined conventional operating room with advanced medical imaging devices. There were still plenty of limitations when endovascular treatment or microsurgical treatment was used individually to deal with large or giant carotid-ophthalmic aneurysms. The purpose of this study was to explore and summarize the technical features and effectiveness of the application of Hybrid-OR in dealing with major intracranial carotid-ophthalmic aneurysms. Methods: The department of neurosurgery treated 12 cases of large or giant intracranial carotid-ophthalmic aneurysms between March 2013 and December 2015 with Hybrid-OR. All cases were treated with clipping and parent vessel reconstruction. Results: With the assistance of Hybrid-OR, the rate of incompletion of intraoperative aneurysm clipping decreased from the original 25% ( 3/12) to 0%, while the rate of vessel stenosis decreased from the original 16.7% (2/12) to 8.35% (1/12). For thromboembolic event, there was one ischemic infarction complication occurred in only one patient, and none of patients appeared embolic infarction complication. All 12 patients were followed up for an average of 3 years and no aneurysms recurred. The postoperative recovery conditions were evaluated with the modified Rankin Scale (mRS): 11 patients showed no symptoms (mRS 0), 1 patient showed slight disability (mRS 1-2), and none of the cases showed severe disability (mRS 5) nor death (mRS 6). Conclusion: The Hybrid-OR provides new ideas to the surgical clipping the large or giant intracranial carotid-ophthalmic aneurysms, which effectively decreased the rate of intraoperative vessel stenosis and unsuccessful clippings.

Role of intraoperative angiography in the surgical treatment of cerebral aneurysms

1998 ◽  
Vol 88 (3) ◽  
pp. 441-447 ◽  
Author(s):  
Troy D. Payner ◽  
Terry G. Horner ◽  
Thomas J. Leipzig ◽  
John A. Scott ◽  
Richard L. Gilmor ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Parent Vessel ◽  
Intraoperative Angiography ◽  
Content Type ◽  
Aneurysm Clip ◽  
Giant Aneurysms ◽  
Vessel Stenosis ◽  
Distal Branch ◽  
Large And Giant Aneurysms ◽  
Fine Print

The benefit of using intraoperative angiography (IA) during aneurysm surgery is still uncertain. Object. In this prospective study, the authors evaluate the radiographically demonstrated success of surgical treatment in 151 consecutive patients harboring 173 aneurysms who selectively underwent IA examination. The authors also assess the frequency with which IA led to repositioning of the aneurysm clip. Methods. Intraoperative angiography was used selectively in this series, based on the surgeon's concern about the potential for residual aneurysm, distal branch occlusion, or parent vessel stenosis. Specific variables were analyzed to determine their impact on the incidence of clip repositioning and the accuracy of IA was evaluated by direct comparison with postoperative angiography (PA) in 90% of the cases in which IA was used. Conclusions. The selective use of IA led to successful treatment as shown by PA, with a low incidence of unexpected residual aneurysm (3.2%), distal branch occlusion (1.9%), and parent vessel stenosis (0%). Intraoperative angiography led to immediate repositioning of the aneurysm clip in 27% of the cases. Anterior cerebral artery aneurysms required clip repositioning less often and superior hypophyseal artery aneurysms required repositioning more often than aneurysms in other locations. Large and giant aneurysms required clip repositioning more often than small aneurysms; however, they were also more likely to display false success on IA as determined by PA. Aneurysms arising along the internal carotid artery were more likely to display successful clipping on IA, as determined by PA, than were aneurysms in other locations. The results of this series support the selective use of IA in the treatment of complex aneurysms, particularly large and giant aneurysms as well as superior hypophyseal artery aneurysms. As measured by PA, IA will improve the outcome of these patients.

scholarly journals An endovascular assisted, nonocclusive cerebral bypass: a technical feasibility study in a rabbit model

2020 ◽  
pp. 1-6
Author(s):  
Alexander Spiessberger ◽  
Fabio Strange ◽  
Basil Erwin Gruter ◽  
Stefan Wanderer ◽  
Daniela Casoni ◽  
...  
Keyword(s):  
Rabbit Model ◽  
High Flow ◽  
Neurological Deficits ◽  
Parent Artery ◽  
Parent Vessel ◽  
Vessel Occlusion ◽  
Intraoperative Angiography ◽  
Novel Technique ◽  
Bypass Patency ◽  
Parent Vessel Occlusion

OBJECTIVETemporary parent vessel occlusion performed to establish a high-flow interpositional bypass carries the risk of infarcts. The authors investigated the feasibility of a novel technique to establish a high-flow bypass without temporary parent vessel occlusion in order to lower the risk of ischemic complications.METHODSIn 10 New Zealand white rabbits, a carotid artery side-to-end anastomosis was performed under parent artery patency with a novel endovascular balloon device. Intraoperative angiography, postoperative neurological assessments, and postoperative MRI/MRA were performed to evaluate the feasibility and safety of the novel technique.RESULTSA patent anastomosis was established in 10 of 10 animals; 3 procedure-related complications occurred. No postoperative focal neurological deficits were observed. The MRI/MRA findings include no infarcts and bypass patency in 50% of the animals.CONCLUSIONSThe authors demonstrated the feasibility of an endovascular assisted, nonocclusive high-flow bypass. Future refinement of the device and technique in an animal model is necessary to lower the complication rate and increase patency rates.

Abstract WP33: Early Lessons Learned From the WEB Device: Feasibility, Technique and Complications—A Real Life Experience

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Nikolaos Mouchtouris ◽  
David Hasan ◽  
Fadi Al Saiegh ◽  
Ahmad Sweid ◽  
Mario Zanaty ◽  
...  
Keyword(s):  
Real Life ◽  
Cerebral Aneurysms ◽  
High Volume ◽  
Additional Treatment ◽  
Lessons Learned ◽  
Parent Vessel ◽  
Aneurysm Embolization ◽  
Web Device ◽  
Wide Neck ◽  
The Web

Introduction: Wide-neck bifurcation cerebral aneurysms have always posed a treatment challenge and have historically required either clip ligation, or stent vs. balloon-assisted coil embolization. This predicament led to the development of the newly FDA-approved Woven EndoBridge (WEB) aneurysm embolization system (Sequent Medical Inc, Aliso Viejo, CA) Which is a self-expanding mesh that achieves intrasaccular flow disruption and does not require antithrombotic medications. In this study, we report our experience with the first 64 consecutive aneurysms treated via WEB embolization at two high-volume institutions. Methods: We reviewed our first 61 consecutive patients with 64 cerebral aneurysms who underwent WEB embolization from February-August 2019. We collected data on patient demographics and clinical presentation, aneurysm characteristics, device and procedural details, and functional outcomes. Results: A total of 64 aneurysms were included in our study. Fifteen patients (24.1%) presented with acutely ruptured aneurysm while the rest were unruptured. The majority of patients (82.8%) required only one attempt for successful device deployment, while a stent was necessary as an adjunct treatment in 4 patients (6.3%) due to WEB herniation. Two patients had residual aneurysm that had to undergo additional treatment; one of them underwent second WEB embolization and one underwent clip ligation. One patient with a PICA aneurysm had device dislodgment with injury to the parent vessel—Onyx and coils were used to deconstruct the vertebral artery. Conclusions: The advent of the WEB device has significantly impacted the surgical decision-making for the treatment of bifurcation, wide-neck aneurysms. We discuss in detail the lessons learned from patient selection, device size selection, technique, and complications from two institutions with high-volume endovascular and microsurgical aneurysm treatment experience.

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