The New Aneurysm Clip System for Particularly Complex Aneurysm Surgery

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. onsE336-onsE338 ◽  
Author(s):  
Matthias J. Krammer ◽  
Christianto B. Lumenta
Keyword(s):  
Anterior Communicating Artery ◽  
Aneurysm Surgery ◽  
Ongoing Debate ◽  
Complex Aneurysm ◽  
Complex Aneurysms ◽  
Microsurgical Clipping ◽  
International Subarachnoid Aneurysm Trial ◽  
Clip Application ◽  
Potential Benefits ◽  
Technical Complication

Abstract BACKGROUND Currently, there is an ongoing debate regarding the best treatment option for ruptured aneurysms. The International Subarachnoid Aneurysm Trial study suggests that an endovascular procedure is the best treatment. In some complex cases, or in patients with an additional large intracerebral hemorrhage, aneurysms require further microsurgical clipping. OBJECTIVE We introduce a new clip system to improve clipping procedures in especially complex aneurysms. METHODS The inverted opening mechanism of the clip in combination with the special clip applier provides the surgeon with a good overview in the operating field. The new design also enables a wider opening of the clip jaws in contrast to all other well-known titanium aneurysm clips. This should provide a better and safer application and decrease the danger of premature rupture. RESULTS From January 2006 to July 2008, 55 aneurysms were clipped in 45 patients. The most common aneurysm location was the anterior communicating artery (20 patients) followed by the M1 segment of the middle cerebral artery (16 patients). Four patients had 2, one had 3, and one had 5 aneurysms. Two clipping procedures were performed for an ateriovenous malformation-associated aneurysm. All aneurysms were clipped without any technical complication. CONCLUSION The use of the new clip system, especially in complex aneurysm surgery, has potential benefits because of the better surgical vision during clip application and the wider opening of the clip jaws. It is easy to handle and compatible with magnetic resonance imaging.

scholarly journals Microsurgery for Multiple Intracranial Aneurysms

2021 ◽  
Vol 32 (1) ◽  
pp. 81-88
Author(s):  
Laís Miotta Simoncello ◽  
Hsuan Hua Chen ◽  
Lucas do Amaral Genta Mansano ◽  
Manauela Iglesias Borges ◽  
Sophia Fuentes Rosa ◽  
...  
Keyword(s):  
Intracranial Aneurysms ◽  
Cerebral Aneurysms ◽  
Single Stage ◽  
Anterior Communicating Artery ◽  
Multiple Intracranial Aneurysms ◽  
Complex Aneurysms ◽  
Microsurgical Clipping ◽  
Microsurgical Approach ◽  
The Right ◽  
Age Range

Background: A total of 23 patients with 52 aneurysms were surgically treated in single surgery at a Neurosurgical Service of the Health Service of the State of São Paulo from 2009 to 2011. Method: Retrospective analysis of patients undergoing clipping of two or more cerebral aneurysms in a single stage, from January 2007 to July 2012. Results: Twenty-nine patients underwent two or more clipping cerebral aneurysms in a single surgery – 28 with a single craniotomy and one through two craniotomies. Of these, 20, 7, 1 and 1 were submitted to the clipping of 2, 3, 4 and 5 cerebral aneurysms, respectively. Five were male and 24 were female, and the age range was 40 to 66-years-old. Eight left craniotomies were performed to approach 17 lateralized brain aneurysms to the left and five to the right, as well as three anterior communicating complex aneurysms. Twelve craniotomies were performed on the right to approach 23 intracranial aneurysms lateralized to the right and six on the left, as well as 15 anterior communicating artery complex aneurysms and 1 on the basilar artery. Of the 29 patients, 28 evolved with 1-3 pts and only one with 4-5 pts on the Rankin scale, six months after surgery. Conclusion: We advocate microsurgical approach for most of the cases of multiple intracranial aneurysms aiming the microsurgical clipping of all intracranial aneurysms if feasible through a single stage and a single craniotomy.

Factors determining best surgical exposure and safe clip positioning in anterior communicating artery (AComA) aneurysms surgery – particular significance of AComA complex rotation in axial plane

2019 ◽  
Vol 91 (5) ◽  
pp. 1-5
Author(s):  
Wojciech Świątnicki ◽  
Anna Radomiak-Załuska ◽  
Mariusz Heleniak ◽  
Piotr Komuński
Keyword(s):  
Axial Plane ◽  
Coronal Plane ◽  
Anterior Communicating Artery ◽  
Posterior Angle ◽  
Complex Rotation ◽  
Microsurgical Clipping ◽  
Significant Difference ◽  
Clip Application ◽  
Temporary Clip ◽  
Junction Angle

Introduction. The aim of this study was to evaluate whether Anterior Communicating Artery (AComA) complex rotation in axial plane may influence the ease of surgical exploration in this region and safety of clip positioning when left vs right-sided approach is compared. Materials and methods. This is a retrospective study based on analysis of patients operated due to AComA aneurysm, both ruptured and unruptured. AComA complex position in relation to coronal plane was evaluated using 3D-CTA VR reconstructions. Next, comparison between surgical approach from the side where A1-A2 junction (angle) was located anterior and posterior to coronal plane was performed in relation to surgical difficulties and intra- and postoperative complications. Results. Subgroup statistical analysis revealed that there is a strong and statistically significant correlation between AComA complex rotation and surgical difficulties expressed by the need of repeated temporary clip application and brain transgression. When anterior vs posterior angle side approach was compared in relation to surgical difficulties and complications, there was a statistically significant difference with strong correlation (p <0,05) in favour of posterior angle side approach. Interestingly, in 72,7% and 45,5% of patients that were operated from the side where A1-A2 junction was located posterior to coronal plane, the approach was performed form the side of a non-dominant A1 and aneurysm dome projection side, respectively. Conclusions. Despite its limitations, our results suggest that microsurgical clipping strategy of AComA aneurysms should at least include AComA complex rotation in axial plane, besides well acknowledged factors, when deciding from which side these lesions will be approached.

scholarly journals The Role of Neurophysiological Monitoring during Complex Aneurysm Surgery: Report of Two Cases and Review of the Literature

2019 ◽  
Vol 38 (04) ◽  
pp. 348-353
Author(s):  
Roger Schmidt Brock ◽  
Marcos Queiroz Teles Gomes ◽  
Félix Hendrik Pahl ◽  
José Erasmo Dal Col Lúcio ◽  
José Francisco Pereira Júnior ◽  
...  
Keyword(s):  
Intraoperative Monitoring ◽  
Intracranial Aneurysms ◽  
Neurophysiological Monitoring ◽  
Aneurysm Surgery ◽  
Surgical Team ◽  
Review Of The Literature ◽  
Giant Aneurysms ◽  
Complex Aneurysm ◽  
Complex Aneurysms

AbstractThe surgical treatment of intracranial aneurysms is a routine operation in the neurosurgeon practice. Complex aneurysms are those with morphological irregularities, usually large or giant; thrombosed, partially thrombosed or calcified; with aberrant fundus/neck ratio and near eloquent neurological structures. These cases demand special skills by the surgical team. The present article is a report of two cases of complex aneurysms successfully treated, with a discussion on the role of neurophysiological monitoring. In these two cases of supra- and infratentorial complex giant aneurysms, intraoperative monitoring was extremely relevant. Thus, we believe that treating complex and giant aneurysms carries several pitfalls, and the use of multimodal intraoperative monitoring is mandatory to mitigate risks and deliver the best result to the patient.

Anatomical triangles defining routes to anterior communicating artery aneurysms: the junctional and precommunicating triangles and the role of dome projection

2020 ◽  
Vol 132 (5) ◽  
pp. 1517-1528 ◽  
Author(s):  
Michael E. Ivan ◽  
Michael M. Safaee ◽  
Nikolay L. Martirosyan ◽  
Ana Rodríguez-Hernández ◽  
Barbara Sullinger ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Anterior Communicating Artery ◽  
Intraluminal Thrombus ◽  
Surgical Clipping ◽  
Unruptured Aneurysms ◽  
Microsurgical Clipping ◽  
Large Size ◽  
Clip Application

OBJECTIVEAnterior communicating artery (ACoA) aneurysms are common intracranial aneurysms. Despite advances in endovascular therapy, microsurgical clipping remains an important treatment for aneurysms with broad necks, large size, intraluminal thrombus, complex branches, or previous coiling. Anatomical triangles identify safe corridors for aneurysm access. The authors introduce the A1-A2 junctional triangle and the A1-A1 precommunicating triangle and examine relationships between dome projection, triangular corridors of access, and surgical outcomes.METHODSPreoperative catheter and CT angiograms were evaluated to characterize aneurysm dome projection. Aneurysm projection was categorized into quadrants and octants. Preoperative, intraoperative, and postoperative factors were correlated to aneurysm dome projection and patient outcomes using univariate and multivariate analyses.RESULTSA total of 513 patients with microsurgically treated ACoA aneurysms were identified over a 13-year period, and 400 had adequate imaging and follow-up data for inclusion. Surgical clipping was performed on 271 ruptured and 129 unruptured aneurysms. Good outcomes were observed in 91% of patients with unruptured aneurysms and 86% of those with ruptured aneurysms, with a mortality rate < 1% among patients with unruptured aneurysms. Increasing age (p < 0.01), larger aneurysm size (p = 0.03), and worse preoperative modified Rankin Scale score (p < 0.01) affected outcomes adversely. Aneurysms projecting superiorly and posteriorly required dissection in the junctional triangle, and multivariate analysis demonstrated worse clinical outcomes in these patients (p < 0.01).CONCLUSIONSAnteriorly and inferiorly projecting aneurysms involve only the precommunicating triangle, are simpler to treat microsurgically, and have more favorable outcomes. Superior and posterior dome projections make ACoA aneurysms more difficult to visualize and require opening the junctional triangle. Added visualization through the junctional triangle is recommended for these aneurysms in order to facilitate dissection of efferent branch arteries, careful clip application, and perforator preservation. Dome projection can be determined preoperatively from images and can help anticipate dissection routes through the junctional triangle.

scholarly journals Combined treatment for complex intracranial aneurysm

2015 ◽  
Vol 29 (2) ◽  
pp. 189-193
Author(s):  
A. Chiriac ◽  
Georgiana Ion ◽  
N. Dobrin ◽  
St.M. Iencean ◽  
I. Poeata
Keyword(s):  
Combined Treatment ◽  
Endovascular Coiling ◽  
Endovascular Techniques ◽  
Close Collaboration ◽  
Aneurysm Neck ◽  
Complex Aneurysm ◽  
Neck Reconstruction ◽  
Complex Aneurysms ◽  
Microsurgical Clipping ◽  
Aneurysm Occlusion

Abstract Complex aneurysms often cannot be completely excluded by a single approaches. Today successful treatment of these lesions requires a combination between microsurgical and endovascular techniques. Planning of combined treatment require a very good understanding of aneurysm anatomy and a close collaboration between neurosurgeon and neuroendovascular interventionist. Endovascular coiling can usually be used as early treatment for a partially aneurysm occlusion including the ruptured area and followed by definitive clipping. On the other hand microsurgical clipping also can be used as first treatment for complex aneurysm neck reconstruction, allowing successful secondary placement of coils inside the remnant aneurysm sac

Comprehensive review of the recent advances in devices for endovascular treatment of complex brain aneurysms

2021 ◽  
Author(s):  
Kavi Fatania ◽  
Dr Tufail Patankar
Keyword(s):  
Endovascular Treatment ◽  
Mortality And Morbidity ◽  
Complex Aneurysm ◽  
Complex Aneurysms ◽  
Aneurysm Treatment ◽  
Unruptured Intracranial Aneurysms ◽  
Acceptable Risks ◽  
International Subarachnoid Aneurysm Trial ◽  
Wide Neck ◽  
Promising Avenue

The International Subarachnoid Aneurysm Trial (ISAT) showed superiority for endovascular treatment of ruptured aneurysms and technology has since moved on rapidly. Many approaches and technology now exist for the endovascular management of ruptured and unruptured intracranial aneurysms, which reflects their varied nature – there is no one-size-fits-all technique. We aim to provide an overview of the various classes of device and the major developments over the past decade. Coiling is the oldest of the technology and continues to demonstrate high levels of occlusion and acceptable risks, making it the default treatment choice, particularly in the acutely ruptured aneurysm setting. Advances on coiling include the use of adjuncts such as balloons, stents and fully retrievable temporary neck-bridging devices, which have facilitated the treatment of more complex aneurysms. Flow divertors have also revolutionised complex aneurysm treatment with small added risk in acute aneurysm treatment and seek to remodel the aneurysm–vessel interface without accessing the aneurysm sac. The latest development and most promising avenue appears to be intrasaccular flow disrupting devices like WEB, Contour and Neqstent that provide excellent opportunities to treat wide neck complex aneurysm with minimal mortality and morbidity and good occlusion rates and may in future replace a significant number of stent-assisted coiling too.

Comparing indocyanine green videoangiography to the gold standard of intraoperative digital subtraction angiography used in aneurysm surgery

2013 ◽  
Vol 118 (2) ◽  
pp. 420-427 ◽  
Author(s):  
Chad W. Washington ◽  
Gregory J. Zipfel ◽  
Michael R. Chicoine ◽  
Colin P. Derdeyn ◽  
Keith M. Rich ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Gold Standard ◽  
Anterior Communicating Artery ◽  
Collateral Flow ◽  
Aneurysm Surgery ◽  
Vessel Occlusion ◽  
Intraoperative Angiography ◽  
Indocyanine Green Videoangiography ◽  
Clip Application ◽  
A New Technique

Object The purpose of aneurysm surgery is complete aneurysm obliteration while sparing associated arteries. Indocyanine green (ICG) videoangiography is a new technique that allows for real-time evaluation of blood flow in the aneurysm and vessels. The authors performed a retrospective study to compare the accuracy of ICG videoangiography with intraoperative angiography (IA), and determine if ICG videoangiography can be used without follow-up IA. Methods From June 2007 through September 2009, 155 patients underwent craniotomies for clipping of aneurysms. Operative summaries, angiograms, and operative and ICG videoangiography videos were reviewed. The number, size, and location of aneurysms, the ICG videoangiography and IA findings, and the need for clip adjustment after ICG videoangiography and IA were recorded. Discordance between ICG videoangiography and IA was defined as ICG videoangiography demonstrating aneurysm obliteration and normal vessel flow, but post-IA showing either an aneurysmal remnant and/or vessel occlusion requiring clip adjustment. Results Thirty-two percent of patients (49 of 155) underwent both ICG videoangiography and IA. The post-ICG videoangiography clip adjustment rate was 4.1% (2 of 49). The overall rate of ICG videoangiography–IA agreement was 75.5% (37 of 49) and the ICG videoangiography–IA discordance rate requiring post-IA clip adjustment was 14.3% (7 of 49). Adjustments were due to 3 aneurysmal remnants and 4 vessel occlusions. These adjustments were attributed to obscuration of the residual aneurysm or the affected vessel from the field of view and the presence of dye in the affected vessel via collateral flow. Although not statistically significant, there was a trend for ICG videoangiography–IA discordance requiring clip adjustment to occur in cases involving the anterior communicating artery complex, with an odds ratio of 3.3 for ICG videoangiography–IA discordance in these cases. Conclusions These results suggest that care should be taken when considering ICG videoangiography as the sole means for intraoperative evaluation of aneurysm clip application. The authors further conclude that IA should remain the gold standard for evaluation during aneurysm surgery. However, a combination of ICG videoangiography and IA may ultimately prove to be the most effective strategy for maximizing the safety and efficacy of aneurysm surgery.

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