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JCApril 19th 2012

D. Bervini

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INTRODUCTION

1. Morbidity and mortality of surgery: 20-30%– Inherent treatment risks– Anatomy

• Wide neck• Complex arterial branches• Intraluminal thrombus• Atherosclerotic degeneration• Adherent perforating arteries

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2. Increase in use of endovascular treatment– Coiling (Guglielmi 1990)– Flow diversion and Endoluminal reconstruction

(petrocavernous and paraclinoid ICA and BT)

3. Old surgical series

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4. Improved radiological imaging and earlier diagnosis of large aneurysm

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Older publications do not reflect the current practice environment

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OBJECTIVE

• Examine specific changes in surgical management

• Examine the role of microsurgery in management strategy

• Quantify surgical results for comparison with evolving endovascular therapies

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METHODS

• Retrospective study

• Single center

• Patients with ≥ 25mm aneurysms (thrombus included)

• 13 y period

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Patients• 140 patients• 141 GA• 64% F, 36% M• mean age 54y• 16% (33) SHA

• HH I 5• HH II 5• HH III 6• HH IV 7

• 6 recurrent aneurysms after coiling

• 1 recurrent aneurysm after clipping

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Aneurysms

• mean diameter 29mm

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Surgical managment

• surgery VS coil on individual basis• Exclusion:

– HH V – aneurysm calcifications– location on the basilar trunk or vertebrobasilar

junction– advanced age– significant anesthetic risk– patient and family preferences

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• primary strategy: direct aneurysm clipping

• alternative strategy = indirect occlusion:

• clipping parent artery

• bypass with clipping parent artery

• bypass with endovascular occlusion

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Balloon test occlusion (BTO)

• 26 patients• Cavernous or supraclinoid ICA aneurysms• Failed

– 10 with BTO inflation alone high-flow bypass– 16 with additional hypotensive challenge low-

flow bypass

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Outcomes

• Aneurysm occlusion (angiography)– Complete– Minimal residual aneurysm (dog-ear)– Incomplete (>5%)

• Aneurysm treatment failure = growth of residual aneurysm or rupture

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• Neurological outcome = GOS

• Improved VS unchanged VS worse VS dead

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Results

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Bypass

• 38%

– ECA-MCA 26%

– STA-MCA 20%

– Intracranial-intracranial 28%

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Outcome

Aneurysms• 77% complete occluded (79% clip / 72%

indirect)• 10% minimal residual (clip)• 11 % incompletely occluded (parent artery

clip with/without bypass)

• 3.5% retreatment

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Post-operative durability of GA control

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Outcome

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• Posterior circulation aneurysms = more complications = independent risk factor.

• SAH patients had worse outcomes, mortality 39% (8% for no-SAH)

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Discussion

• Dolichoectatic morphology• Aberrant branch anatomy• Atherosclerotic neck bypass• Intraluminal thrombus 47% clipping• Previous coil

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• Heavy reliance on bypass techniques (38%)

OR

• adjuncts that facilitate direct clipping, like deep hypothermic circulatory arrest

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Deep hypothermic circulatory arrest

• Eliminate risk of aneurysm rupture

• Permits clip collapse

• Permits manipulation (remove thrombus, create supple neck)

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BUT

• Significant operation morbidity

– Compromise of distal circulation by cannulation– Cerebral ischemic injury– Postoperative bleeding complications– Cumulative mortality-morbidity 32%

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Complications of bypass and indirect aneurysm occlusion

• Thrombotic occlusion of perforators or branch arteries (7%)

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FIGURE 3 . Case 15. A, axial T2-weighted MR imaging revealed a giant left ICA bifurcation aneurysm and a large anterior communicating artery aneurysm in this 51-year-old woman. B, 3D reconstructed angiogram (left ICA injection) demonstrated its dolichoectatic morphology. An end-to-side anastomosis between radial artery and the efferent MCA was part of an ECA-MCA bypass. C, supraclinoid ICA was occluded with a clip as it entered the aneurysm, distal to PCoA. Indocyanine green videoangiography demonstrated patency of the bypass graft, filling of distal MCA branches, filling of the supraclinoid ICA up to the clip, and faint flow of dye within the aneurysm. Postoperative CT angiography showed a thin layer of new intra-aneurysmal thrombus anteriorly, posteriorly, and inferiorly on axial (D) and coronal (E) views. F, subsequent digital subtraction angiography demonstrated bypass patency and progressive intraluminal thrombosis (left ICA injection, anteroposterior view). CTA on postoperative day 5 revealed further intraluminal thrombosis with 2 serpentine channels connecting the bypass with the A1 segment on the opposite side of the aneurysm, as seen on axial (G) and coronal (H) views. Postsurgical thrombosis occluded the anterior choroidal artery, and she experienced a capsular infarct. This case demonstrates that postsurgical aneurysm thrombosis after proximal clip occlusion can occlude small branch arteries. ICA, internal carotid artery; MCA, middle cerebral artery; PCA, posterior cerebral artery; ECA, external carotid artery; PCoA, posterior communicating artery; CTA, computed tomographic angiography.

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Computational fluid dynamic

• Preferred treatment:– maintain robust flow in regions where branch

arteries originate– accepting stagnation in perforator-free zones

(dome and fundus)

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Conclusion

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Superiority of Surgical Managment• Good results

– GOS 4-5 in 81%– Improved/unchanged in 78%

• Mortality 13% (vs 29%)• Morbidity 9% (vs 32%)• Complete occlusion 77% (vs 36%)• endovascular treatment: multiple treatments,

repeat risks exposure and relapsing clinical course.

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Weakness of the article

• Retrospecive view• Lack of control group• Short follow-up duration (2y), especially for

indirect treatment (bypass)• Selection biais (chose for surgical treatment

because it was felt to offer better outcome)• Indirect treatment is not completely protective• No entirely surgical series (23 pts

endovascular)

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