management of complex aneurysms

Management of Complex Aneurysms:

Role of Arterial Reconstruction

Neil A. Martin, MD

Geisinger Health

Danville, Pa

Techniques for Aneurysm Occlusion

• Simple neck clipping

• Clip reconstruction of parent artery

• Clipping under hypothermic cardiac arrest

• Parent artery occlusion (balloon, coil, clip)

• Endosaccular coils

• Stent plus coils

• Wrapping

• Parent artery occlusion with bypass

Bypass for Aneurysms: Advantages

• Parent artery occlusion generally provides

simple, complete, permanent treatment

• Bypass prevents distal ischemia, and collateral

flow stress (de novo aneurysm formation)

• No need to reconstruct calcified,

atherosclerotic, or thombosed neck region

• Avoids risk of cardiac arrest

Bypass

Types

Type II

Patient HB: 48 yo woman with headaches

and diplopia

Problem: No cross-filling, rapid failure of BTO

Saphenous vein graft from ICA to MCA

Pre-op Post-op

Type II Bypass: Saphenous Vein Interposition

Fusiform MCA Aneurysm

Saphenous vein from ECA

Type III

Failed BTO at

9 minutes

STA vs Saphenous Vein

STA

• One anastomosis

• Acute occlusion: 2-5%

• Late occlusion: 5-10%

• One incision

Vein

• Two anstomoses

• Acute occlusion: 5-

10%

• Late occlusion: 25-

30%

• Three incisions

• Hyperperfusion

STA vs Saphenous Vein

STA

• Cavernous aneurysm

with small

communicating

arteries

• Aneurysm involving

one branch vessel

(MCA, PICA)

Vein

• Cavernous aneurysm

with no

communicating

arteries

• Aneurysm involving

major trunk (MCA

M1)

30 y.o. photographer with headaches, episodic aphasia,

and right side weakness

40 yo woman, progressive headaches, decreased visual

acuity

ICA aneurysm extends to include Pcom origin - persistent

aneurysm filling post op

Pre opPost op

Bypass Patency

• Superficial temporal artery : 96%

• Saphenous vein grafts : 95%

• Cerebral artery anastomoses : 100%

135761Spetzler ‘96

9779

(83%)

95Martin ‘07

433946Drake ‘94

242531Ausman ‘90

542029Sundt ‘86

DeadFair-PoorExc-Goodn

Revascularization for Aneurysms: Results

END