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

Restricted access


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.


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.


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).


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 paraclinoid aneurysms.

ABBREVIATIONS DSA = digital subtraction angiography; ECA = external carotid artery; FDS = flow-diverting stent; ICA = internal carotid artery; RSD = retrograde suction decompression; SAH = subarachnoid hemorrhage; TIA = transient ischemic attack; UTSW = University of Texas Southwestern.

Article Information

Correspondence Bruno C. Flores: University of Texas Southwestern Medical Center, Dallas, TX.

INCLUDE WHEN CITING Published online May 4, 2018; DOI: 10.3171/2017.11.JNS17546.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Artist’s illustration of the surgical principles of the RSD technique for treatment of large and giant paraclinoid aneurysms. A: The ICA has been trapped by proximal occlusion at the cervical ICA segment just distal to the bifurcation, and a temporary clip at the supraclinoid ICA just proximal to the origin of the posterior communicating artery. An angiocatheter was introduced on an oblique fashion into the cervical ICA for suction decompression. B: Magnified lateral view of the cavernous and intracranial ICA showing the relationship of the paraclinoid aneurysm with the adjacent cavernous and supraclinoid branches of the internal carotid artery. C: Despite cervical and supraclinoid ICA occlusions, aneurysm turgor is maintained by retrograde filling through the cavernous ICA branches and the ophthalmic artery. D: Retrograde suction is applied through the cervical ICA (right), with resultant transient aneurysm sac deflation. a. = artery; inf. = inferior. Copyright Suzanne Truex. Published with permission.

  • View in gallery

    PRISMA Flow Diagram for the RSD systematic review. Based on template from Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097, 2009. doi:10.1371/journal.pmed1000097. Figure is available in color online only.

  • View in gallery

    Intraoperative microscope photographs of a patient presenting with a giant, unruptured inferiorly and posteriorly projecting paraclinoid ICA aneurysm. Right-sided pterional craniotomy, transsylvian approach. A: A temporary aneurysm clip has been placed at the distal supraclinoid ICA, proximal to the origin of the posterior communicating artery. Cervical carotid exposure and temporary occlusion was obtained concomitantly by the assistant surgeon (not shown). B and C: Retrograde suction decompression through cervical ICA access results in progressive and marked aneurysm deflation, allowing for excellent circumferential dissection corridors at the carotid-oculomotor (B) and optico-carotid (C) triangles. D: One fenestrated right-angled aneurysm clip has been applied proximally for partial paraclinoid ICA clip reconstruction. Note the interval aneurysm re-expansion with temporary interruption of the RSD. E: RSD is then restarted before application of final tandem clip construct with excellent aneurysm deflation and visualization of the residual ICA ventral and lateral walls. Figure is available in color online only.

  • View in gallery

    A and B: Preoperative cerebral angiography of a giant, partially thrombosed paraclinoid ICA aneurysm presenting with progressive vision loss. Note that on the lateral views that the aneurysm neck is distal to the ophthalmic artery origin (B). Retrograde suction decompression technique was applied for aneurysm thrombectomy and primary clip reconstruction. C and D: Postoperative cerebral angiography on anteroposterior (C) and lateral (D) views show complete aneurysm obliteration and patency of the ophthalmic artery, with no stenosis of the paraclinoid ICA.



Abla AAZaidi HACrowley RWBritz GWMcDougall CGAlbuquerque FC: Optic chiasm compression from mass effect and thrombus formation following unsuccessful treatment of a giant supraclinoid ICA aneurysm with the Pipeline device: open surgical bailout with STA-MCA bypass and parent vessel occlusion. J Neurosurg Pediatr 14:31372014


Albert FKForsting MAschoff AKrieger DKunze S: Clipping of proximal paraclinoid aneurysm with support of the balloon-catheter “trapping-evacuation” technique. Technical note. Acta Neurochir (Wien) 125:1381411993


Almeida GMShibata MKBianco E: Carotid-ophthalmic aneurysms. Surg Neurol 5:41451976


Arnautović KIAl-Mefty OAngtuaco E: A combined microsurgical skull-base and endovascular approach to giant and large paraclinoid aneurysms. Surg Neurol 50:5045201998


Barrow DLAlleyne C: Natural history of giant intracranial aneurysms and indications for intervention. Clin Neurosurg 42:2142441995


Batjer HHFrankfurt AIPurdy PDSmith SSSamson DS: Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms. J Neurosurg 68:2342401988


Batjer HHKopitnik TAGiller CASamson DS: Surgery for paraclinoidal carotid artery aneurysms. J Neurosurg 80:6506581994


Batjer HHSamson DS: Retrograde suction decompression of giant paraclinoidal aneurysms. Technical note. J Neurosurg 73:3053061990


Benedetti ACurri D: Direct attack on carotid ophthalmic and large internal carotid aneurysms. Surg Neurol 8:49541977


Benedetti ACurri DCarbonin CRubini L: On the radical treatment of a large carotid-ophthalmic aneurysm: case report. J Neurosurg Sci 19:1761801975


Cawley CMZipfel GJDay AL: Surgical treatment of paraclinoid and ophthalmic aneurysms. Neurosurg Clin N Am 9:7657831998


Chen SFKato YSubramanian BKumar AWatabe TImizu S: Retrograde suction decompression assisted clipping of large and giant cerebral aneurysms: our experience. Minim Invasive Neurosurg 54:142011


Colli BOCarlotti CGAssirati JAAbud DGAmato MCMDezena RA: Results of microsurgical treatment of paraclinoid carotid aneurysms. Neurosurg Rev 36:991152013


Dandy WE: The surgical treatment of intracranial aneurysms of the internal carotid artery. Ann Surg 114:3363401941


Day AL: Aneurysms of the ophthalmic segment. A clinical and anatomical analysis. J Neurosurg 72:6776911990


Dehdashti ARLe Roux ABacigaluppi SWallace MC: Long-term visual outcome and aneurysm obliteration rate for very large and giant ophthalmic segment aneurysms: assessment of surgical treatment. Acta Neurochir (Wien) 154:43522012


Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:12951979


Drake CGVanderlinden RGAmacher AL: Carotid-ophthalmic aneurysms. J Neurosurg 29:24311968


Elhammady MSNakaji PFarhat HMorcos JJAziz-Sultan MA: Balloon-assisted clipping of a large paraclinoidal aneurysm: a salvage procedure. Neurosurgery 65:E1210E12112009


Eliava SSFilatov YMYakovlev SBShekhtman ODKheireddin ASSazonov IA: Results of microsurgical treatment of large and giant ICA aneurysms using the retrograde suction decompression (RSD) technique: series of 92 patients. World Neurosurg 73:6836872010


Fahlbusch RNimsky CHuk W: Open surgery of giant paraclinoid aneurysms improved by intraoperative angiography and endovascular retrograde suction decompression. Acta Neurochir (Wien) 139:102610321997


Fan YWChan KHLui WMHung KN: Retrograde suction decompression of paraclinoid aneurysm—a revised technique. Surg Neurol 51:1291311999


Flamm ES: Suction decompression of aneurysms. Technical note. J Neurosurg 54:2752761981


Fox JL: Microsurgical treatment of ventral (paraclinoid) internal carotid artery aneurysms. Neurosurgery 22:32391988


Fox JL: Multiple giant aneurysms. Surg Neurol 12:1471511979


French LAChou SNStory JLSchultz EA: Aneurysm of the anterior communicating artery. J Neurosurg 24:105810621966


Fulkerson DHHorner TGPayner TDLeipzig TJScott JADenardo AJ: Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes. Neurosurgery 64 (3 Suppl):ons107ons1122009


Gao XYu CWang XZhang HLi ZZhu T: Microsurgical treatment of large and giant paraclinoid carotid aneurysms using a revised endovascular suction decompression technique with Invatec Mo.Ma device. J Clin Neurosci 33:2642682016


Gelber BRSundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1101980


Giacomini LPiske RLBaccin CEBarroso MJoaquim AFTedeschi H: Neurovascular reconstruction with flow diverter stents for the treatment of 87 intracranial aneurysms: clinical results. Interv Neuroradiol 21:2922992015


Griessenauer CJPiske RLBaccin CEPereira BJAReddy ASThomas AJ: Flow diverters for treatment of 160 ophthalmic segment aneurysms: evaluation of safety and efficacy in a multicenter cohort. Neurosurgery 80:7267322017


Guidetti BLa Torre E: Carotid-ophthalmic aneurysms. A series of 16 cases treated by direct approach. Acta Neurochir (Wien) 22:2893041970


Guidetti BLa Torre E: Management of carotid-ophthalmic aneurysms. J Neurosurg 42:4384421975


Hauck EFWohlfeld BWelch BGWhite JASamson D: Clipping of very large or giant unruptured intracranial aneurysms in the anterior circulation: an outcome study. J Neurosurg 109:101210182008


Heros RCNelson PBOjemann RGCrowell RMDeBrun G: Large and giant paraclinoid aneurysms: surgical techniques, complications, and results. Neurosurgery 12:1531631983


Hoh DJLarsen DWElder JBKim PEGiannotta SLLiu CY: Novel use of an endovascular embolectomy device for retrograde suction decompression-assisted clip ligation of a large paraclinoid aneurysm: technical case report. Neurosurgery 62 (5 Suppl 2):ONSE412ONSE4142008


Jacobson JH IIWallman LJSchumacher GAFlanagan MSuarez ELDonaghy RM: Microsurgery as an aid to middle cerebral artery endarterectomy. J Neurosurg 19:1081151962


Kallmes DFBrinjikji WBoccardi ECiceri EDiaz OTawk R: Aneurysm Study of Pipeline in an Observational Registry (ASPIRe). Intervent Neurol 5:89992016


Kallmes DFHanel RLopes DBoccardi EBonafé ACekirge S: International retrospective study of the Pipeline Embolization Device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol 36:1081152015 (Erratum in AJNR Am J Neuroradiol 36:E39–E40 2015)


Kan PSiddiqui AHVeznedaroglu ELiebman KMBinning MJDumont TM: Early postmarket results after treatment of intracranial aneurysms with the Pipeline embolization device: a U.S. multicenter experience. Neurosurgery 71:108010882012


Kothandaram PDawson BHKruyt RC: Carotid-ophthalmic aneurysms. A study of 19 patients. J Neurosurg 34:5445481971


Li JLan ZGLiu YHe MYou C: Large and giant ventral paraclinoid carotid aneurysms: surgical techniques, complications and outcomes. Clin Neurol Neurosurg 114:9079132012


Ljunggren BSharma SFodstad H: History and epidemiology of SAH and cerebrovascular malformaitons in Pasqualin ADa Pian R (eds): New Trends in Management of Cerebrovascular Malformations. Vienna: Springer Vienna1994 pp 315


Locksley HB: Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. J Neurosurg 25:2192391966


Lonjon MPennes FSedat JBataille B: Epidemiology, genetic, natural history and clinical presentation of giant cerebral aneurysms. Neurochirurgie 61:3613652015


Lylyk PMiranda CCeratto RFerrario AScrivano ELuna HR: Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery 64:632643 N62009


Matano FTanikawa RKamiyama HOta NTsuboi TNoda K: Surgical treatment of 127 paraclinoid aneurysms with multifarious strategy: factors related with outcome. World Neurosurg 85:1691762016


Mattingly TKole MKNicolle DBoulton MPelz DLownie SP: Visual outcomes for surgical treatment of large and giant carotid ophthalmic segment aneurysms: a case series utilizing retrograde suction decompression (the “Dallas technique”). J Neurosurg 118:9379462013


Mizoi KTakahashi AYoshimoto TFujiwara SKoshu K: Combined endovascular and neurosurgical approach for paraclinoid internal carotid artery aneurysms. Neurosurgery 33:9869921993


Moher DLiberati ATetzlaff JAltman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b25352009


Murayama YTakao HIshibashi TSaguchi TEbara MYuki I: Risk analysis of unruptured intracranial aneurysms: prospective 10-year cohort study. Stroke 47:3653712016


Ng PYHuddle DGunel MAwad IA: Intraoperative endovascular treatment as an adjunct to microsurgical clipping of paraclinoid aneurysms. J Neurosurg 93:5545602000


Norlen GOlivecrona H: The treatment of aneurysms of the circle of Willis. J Neurosurg 10:4044151953


Nutik S: Carotid paraclinoid aneurysms with intradural origin and intracavernous location. J Neurosurg 48:5265331978


Otani NWada KToyooka TFujii KUeno HTomura S: Retrograde suction decompression through direct puncture of the common carotid artery for paraclinoid aneurysm. Acta Neurochir Suppl 123:51562016


Otani NWada KToyooka TFujii KUeno HTomura S: Usefulness of suction decompression method combined with extradural temporopolar approach during clipping of complicated internal carotid artery aneurysm. World Neurosurg 90:2932992016


Parkinson RJBendok BRGetch CCYashar PShaibani AAnkenbrandt W: Retrograde suction decompression of giant paraclinoid aneurysms using a No. 7 French balloon-containing guide catheter. Technical note. J Neurosurg 105:4794812006


Polevaya NVKalani MYSSteinberg GKTse VCK: The transition from hunterian ligation to intracranial aneurysm clips: a historical perspective. Neurosurg Focus 20(6):E32006


Pool JLColton RP: The dissecting microscope for intracranial vascular surgery. J Neurosurg 25:3153181966


Puffer RCKallmes DFCloft HJLanzino G: Patency of the ophthalmic artery after flow diversion treatment of paraclinoid aneurysms. J Neurosurg 116:8928962012


Punt J: Some observations on aneurysms of the proximal internal carotid artery. J Neurosurg 51:1511541979


Rouchaud ALeclerc OBenayoun YSaleme SCamilleri YD’Argento F: Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms. AJNR Am J Neuroradiol 36:3303362015


Saatci IYavuz KOzer CGeyik SCekirge HS: Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol 33:143614462012


Sahlein DHFouladvand MBecske TSaatci IMcDougall CGSzikora I: Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results. J Neurosurg 123:8979052015


Scott JAHorner TGLeipzig TJ: Retrograde suction decompression of an ophthalmic artery aneurysm using balloon occlusion. Technical note. J Neurosurg 75:1461471991


Seifert VGüresir EVatter H: Exclusively intradural exposure and clip reconstruction in complex paraclinoid aneurysms. Acta Neurochir (Wien) 153:210321092011


Sengupta RPGryspeerdt GLHankinson J: Carotid-ophthalmic aneurysms. J Neurol Neurosurg Psychiatry 39:8378531976


Shimizu TNaito IAihara MFujimaki HAsakura KMiyamoto N: Visual outcomes of endovascular and microsurgical treatment for large or giant paraclinoid aneurysms. Acta Neurochir (Wien) 157:13202015


Skrap MPetralia BToniato G: Temporary balloon occlusion during the surgical treatment of giant paraclinoid and vertebrobasilar aneurysms. Acta Neurochir (Wien) 152:4354422010


Strauss IMaimon S: Silk flow diverter in the treatment of complex intracranial aneurysms: a single-center experience with 60 patients. Acta Neurochir (Wien) 158:2472542016


Sugita KKobayashi SKyoshima KNakagawa F: Fenestrated clips for unusual aneurysms of the carotid artery. J Neurosurg 57:2402461982


Sundt TM JrPiepgras DG: Surgical approach to giant intracranial aneurysms. Operative experience with 80 cases. J Neurosurg 51:7317421979


Takahashi TSuzaki NTsugane SYamauchi KTakada S: Suction decompression methods for giant internal carotid ophthalmic aneurysms by using revised double lumen balloon catheters. Acta Neurochir Suppl 103:9102008


Takeuchi STanikawa RGoehre FHernesniemi JTsuboi TNoda K: Retrograde suction decompression for clip occlusion of internal carotid artery communicating segment aneurysms. World Neurosurg 89:19252016


Tamaki NKim SEhara KAsada MFujita KTaomoto K: Giant carotid-ophthalmic artery aneurysms: direct clipping utilizing the “trapping-evacuation” technique. J Neurosurg 74:5675721991


Thorell WRasmussen PPerl JMasaryk TMayberg M: Balloon-assisted microvascular clipping of paraclinoid aneurysms. Technical note. J Neurosurg 100:7137162004


Tytus JSWard AA Jr: The effect of cervical carotid ligation on giant intracranial aneurysms. J Neurosurg 33:1841901970


Vega-Basulto S: Técnica de descompresión-succión retrógada en los aneurismas paraclinoideos. Rev Neurol 37:3123172003


Vega-Basulto SDSilva-Adan SLaserda-Gallardo APenones-Montero RVarela-Hernandez A: Aneurismas intracraneales supratentoriales gigantes. Analisis de 22 casos. Neurocirugía 14:16242003


Xu BNSun ZHJiang JLWu CZhou DBYu XG: Surgical management of large and giant intracavernous and paraclinoid aneurysms. Chin Med J (Engl) 121:106110642008


Xu BNSun ZHRomani RJiang JLWu CZhou DB: Microsurgical management of large and giant paraclinoid aneurysms. World Neurosurg 73:137146 e17 e192010


Yasargil MGFox JL: The microsurgical approach to intracranial aneurysms. Surg Neurol 3:7141975


Zhou GSu MYin YLLi MH: Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus 42(6):E172017




All Time Past Year Past 30 Days
Abstract Views 129 129 129
Full Text Views 78 78 78
PDF Downloads 79 79 79
EPUB Downloads 0 0 0


Google Scholar