Mechanical characteristics and surface elemental composition of a Yasargil titanium aneurysm clip after long-term implantation

Limitation of fenestrated clips during clipping of middle cerebral artery aneurysm: Technical note

Background

The middle cerebral artery (MCA) is a common site of cerebral aneurysms and 82.6% occur at the bifurcation. When surgery is selected as a therapeutic option, it intends to clip the neck completely because if some remnant occurs, there exists the possibility of regrowth and bleeding in the short- or long-term.

Methods

We analyzed one drawback of the fenestrated clips of Yasargil and Sugita types to occlude the neck totally at a specific point formed by the union of the fenestra with the blades, creating a triangular space where the aneurysm can protrude, giving place to a remnant that can lead to a future recurrence and rebleeding. We show two cases of ruptured MCA aneurysms in which a cross-clipping technique occluded a broad base and dysmorphic aneurysm using straight fenestrated clips.

Results

In both cases (one using a Yasargil clip and the other with a Sugita clip), a small remnant was visualized when fluorescein videoangiography (FL-VAG) was used. In both cases, the small remnant was clipped with a 3 mm straight miniclip.

Conclusion

We should be aware of this drawback when clipping aneurysms using fenestrated clips to ensure a complete obliteration of the aneurysm's neck.

Insufficient Closing Forces of Yasargil Titanium Clips in Two Small Aneurysms Detected with Intraoperative Indocyanine Green Videoangiography

Background and Study Aims Aneurysm clips must have adequate closing forces because residual blood flow in clipped aneurysms may result in aneurysm recurrence. Such flow can be intraoperatively detected by visual inspection, microvascular Doppler sonography, indocyanine green videoangiography (ICG-V), angiography, and puncture.

Patients We present two patients with ruptured very small middle cerebral artery aneurysms (3 and 2.9 mm). The necks of both aneurysms were microsurgically clipped with Yasargil aneurysm clips without any complications.

Results In both aneurysms, visual inspection suggested complete occlusion, but ICG-V showed persistent residual blood flow between the middle parts of the clip blades.

The first patient was treated with a 5.4-mm FT744T clip (closing force of 1.47 N). After the ICG-V finding, a second 3.9-mm FT714T clip (closing force of 1.08 N) was placed on the tips of the already implanted clip to increase the closing forces. Subsequent ICG-V did not show any further residual blood flow. In the second patient, the aneurysm was clipped with an 8.0-mm FE764K clip (closing force of 1.77 N). Intraoperative ICG-V showed persistent residual blood flow within the aneurysmal dome despite complete closure of the clip. The clip was repositioned closer to the parent vessel. Consecutive ICG-V did not show any residual blood flow.

Conclusion Visually undetected incomplete aneurysm occlusion can be revealed with ICG-V. In very small aneurysms, standard closing forces of clips may not be sufficient and complete closure of the clip branches should be intraoperatively validated with ICG-V.

Hybrid Surgery for Multiple Visceral Artery Aneurysms: A Case Report

BACKGROUND

We present a case with multiple visceral artery aneurysms that were treated with a hybrid approach involving both surgical and endovascular treatment.

CASE REPORT

The patient was a 48-year-old female. She was diagnosed with multiple visceral artery aneurysms including 2 splenic artery aneurysms, celiac artery aneurysm, and bilateral renal artery aneurysms during an examination for loss of appetite. With regard to 2 splenic artery aneurysms, the proximal aneurysm was treated surgically, whereas the peripheral aneurysm that was located deeply in the abdomen was treated with coil embolization. The celiac artery aneurysm located at the bifurcation of the common hepatic artery and splenic artery, an intracranial aneurysm clip was used. The left and right renal aneurysms were resected and renal arteries were reconstructed surgically. The postoperative course was uneventful. The pathological diagnosis of all aneurysms was segmental arterial mediolysis. The reconstructed vessels were patent without stenosis or recurrence at 1 year after the operation.

CONCLUSIONS

Hybrid treatment involving surgical resection, endovascular coil embolization, and obliteration with clips was useful in the treatment of multiple visceral artery aneurysms.

Multiple visceral artery aneurysms managed by Yasargil aneurysm clips

Here, we present the case of a 37-year-old woman with multiple visceral artery aneurysms in the pancreaticoduodenal, inferior pancreatic and splenic arteries associated with celiac trunk stenosis. An aneurysmectomy and end-to-end anastomosis was performed for two adjacent aneurysms, while clipping with intracranial aneurysm clips were performed for the other three aneurysms. During 36-month follow-up, no recurrence or newly developed lesions were noted, and the celiac artery had been reconstituted spontaneously. We believe that using intracranial aneurysm clips in the treatment of visceral artery aneurysms is feasible and safe and can be considered when endovascular procedures are unlikely to be successful.

What is the role of clipping surgery for ruptured cerebral aneurysms in the endovascular era? A review of recent technical advances and problems to be solved

Craniotomy and clipping have been robust treatments for ruptured cerebral aneurysm for more than 50 years, with satisfactory overall outcomes. Technical advances, such as developments in microsurgical tools and equipment, adjunctive therapy, and novel monitoring methods enable safer and more efficient treatment. However, overall surgical results have not shown any major improvements, as outcomes are mainly determined by the damage from initial bleeding, and new treatment strategies are not always free from associated complications and problems. Recent advances in endovascular treatment are shifting the treatment for ruptured cerebral aneurysm from craniotomy and clipping to intravascular coil embolization. However, craniotomy and clipping are very important for the treatment of ruptured cerebral aneurysm. This paper discusses recent advances and future perspectives in the field of clipping surgery for ruptured aneurysms.

The Comparative Study of Microsurgical Cerebral Aneurysm Clip Implants; Titanium Clip vs. Stainless Steel Clip

OBJECTIVE

To perform a comparative study between two groups of populations, titanium (T) group versus stainless steel (S) group, who were clipped with titanium and stainless steel materials, respectively, the incidence of regrowth from the original aneurysms, the clip slippage, and post-clipping seizure attack were analyzed. The patients were followed more than 5 years after microsurgical cerebral aneurysms clipping.

METHODS

Data from 1986 through 2008 were extensively reviewed on a consecutive series of 3,770 patients who referred for ruptured/unruptured cerebral aneurysms. Forty-seven patients in the S group and 48 in the T group who met inclusion criteria, were selected for this study.

RESULTS

The incidence of regrowth were noted that two out of total 47 patients (4.3%) in the S group, and none in the T group. The clip slippage was not observed in both groups. And there was no statistical difference (p = 0.242) in terms of regrowth between two groups. Seven out of 47 cases (14.9%) developed post-clipping seizure in the S group. On the other hand, two (4.2%) of 48 patients presented the symptom in the T group. Also, there was no significant difference (p = 0.091) between two groups.

CONCLUSIONS

The metallic types of clip employed for the microsurgical cerebral aneurysm clipping does not have any significant clinical outcome differences in this study.