Fenestrated aneurysm clips in the surgical management of anterior communicating artery aneurysms: operative techniques and strategy

Abstract

Aneurysms of the anterior communicating artery (ACoA) can be a considerable challenge to treat surgically based on variations in the anatomy and morphological features of the ACoA complex. The fenestrated aneurysm clip can be a simple and practical tool in the operative management of ACoA aneurysms. The goal in this study was to characterize the particular surgical situations in which the use of a fenestrated clip facilitates the clip ligation of ACoA aneurysms. The authors present their operative strategy and techniques for the use of fenestrated clips in the treatment of ACoA aneurysms. One hundred ninety-nine patients underwent surgical clipping of an ACoA aneurysm at the authors' institution between the years 1991 and 2008. Of these patients, fenestrated aneurysm clips were used in 20 cases (10%). The following structures were enclosed in the clip aperture: ipsilateral A(2) artery, 12 patients (60%); ipsilateral A(1) artery, 4 patients (20%); ipsilateral A(1) artery plus recurrent artery of Heubner, 1 patient (5%); ACoA, 1 patient (5%); frontopolar artery, 1 patient (5%); and no structures, 1 patient (5%). Aneurysms approached from the left side more frequently required fenestrated clips than did right-sided aneurysms (80 vs 20%, p = 0.0073). In all cases, patency of the A(2) vessels was confirmed on postoperative angiography. In 2 patients, small remnant aneurysm necks were identified on postoperative angiography. The use of fenestrated aneurysm clips can minimize tedious and potentially dangerous dissection of adherent branch vessels, while maintaining the integrity of structures placed within the clip aperture. The ACoA aneurysms pointing in a superior direction are more likely to require clip fenestration around the A(2) vessel, whereas those pointing in an inferior direction are more likely to require clip fenestration around the A(1) vessel. The parallel approximation of the fenestrated clip blades makes them especially useful in the treatment of large or giant aneurysms.