Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note

Microsurgical thrombectomy: where the ancient art meets the new era

Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option (developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Clinical outcomes, procedural times, and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. One-hundred nine patients fulfilled the study criteria (77 MTs vs 32 STs). Factors driving outcome were age (aOR: 0.95, 95%CI, 0.91-0.98), hemisphere side (aOR: 0.38, 95%CI, 0.15-0.96), and DWI-ASPECT (aOR: 1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure (P = 0.45) and start of procedure-recanalization (P = 0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization (P = 0.155) and outcome (P = 0.221). The prognosticators of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side, and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.

Reverse Suction Decompression Using the Superior Thyroid Artery During Clipping of a Complex Anterior Choroidal Artery Aneurysm

Direct aneurysmal suction decompression was first described by Dr. Flamm in 1981 to improve safety and ease clipping of complex aneurysms by deflating their dome.1 This technique evolved over the following decade, from direct aneurysmal puncture to indirect-reverse-suction decompression (RSD).2,3 The conventional technique for RSD involves a cannulation of the internal (ICA) or common (CCA) carotid arteries.2-9 Direct puncture of either the CCA or ICA carry risk of arterial wall damage (e.g., dissection), which may result in significant morbidity.10,11 We routinely cannulate the superior thyroidal artery (SThA) as the vascular access to perform RSD. This subtle technical nuance prevents dissection of either the CCA or ICA while providing a reliable source for RSD.12 In this operative video, the SThA was cannulated to apply reverse suction decompression, which allowed releasing perforating arteries from the dome of an anterior choroidal artery aneurysm in a 68-year-old lady. The patient tolerated the procedure well, was discharged without neurologic deficits, and resumed normal life with no aneurysm remnant. The patient consented to the procedure and video/photography publication. RSD is an optimal technique to enhance efficiency and safety when dissecting around the dome of a complex intradural ICA aneurysm. The use of the SThA avoids the risk of ICA or CCA wall damage due to access, which defeats the protective purpose of RSD itself. Video 1 provides an educational example of the SThA cannulation technique for RSD during dissection and clipping of a complex anterior choroidal artery aneurysm.

Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms

Objective

Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques.

Methods

The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively.

Results

There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance.

Conclusion

In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

Incision Edge "Lifting Method" in Cerebral Bypass Surgery: A Novel Optional Technique for Narrow or Thin Recipient Arteries

BACKGROUND

Cerebral bypass surgery, such as the superficial temporal artery-middle cerebral artery bypass, is one of the essential procedures for cerebral revascularization. However, very narrow or thin blood vessels will increase the risk of anastomotic problems, such as occurs in Moyamoya disease. For such vessels, we have devised a "lifting method" in the recipient arteriotomy. In the present study, we have introduced this novel optional technique and evaluated its effects.

METHODS

The lifting method is a procedure of lifting the incision edge of a linear incision on the recipient vessel to widen the ostium. We attempted the lifting method in 23 consecutive patients (41 arteries) and, as a historical control, compared the results with those from the conventional method in 25 consecutive patients (37 arteries) for the previous 3 years. We compared patient age, years of surgical experience, recipient vessel diameter, anastomotic events, and final patency. As a subanalysis, the same evaluations were performed separately for patients with Moyamoya disease. Furthermore, the time required for the lifting procedure was measured retrospectively.

RESULTS

The incidence of anastomotic events with the conventional method was 13.5% overall and 19% in those with Moyamoya disease. No adverse events occurred with the lifting method (P < 0.05). No statistically significant differences were found for the other factors, including final patency between the 2 groups. The time required for the lifting procedure averaged 1 minute, 15 seconds.

CONCLUSIONS

Use of the lifting method widens and secures the ostium in a recipient vessel and greatly facilitates operability. We have found it to be a foolproof method enabling safe and reliable anastomosis even with narrow or thin vessels.

Autologous Transfusion of Blood Aspirated during Suction Decompression in Clipping of Large or Giant Cerebral Aneurysm

The suction decompression (SD) method, which proactively aspirates the blood flowing into the aneurysm and reduces the internal pressure of the aneurysm, is useful for clipping surgery of large and giant cerebral aneurysm. However, there has been little discussion on re-utilization of blood aspirated during SD. This study aimed to examine the safety, convenience, and usefulness of autologous transfusion of aspirated blood using a transfusion bag. At the time of craniotomy, the cervical carotid artery is fully exposed. An angiocatheter sheath was inserted into the carotid artery and placed in the internal carotid artery. In SD, blood was aspirated from the sheath at a constant speed and quickly stored in a blood transfusion storage bag. Blood aspiration was repeated with a new syringe; once the transfusion bag was full, the blood was re-administered to the patient. Changes in vital sign and hemoglobin/hematocrit values before and after SD were examined in five cases performed in this procedure. The aspirated blood volumes of five cases ranged from 130 to 400 mL, and all aspirated blood was successfully re-transfused. There was no critical change in vital sign, and no significant decrease in the hemoglobin/hematocrit value. No findings suggestive of complications of thrombus formation, infection, and hemolysis were noted. Re-transfusion of aspirated blood during SD using a transfusion bag is a simple and safe method, which can minimize potential risk of re-utilizing aspirated blood, and enables the safe and easy execution of SD regardless of aspirated blood volume.

Entire Orifice Blocking-Assisted Microsurgical Treatment: Clipping of Intracranial Giant Wide-Neck Paraclinoid Aneurysms

OBJECTIVE

Giant wide-neck paraclinoid aneurysms remain a formidable challenge for neurosurgeons due to the brisk retrograde blood flow during surgical clipping. Theoretically, Entire orifice blockade (EOB) by placing a longitudinal intracarotid balloon catheter across the aneurysm neck could achieve a good vascular control in treating cerebral aneurysms, but related studies have been scarce. The aim of this study was to evaluate the safety and efficiency of the EOB-assisted microsurgical technique for treating giant wide-neck paraclinoid aneurysms.

METHODS

Clinical data and treatment summaries of patients with giant wide-neck paraclinoid aneurysms who underwent EOB-assisted microsurgical clipping were retrospectively reviewed.

RESULTS

A total of 26 patients were analyzed. All but 3 patients harbored unruptured aneurysms. The mean largest diameter of the aneurysms was 26.8±2.0 mm, and the mean neck size was 12.5±2.4 mm. All lesions were successfully clipped without residual aneurysms. Post-operative images revealed no major branch occlusion due to thromboembolic complications. Four patients presented neurologic deficits caused by vasospasm, 3 of which were completely resolved by postoperative treatment. At a mean follow-up time of 1.86 ± 0.95 years (range, 0.5-3.5 years), none of the patients died, and 96.2% (n = 25) of the patients had favorable clinical outcomes with modified Rankin Scale values of 0-2.

CONCLUSIONS

For patients with giant wide-neck paraclinoid aneurysms, EOB-assisted microsurgical clipping is a safe and useful procedure for obtaining vascular control, for softening and shrinking the aneurysm sac and for providing a wide and clean operative field that allows the clip to be effectively placed.

Clipping treatment of posterior communicating artery aneurysms associated with arteriosclerosis and calcification: A single center study of 136 cases

It is widely acknowledged that arteriosclerosis and calcification of the parent artery and aneurysm neck make it difficult to clip posterior communicating artery (PCoA) aneurysms. A total of 136 cases of PCoA aneurysms accompanied by arteriosclerosis and calcification were collected and treated with clipping in the present study. Of the 136 patients, 112 were females (82.4%) and 24 were males (17.6%), with ages ranging from 37 to 76 years (mean age, 60.2 years). Rupture of a PCoA aneurysm was identified in 132 cases (97.1%), and there were 4 cases of unruptured PCoA aneurysms (2.9%). According to the severity of arteriosclerosis and calcification, the aneurysms were divided into type I, II or III. The treatment of type I aneurysms achieved the best curative effect. It is difficult to temporarily occlude type II and III aneurysms during surgery, and temporary occlusion failed in almost 50% of cases. Types II and III were prone to intraoperative aneurysm ruptures. A significantly higher rate of intraoperative aneurysm rupture was seen in type III compared with type II cases. Type II and III cases were more likely to be treated using a fenestrated clip for aneurysm clipping compared with type I cases, and fenestrated clips were used significantly more frequently in type III cases compared with type II cases. Arteriosclerosis and calcification were likely to affect the prognosis of patients, particularly in cases with type III arteriosclerosis and calcification of the parent artery and aneurysm neck. Therefore, the stratification of the arteriosclerosis and calcification of the parent artery and aneurysm neck into types I-III can guide the intraoperative aneurysm clipping strategy, aid in choosing the correct clips, and inform predictions of the occurrence of rupture and hemorrhage, as well as the prognosis for aneurysms.