Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms

Esposito, Giuseppe; Fierstra, Jorn; Regli, Luca

doi:10.1007/s00701-016-2868-3

Cited by 31 publications

(10 citation statements)

References 27 publications

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“…This is an expected finding since a general consensus among the cerebrovascular specialists exists wherein any angioanatomical feature indicating the presence of a complex aneurysm should lead to a more detailed workup, including preoperative DSA. The aneurysmal complexity is namely related to at least one of the following features: (1) size ≥2.5 cm, (2) anatomic location (vertebral, basilar, paraclinoid), (3) involvement of critical perforating or branch vessels, (4) previous treatment (endovascular or surgical), (5) dissecting, fusiform, saccular lesions with very broad neck, (6) intraluminal thrombosis, and ( 7) atherosclerotic plaques and calcifications of the aneurysm wall and/or neck [17][18][19][20][21][22][23][24]. There are no patient-related factors (except clinical status) that influence the decision for a preoperative DSA.…”

Section: Discussionmentioning

confidence: 99%

When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice

Sebök

Dufour

Cenzato

et al. 2021

Acta Neurochirurgica Supplement

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Introduction: The goal of this survey is to investigate the indications for preoperative digital subtraction angiography (DSA) before clipping of ruptured and unruptured intracranial aneurysms in an international panel of neurovascular specialists.Methods: An anonymous survey of 23 multiple-choice questions relating to indications for DSA before clipping of an intracranial aneurysm was distributed to the international panel of attendees of the European-Japanese Cerebrovascular Congress (EJCVC), which took place in Milan, Italy on 7–9 June 2018. The survey was collected during the same conference. Descriptive statistics were used to analyze the data.Results: A total of 93 surveys were distributed, and 67 (72%) completed surveys were returned by responders from 13 different countries. Eighty-five percent of all responders were neurosurgeons. For unruptured and ruptured middle cerebral artery (MCA) aneurysms without life-threatening hematoma, approximately 60% of responders perform surgery without preoperative DSA. For aneurysms in other locations than MCA, microsurgery is done without preoperative DSA in 68% of unruptured and in 73% of ruptured cases. In cases of ruptured MCA or ruptured non-MCA aneurysms with life-threatening hematoma, surgery is performed without DSA in 97% and 96% of patients, respectively. Factors which lead to preoperative DSA being performed were: aneurysmal shape (fusiform, dissecting), etiology (infectious), size (>25 mm), possible presence of perforators or efferent vessels arising from the aneurysm, intra-aneurysmal thrombus, previous treatment, location (posterior circulation and paraclinoid aneurysm) and flow-replacement bypass contemplated for final aneurysm treatment. These are all factors that qualify an aneurysm as a complex aneurysm.Conclusion: There is still a high variability in the surgeons’ preoperative workup regarding the indication for DSA before clipping of ruptured and unruptured intracranial aneurysms, except for ruptured aneurysms with life-threatening hematoma. There is a general consensus among cerebrovascular specialists that any angioanatomical feature indicating a complex aneurysm should lead to a more detailed workup including preoperative DSA.

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Section: Discussionmentioning

confidence: 99%

When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice

Sebök

Dufour

Cenzato

et al. 2021

Acta Neurochirurgica Supplement

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“…In those cases, where complete surgical trapping or endovascular coil embolization of the aneurysm is impossible due to delicate perforator anatomy, proximal or distal occlusions may be performed. This strategy relies on intra-aneurysmal flow modification to reduce the risk of aneurysm rupture, to induce slow aneurysm thrombosis, and to preserve flow into the perforating branches [10,46]. In some cases, however, postoperative aneurysm ruptures with devastating consequences have been reported with this technique [47].…”

Section: Parent Artery Occlusion In Conjunction With Bypass Surgerymentioning

confidence: 99%

Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms

Gmeiner

Gruber

2021

Acta Neurochirurgica Supplement

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Introduction: Very large and giant aneurysms are among the most challenging cerebrovascular pathologies in neurosurgery.Methods: The aim of this paper is to review the current literature on the management of very large and giant aneurysms and to describe representative cases illustrating possible treatment strategies.Results: In view of the poor natural history, active management using multiprofessional individualized approaches is required to achieve aneurysm occlusion, relief of mass effect, and obliteration of the embolic source. Both reconstructive (clipping, coiling, stent-assisted coiling, flow diversion [FD]) and deconstructive techniques (parent artery occlusion [PAO], PAO in conjunction with bypass surgery, and strategies of flow modification) are available to achieve definitive treatment with acceptable morbidity.Conclusions: Patients harboring such lesions should be managed at high-volume cerebrovascular centers by multidisciplinary teams trained in all techniques of open and endovascular neurosurgery.

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“…Complete trapping may be the best alternative for aneurysms free of perforating vessels. In rare cases, efferent outflow occlusion may be preferable when the afferent artery is difficult to reach and sacrifice, 8,15,16 although negative results have been documented in the literature. 23 In addition, AR may be implemented following vascular reconstruction for debulking purposes.…”

Section: Microsurgical Selection For Cmcaasmentioning

confidence: 99%

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms

Wang

Cai

et al. 2019

Neurosurgical Focus

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OBJECTIVEThe rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).METHODSAll IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.RESULTSIn total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10–37 mm), and the patients had a mean age of 31.7 years (range 14–56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2–74 months) and 53.1 months (range 19–82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.CONCLUSIONSThe satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.

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Distal outflow occlusion with bypass revascularization: last resort measure in managing complex MCA and PICA aneurysms

Abstract: We believe that partial trapping with distal outflow occlusion for treating complex intracranial aneurysms represents a useful strategy as a last resort measure. To avoid cerebral ischemia, flow-replacement bypass is key to success.

Cited by 31 publications

References 27 publications

When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice

When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice

Current Strategies in the Treatment of Intracranial Large and Giant Aneurysms

Internal maxillary artery bypass for the treatment of complex middle cerebral artery aneurysms

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