Complete Exclusion Of Aneurysm Research Articles

Comparative Analysis of Tailored Minicraniotomy versus Standard Pterional Craniotomy in the Treatment of Anterior Circulation Aneurysms: A Single-Center Case–Control Observational Study

Abstract Introduction Multiple minicraniotomies (Mct) have been proposed as alternatives to standard pterional craniotomy (Pct) for intracranial aneurysm treatment. These approaches offer limited surgical corridors and distinct working angles, posing challenges in addressing all aneurysm types with one method. We suggest a tailored Mct technique, comprising three minimally invasive approaches targeting anterior circulation aneurysm sites (middle cerebral artery, internal carotid artery, anterior communicating artery). Methods We conducted a retrospective, case–control study at a single center comparing Pct and Mct outcomes for ruptured and unruptured aneurysms. Parameters evaluated included conversion rates to Pct or decompressive hemicraniectomy (DHC), intraoperative rupture (IOR), surgical complications, complete aneurysm exclusion, 6-month modified Rankin Scale (mRS) scores, and aesthetic outcomes using a visual analog scale. A total of 146 patients were included, with 103 in the Mct group and 43 in the Pct group, comparable in mean age, sex, and aneurysm topography. Hunt–Hess scores and Fisher grades were lower in the Mct group initially. Results No cases required conversion from Mct to Pct or DHC. No significant differences were observed in IOR, surgical complications, and aneurysm exclusion rates between groups. The Mct group demonstrated better 6-month mRS scores and aesthetic outcomes. Conclusion Our study indicates that tailored Mct is as safe and effective as standard Pct for intracranial aneurysms, with significant cosmetic benefits. Thus, tailored Mct can be considered a valuable alternative not only to Pct but also to other minimally invasive surgical methods for these aneurysms.

Double Transposition and Physician-Modified Endografting for Complex Arch Aneurysm

Hybrid repair of complex aortic arch disease typically requires aortic debranching to create a proximal landing zone for completion arch endografting. Despite advances in endograft technology, physician-modified endografting may be required to customize a prosthesis for challenging anatomy. We present a case of a complex distal arch aneurysm after a prior coarctation repair with a pediatric interposition graft several decades earlier, treated with hybrid repair by double transposition for arch debranching and physician-modified arch endografting for complete aneurysm exclusion.

Standardized approach for four-fenestrated physician-modified endograft to treat complex abdominal aortic aneurysms using Valiant Captivia

We describe the feasibility and safety of a standardized approach for four-fenestrated physician-modified endograft (PMEG) placement to treat complex abdominal aortic aneurysms using the Valiant Captivia platform (Medtronic). The standardization is based on specific selection criteria for anatomical feasibility, measurement method, and modification technique of a single endograft type. Six cases (two juxtarenal, two pararenal, and two type IV thoracoabdominal aneurysms) were treated, with 24 target vessels incorporated with fenestrations. Four cases were treated in an urgent setting and two were elective. The time modification required was 121 ± 18 minutes. Technical success was 100%, with no mortality or complications at 30 days. Postoperative computed tomography at 3 months demonstrated complete aneurysm exclusion, without a type I or III endoleak, no main graft- or fenestration-related loss of integrity, and no target vessel misalignment or stent fracture. The present standardized approach seems safe and feasible and might represent an initial benchmark for comparison with future studies.

Bone anatomic variations of the parasellar region and its technical implications in para clinoid and posterior communicating segment aneurysms microsurgical clipping - Technical note.

Microsurgical treatment of paraclinoid aneurysms is a complex task that generally requires anterior clinoid process (ACP) removal to obtain adequate surgical exposure. This procedure poses a considerable technical difficulty due to the association of the ACP to critical neurovascular structures. Furthermore, anatomical variations in the parasellar region, such as the caroticoclinoid foramen (CCF) or an interclinoid bridge (ICB), may impose additional challenges and increase surgical complications. The present study aims to briefly review some anatomic variations in the parasellar region and describe a step-by-step surgical technique for a hybrid anterior clinoidectomy based on the senior author's experience. We present two cases with bone variations on the parasellar region in patients with a paraclinoid aneurysm and another with a posterior communicating segment aneurysm treated by microsurgical clipping at our hospital. We focused on safely dealing with these variations during surgery, without further complications, and with good postoperative results. Patients were discharged with no significant deficit. Postoperative control, computed tomography angiography showed complete exclusion of aneurysms. Although anatomical variations in the parasellar region can complicate surgical clipping of these aneurysms, it is essential to ensure the best possible surgical outcome to conduct thorough preoperative and radiological evaluations.

Thoracic endovascular repair of descending thoracic aorta aneurysm using thoracic stent graft in a challenging complex patient: An innovative access technique during an emergency using a mini-thoracotomy approach.

Repairing thoracic aortic aneurysms with endovascular aortic repair (TEVAR) is a safe and minimally invasive method with low morbidity and short postoperative recovery. We developed a novel method to treat descending thoracic aortic aneurysms using a mini-thoracotomy approach in complex patients with difficult access. A 56-year-old male patient presented with a 3-day history of chest pain. His past surgical history included infrarenal aortic ligation and right axillobifemoral bypass. Thoracic computed tomography angiography (CTA) revealed a saccular aortic aneurysmal dilatation at zone 2 measuring 4.4 × 4cm. Owing to his surgical history, vascular access through the femoral and iliac arteries or abdominal aorta was impossible. We developed a new technique using a left posterolateral mini-thoracotomy approach to gain vascular access and perform TEVAR, avoiding the need for an open thoracotomy repair. Thoracic CTA performed before discharge revealed complete aneurysmal exclusion and no endoleaks. Postoperative follow-up CTA (6months and annually thereafter) revealed no aneurysm formation or aortic restenosis. The femoral artery, followed by the iliac artery, is the traditional access route for TEVAR. Left posterolateral mini-thoracotomy may be required as an alternative access in complex patients.

Application of hybrid operating room in the surgical treatment for intracranial aneurysm

BackgroundIntracranial aneurysms are associated with a high mortality rate in the event of a rupture and significant morbidity during subsequent treatment. Hybrid treatment approaches for vascular diseases have been incorporated into modern operating rooms as guides for surgical interventions now. The current study evaluates the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment of intracranial aneurysms. AimsTo evaluate the feasibility and effectiveness of hybrid operating room system and its application in the surgical treatment for aneurysms. Methods76 patients with 84 intracranial aneurysms were surgically treated in Hybrid operating room with intraoperative angiography between March 2018 and March 2021. Aneurysm clipping was performed in 76 (94.7 %) cases; Aneurysm trapping with extracranial-intracranial (EC-IC) bypass in 4 (5.3 %) cases. Patient demographics, aneurysm size, location, Hunt and Hess score, were recorded. 69 (90.8 %) patients were followed up 6–12 months post operation. ResultsIntraoperative angiography demonstrated 5 (6.9%) unexpected aneurysm neck residuals leading to adjustment; 6 (8.3%) parent vessel stenosis in which 5 returned to normal after adjustment. Four giant paraclinoid aneurysms trapping with EC-IC bypass showed total successful vessel reconstruction and complete aneurysm exclusion (100%). The postoperative outcome was evaluated with the modified Rankin Scale (mRS). 53 (76.8%) patients showed good outcome (mRS 0), 11 (15.9%) showed mild neurological defect (mRS 1–2), 3 (4.3%) showed poor outcome (mRS 5), and 2 (2.9%) patients died (mRS 6, Hunt-Hess grade V before surgery). Conclusion: Hybrid operating room provides new concepts in the surgically treatment of intracranial aneurysms, especially valuable for the complex aneurysms. The combination of intraoperative imaging of angiography and clipping surgery may offer the opportunity of radical clipping and reduced complications for aneurysm patients.

Physician-Modified Single-Fenestrated EndoSuture Aneurysm Repair (FESAR) for Urgent Juxtarenal AAA Repair.

To describe the endovascular treatment of a symptomatic juxtarenal abdominal aortic aneurysm (JAAA) using a combination of endoanchors (Heli-FX EndoAnchor, Medtronic, Minneapolis, Minnesota) and a physician-modified single-fenestrated endograft. An 85 year-old patient unfit for open aortic repair presented for a symptomatic JAAA, characterized by an infrarenal neck with 0.6 cm in length and 23 mm in diameter. A 28 mm-diameter Endurant aortic cuff (Medtronic, Minneapolis, Minnesota) was modified with a single fenestration for the left renal artery (LRA) and diameter-reducing tie, then re-sheathed and deployed. The LRA was cannulated with a 7F sheath and the constraining wire was withdrawn. Being the shortest neck length on the right side of the cuff, the endograft was anchored to the aortic wall on this side with 2 endoanchors. The LRA was stented and flared, then a distal physician-modified (without free-flow) bifurcated Endurant graft (Medtronic, Minneapolis, Minnesota) was overlapped with the proximal cuff and stabilized with 6 endoanchors. Correct positioning with complete aneurysm exclusion was confirmed with a 30 day and 9 month computed tomography angiograms. In extremely selected cases, association of endoanchors and single-fenestrated physician-modified graft may be useful to treat complex urgent aortic aneurysm using readily available devices. This technical note demonstrates the feasibility of a single-fenestrated physician-modified Endurant endograft deployed in combination with endosuture fixation (FESAR), to urgently treat a juxtarenal aortic aneurysm unfit for open repair and not suitable for standard endovascular repair nor off-the-shelf endografts.

The “safe-line” technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm

The “safe-line” technique as theoretical additional attempt to mitigate spinal cord ischemia after urgent complete endovascular exclusion of a thoracoabdominal aortic aneurysm

Physician Modification of a Custom-Made Fenestrated Endograft By Closure of a Fenestration With Bovine Patch.

Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration. In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively. In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique. The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.

Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches.

Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs. Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors. Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80-490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99-2232.24, p = 0.01). One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.

A Rare Case of Coronary Artery Fistula on Vieussens Arterial Ring

Coronary artery fistulas represent an abnormal communication between coronary circulation and heart chambers or any segment of pulmonary or systemic circulation, without an intervening capillary network. Seldom, this connection can arise on a conotruncal anastomotic variant linking the anterior descending artery and the right coronary artery or a conus artery originating from the right coronary sinus, known as Vieussens’ arterial ring. Here we discuss a case of a 73-yearold man undergoing a coronary CT angiography because of recurrent chest pain and cardiovascular risk factors; the exam showed multiple aneurismatic sacs on a Vieussens arterial ring, associated with a fistulous connection between one of the aneurysms and the main pulmonary artery, highlighted by an hyper dense jet of contrast medium within its lumen. We spotted also enlarged right and left pulmonary arteries and right ventricular dilatation, with a mild hemodynamic overload on echocardiographic evaluation. A coronary angiography confirmed the findings shown by CT scan. After a multidisciplinary discussion, the interventional cardiology team decided to close the fistulous connection. Therefore, in a subsequent procedure the malformation was treated by catheterizing the branch stemming from the anterior descending artery and placing embolization coils in the first aneurysmatic sac and in the vessel itself; the same treatment was performed on the branch originating from the right coronary sinus. Final angiographic control showed complete exclusion of the saccular aneurysms from the circulation and closure of the associated fistula. There was no peri or post-procedural complication.

Physician-Modified Endograft With Inner Branches for the Treatment of Complex Aortic Urgencies

Purpose To describe the use of physician-modified endograft (PMEG) with the exclusive use of inner branches or in combination with fenestrations for the urgent treatment of complex aortic aneurysms. Technique We present two urgent cases. A patient with a 6.8 cm saccular juxtarenal aneurysm and another patient with a contained rupture of the thoracoabdominal aorta right above the celiac trunk (CT). In both cases, a Cook Zenith TX2 thoracic endograft was back-table modified, in the first case by adding three fenestrations and one inner branch for the left renal artery to improve sealing due to its partial involvement in the aneurysm and, in the second case, with the use of two inner branches for the CT and superior mesenteric artery. Both procedures were successful, with uneventful postoperative courses and complete aneurysm exclusion on postoperative CT angiography. Conclusion Use of PMEGs with inner branches is feasible for urgent repair in complex aortic anatomy.

Single Centre Experience in Open and Endovascular Treatment of Renal Artery Aneurysms

Background: The true incidence and natural history of renal artery aneurysm (RAA) remain unclear and still exists controversy over indication for treatment. Several techniques of conventional surgical reconstructions are described in literature, and more recently endovascular therapies have been reported with satisfying results and lower complication rate. This paper aims to investigate the outcomes of both endovascular and open repair of RAA achieved in a single institution involving 3 medical teams (urology, vascular surgery and neuroradiology). Material and Methods: We conducted a single-centre retrospective observational study about all patients surgically or endovascularly treated for RAA over a 15-year period. Pre-operative, procedural and post-operative data at the early, mid- and long-term follow-up were collected and analysed, focusing on operative technique used for repair and related outcomes. Results: A total of 27 patients (n = 17 (63%) women, mean age 58 ± 13.2, n = 26 saccular RAA) were included. Mean aneurysm was size was 18.8 ± 6.3 mm. Most diagnosis were accidental. Symptomatic RAA showed with macroscopic haematuria (n = 3, 25.9%), unstable hypertension (n = 2; 7%), chronic lumbar pain (n = 1, 3.7%) and renal infarct (n = 1, 3.7%).Conventional surgery (ex-vivo repair, aneurysmorraphy, aneurysm resection and end-to-end anastomosis) was performed in 14 (51.8%) cases and endovascular coiling embolization in 13 (48.2%). Mean hospital length of stay was 5.4 ± 3.6 days. Intensive Care Unit stay was needed only in the surgically treated patients (mean 1.1 ± 1.2 days). During the early follow-up, morbidity rate was 7/14 in surgically treated patients vs. 1/13 in endovascular group; it included bleeding, retroperitoneal hematoma, arterial thrombosis and bowel obstruction. The discharge imaging showed complete aneurysm exclusion and renal artery patency in all cases.At a mean follow-up of 39 ± 42 months, 3 patients (11%) were lost to follow up and 2 (7.4 %) died from unrelated cause. None of these patients required dialysis but a statistically significant (P = 0.09) decrease in GFR was noted between the preoperative period and last follow-up control. RAA repair neither showed blood pressure control improvement nor reduced the need for anti-hypertensive drug use. Conclusion: Open or endovascular techniques are both safe and efficient to treat RAA. Even though, surgical management is burdened with higher morbidity rate, the operative technique should be selected according to anatomical features, diameters and location of RRA; and the number of renal branches involved. Further larger studies are needed to define the feasibility and safety for a wider application of the endovascular approach.

Paraclinoid aneurysms: Outcome analysis and technical remarks of a microsurgical series

IntroductionA critical appraisal of the surgical results of paraclinoid aneurysms is essential in the flow diverters era.This study overviews the data of a three-decade surgical series of paraclinoid aneurysms while focusing on their technical remarks. MethodsOverall data of a surgical consecutive series of paraclinoid aneurysms treated between 1993 and 2021 were retrospectively reviewed. Aneurysms were classified according to size and projection. Indications for surgery were different based on the availability of endovascular techniques, especially flow diverter, at the time of treatment. A statistical comparison between ruptured and unruptured aneurysms was accomplished. Results58 patients were operated upon. Ophthalmic aneurysms were 68%, giant aneurysms 20%, and ruptured aneurysms 45%. Clipping and bypass were executed in 91% and 9% of cases, respectively. An mRS of 0–2 was achieved in 77% of patients, independently by the clinical onset. The mortality rate was 5%. Visual field was improved or unchanged in 71% of elective patients, whereas the incidence of de novo third and sixth cranial nerves deficit was 8% and 5%, respectively. On an average follow-up of 53.3 ± 38 months, a complete and durable aneurysm exclusion was achieved in 91.3% of patients with a single surgery. ConclusionsMicroneurosurgery is still a valuable treatment option for selected ruptured and unruptured paraclinoid aneurysms. In our experience, it has proven to be definitive and durable, with acceptable morbidity and mortality. Clipping is the treatment of choice in most surgical cases, achieving a good visual outcome in symptomatic patients.

One-year results of stent graft repair for carotid artery pseudo-aneurysm in patients with Behcet's disease.

Behcet's disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet's disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit. During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention. The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%). Stent graft repair for carotid artery pseudo-aneurysm in Behcet's disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.

Abstract No. 450 Endovascular treatment of renal artery aneurysms: a single-center experience

Renal artery aneurysms (RAA) represents a rare and potentially life-threatening condition with a documented incidence of 0.09% of the general population. Endovascular treatment for RAA is becoming widely accepted over open surgical repair due to decreased morbidity and comparable mortality. We report safety and efficacy of endovascular treatment of RAA. A single-center retrospective review of all endovascular treatment of RAA from November 2008 to September 2019 was performed. Eleven RAA (81.8% F, age 58.4) were identified (Table). Procedural and clinical details, aneurysm characteristics, and outcomes were recorded. Technical success, defined as complete aneurysm exclusion with preservation of renal function (no change in GFR/Cr), 30-day mortality rate, minor and major adverse events (following the Society of Interventional Radiology Clinical Practical guidelines), and re-intervention rates were recorded. The mean follow-up period was 23 months (range, 1–130). Technical success rate was 100%. No re-intervention was required. One 30-day mortality was reported (9%), likely due to the patient’s underlying stage IV renal cell carcinoma and unrelated to intervention. No significant changes in renal function was seen. One minor adverse event was recorded, which was attributed to renal infarctions < 50% without elevation in baseline GFR. Endovascular treatment of RAA is associated with high technical success rates and comparatively low major AEs.Tabled 1Baseline Demographics and Clinical and Procedural CharacteristicsAneurysm (n = 11)Age, mean (SD)58 (16.5)Gender, n, (%) Male1 (10) Female10 (82)Race White4 (36) Black3 (27) Asian1 (9) Hispanic or Latina0 (0) Other2 (18) Unknown1 (9)BMI, kg/m2, mean (SD)31.33 (8)Aneurysm location or site Left renal7 (64) Right renal4 (36)Size (cm)1.5 (0.8–2.9)Aneurysm (n = 11)Embolization agent, n (%) Coils5 (45) Glue2 (18) Stent-assisted coiling3 (27) Balloon-assisted coil1 (9)GFR, pre-embolization60GFR, post-embolization60Creatinine, pre-embolization0.84Creatinine, post-embolization0.89Technical success11 (100)Complications Major0 Minor1 (9)30-day mortality rate1 (9) Open table in a new tab

PICA injury secondary to anterior odontoid screw fixation: Case report of an exceptional complication

BackgroundOdontoid fracture is a common injury in the upper cervical spine that can sometimes be managed by anterior odontoid screw fixation. Case descriptionWe report the first case of iatrogenic postero-inferior cerebellar artery (PICA) injury while performing anterior odontoid screw fixation for a type II odontoid fracture in a 22-year-old man. Fisher grade 4 subarachnoid hemorrhage secondary to iatrogenic pseudoaneurysm formation was managed by the endovascular neuroradiologist. Odontoid fracture was then managed posteriorly using Harm's technique. Postoperative 12-month follow-up revealed good clinical and radiological results. CT scan showed fusion. Complete exclusion of the pseudo aneurysm with a mild stroke in the inferior left cerebellar hemisphere were noted on the MRI. There were no cerebellar ataxia or swallowing disorders. ConclusionTo the best of our knowledge, this is the first case report of iatrogenic PICA injury in anterior odontoid screw fixation. The patient was well managed in our institution within a multidisciplinary team. We recommend that surgical management of odontoid fractures should be performed in expert centres.

Microneurosurgery for Paraclinoid Aneurysms in the Context of Flow Diverters.

The advent of flow diverter (FD) stentshas apparently reduced the role of microneurosurgery for paraclinoid aneurysms despite sparse high-quality evidence about their long-term effects.The present study critically reviews the overall results of a microneurosurgical series of 57 paraclinoid aneurysms.Of these aneurysms, 47.4% were regular in size while 19.3 were giant. Barami type I was predominant. In 21 aneurysms a hemorrhagic onset occurred. Pterional approach with intradural anterior clinoidectomy was preferred by far. Clipping was possible in 91.2% of aneurysms and a high-flow bypass was the choice in five cases. An mRS of 0-2 was achieved in 77.3% of patients, typically <50years old.Visual field appeared improved or unchanged in 36.3% and 63.6% of the symptomatic patients, respectively. In 76.1% of incidental aneurysms, campimetry was unaffected by surgery.A complete aneurysm exclusion was achieved in 93% of cases usinga single procedure. No recurrences were documented on an average follow-up of 54.1±34months.Microneurosurgery is still a valuable, definitive, and durable option for Barami type Ia, Ib, or II paraclinoid aneurysm, especially in patients <50years old and visually symptomatic. Conditions other than these areideal candidates for FD stents.

Application of the Willis Covered Stent in the treatment of intracranial unruptured aneurysms in internal carotid artery: A retrospective single-center experience

The purpose of this study was to retrospectively analyse the clinical and angiographic outcomes of Willis covered stent placement for unruptured aneurysms in internal carotid artery. Forty-six consecutive patients with internal carotid artery aneurysms (49 cases) were included to evaluate clinical and angiographic outcomes. Covered stent placement was successful in 47 cases, whereas stent navigation failed in 2 cases. Of the 49 aneurysms (mean aneurysm size, 7.9 mm), 5, 6, and 38 were located in the petrous, cavernous, and ophthalmic segments, respectively. Immediate angiography revealed complete aneurysm exclusion in 36 (76.6%) cases, whereas minimal endoleak was observed in 11 cases. Four patients had procedure-related complications, including 1 patient with acute in-stent thrombosis, 2 with a post-operative subarachnoid haemorrhage, and 1 with artery rupture. Angiographic and clinical follow-up was available for 36 patients (38 aneurysms). Complete aneurysm occlusion was achieved in 34 (89.5%) cases, endoleak was present in 2 cases, and aneurysm recurrence occurred in 2 cases. Asymptomatic in-stent stenosis was observed in 3 patients. No hemorrhagic or ischemic events occurred during the follow-up period. At follow-up, the modified Rankin scores were 0–2 for 35 patients and >2 for 1 patient. Satisfactory angiographic outcomes were achieved in our study. However, the risks of stent navigation failure, endoleak after balloon re-inflation, procedure-related complications and coverage of side branches should be considered when choosing the best therapeutic option for internal carotid artery aneurysms.

"Reverse Picket Fence" Technique for Clipping of a Large, Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

The "picket fence" technique is a clipping technique used for large, wide-neck complex aneurysms not suitable for conventional clipping.1 With this technique, simple or fenestrated straight clips are stacked side-by-side perpendicular to the neck rather than the conventional parallel placement. In complex aneurysms projecting away from the surgeon, the picket fence technique is impossible. Instead, fenestrated clips are applied in a reverse direction from neck-to-dome, using the blade heels to close the neck. This fenestration tube transmits the bifurcation. This video demonstrates a "reverse picket fence" clipping technique of an incidental, large anterior communicating artery (ACoA) aneurysm in a 52-yr-old woman. Bilaterally adherent A2-anterior cerebral artery (ACA) segments led to abortion of a prior clipping attempt at an outside hospital. After obtaining patient consent, a modified orbitozygomatic craniotomy was performed with gyrus rectus removal. Temporary clips were applied to A1-ACA for freeing the adherent A2-ACA segments from the dome. The aneurysm was clipped using a "reverse picket fence" technique transmitting the A1-A2-A2 bifurcation through the fenestration tube. Bilateral recurrent artery of Heubner was preserved. Indocyanine angiography demonstrated parent vessel patency with complete aneurysm exclusion. Postoperatively, the patient experienced short-term memory loss, which resolved over 6 mo with cognitive rehabilitation. The "reverse picket fence" technique can be considered for large aneurysms directed away from the surgeon, obviating the need for difficult dissection of adherent efferent arteries from aneurysmal sac. Adjusting the heel position of each fenestrated clip in this construct allows the patency of hidden perforators behind the aneurysm to be maintained. Video © Barrow Neurological Institute. Used with permission.