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

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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 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. bruno.flores@yahoo.com.

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.

Headings

Figures

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    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.

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    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.

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