The 25th anniversary of the retrograde suction decompression technique (Dallas technique) for the surgical management of paraclinoid aneurysms: historical background, systematic review, and pooled analysis of the literature

Abstract

OBJECTIVE Paraclinoid internal carotid artery (ICA) aneurysms frequently require temporary occlusion to facilitate safe clipping. Brisk retrograde flow through the ophthalmic artery and cavernous ICA branches make simple trapping inadequate to soften the aneurysm. The retrograde suction decompression (RSD), or Dallas RSD, technique was described in 1990 in an attempt to overcome some of those treatment limitations. A frequent criticism of the RSD technique is an allegedly high risk of cervical ICA dissection. An endovascular modification was introduced in 1991 (endovascular RSD) but no studies have compared the 2 RSD variations. METHODS The authors performed a systematic review of MEDLINE/PubMed and Web of Science and identified all studies from 1990-2016 in which either Dallas RSD or endovascular RSD was used for treatment of paraclinoid aneurysms. A pooled analysis of the data was completed to identify important demographic and treatment-specific variables. The primary outcome measure was defined as successful aneurysm obliteration. Secondary outcome variables were divided into overall and RSD-specific morbidity and mortality rates. RESULTS Twenty-six RSD studies met the inclusion criteria (525 patients, 78.9% female). The mean patient age was 53.5 years. Most aneurysms were unruptured (56.6%) and giant (49%). The most common presentations were subarachnoid hemorrhage (43.6%) and vision changes (25.3%). The aneurysm obliteration rate was 95%. The mean temporary occlusion time was 12.7 minutes. Transient or permanent morbidity was seen in 19.9% of the patients. The RSD-specific complication rate was low (1.3%). The overall mortality rate was 4.2%, with 2 deaths (0.4%) attributable to the RSD technique itself. Good or fair outcome were reported in 90.7% of the patients. Aneurysm obliteration rates were similar in the 2 subgroups (Dallas RSD 94.3%, endovascular RSD 96.3%, p = 0.33). Despite a higher frequency of complex (giant or ruptured) aneurysms, Dallas RSD was associated with lower RSD-related morbidity (0.6% vs 2.9%, p = 0.03), compared with the endovascular RSD subgroup. There was a trend toward higher mortality in the endovascular RSD subgroup (6.4% vs 3.1%, p = 0.08). The proportion of patients with poor neurological outcome at last follow-up was significantly higher in the endovascular RSD group (15.4% vs 7.2%, p < 0.01). CONCLUSIONS The treatment of paraclinoid ICA aneurysms using the RSD technique is associated with high aneurysm obliteration rates, good long-term neurological outcome, and low RSD-related morbidity and mortality. Review of the RSD literature showed no evidence of a higher complication rate associated with the Dallas technique compared with similar endovascular methods. On a subgroup analysis of Dallas RSD and endovascular RSD, both groups achieved similar obliteration rates, but a lower RSD-related morbidity was seen in the Dallas technique subgroup. Twenty-five years after its initial publication, RSD remains a useful neurosurgical technique for the management of large and giant parac...

Microsurgical Clipping of Carotid-Ophthalmic Tandem Aneurysms: Case Report and Surgical Nuances

“…Different techniques are today available for this purpose. They comprehend cervical or petrous ICA exposure, extradural or intradural clinoid ICA exposure, endovascular control with balloon-assisted occlusion or suction decompression (Dallas technique), adenosine-induced cardiac standstill, and intracavernous control [ 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. Each of these techniques has advantages and disadvantages.…”

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

“…In cases of large and giant ICA aneurysms, the neck of the aneurysm is often located in the juxtadural portion of the distal dural ring. Therefore, intracranial proximal control is often impossible without direct cavernous sinus exploration, which has a significant risk for complications [ 10 ]. For this reason, temporary clipping for proximal control is usually performed on cervical ICA.…”

“…After Flamm 9) published the first technihttps://doi.org/10.3340/jkns.2021.0066 cal note on direct aneurysm puncture for suction decompression in 1981, this technique, termed RSD, was modified by Batjer and Samson 3) . Since the introduction of the RSD technique, more than 500 aneurysms have been treated using this approach, and morbidity and mortality rates of 19.9% and 1.3%, respectively, have been achieved 10) . Furthermore, the RSD technique enables the adequate relaxation of the aneurysm dome by applying temporary clipping on the extracranial and intracranial carotid arteries and aspirating blood by direct ICA puncture, which may raise concerns about procedure-related complications such as thromboembolic ischemia, ICA dissection or occlusion, and anemia.…”

Opciones de tratamiento en aneurismas paraclinoideos gigantes: a propósito de primer caso con manejo quirúrgico y endovascular del Hospital Civil Fray Antonio Alcalde

“…El bypass microquirúrgico sigue siendo una modalidad de tratamiento viable, cuando el clipaje aneurismático falla, por ejemplo; cuando la tensión de la pared del aneurisma no se puede reducir con adenosina y descompresión por succión 8,11,12 . Sí el paciente tolera una oclusión temporal con balón y el aneurisma no se considera factible para el tratamiento endovascular; el segmento de la arteria carótida interna que involucra el aneurisma puede quedar atrapado o sacrificado microquirúrgicamente sin necesidad de aumentar el flujo.…”