Clip-grafts for aneurysm and small vessel surgery.

Part 4: Relative application to various aneurysms and repair of anterior communicationg aneurysms using right-angle clip holder.

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✓ Analysis of the use of the clip-graft for intracranial aneurysms indicates that the clip-graft is chiefly applicable to internal carotid and anterior communicating artery aneurysms. The development of the right-angle clip holder has extended its use to anterior communicating artery aneurysms that project posteriorly or superiorly. The dangers of dissection in the septal region are discussed. With few exceptions, the clip-graft is not applicable to the vertebrobasilar system or middle cerebral artery trifurcation aneurysms, although it has been used for aneurysms arising from the trunk of the latter vessel.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Mayo Clinic, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Steps in repair of carotid artery aneurysm. Clip-graft, 3.5 by 5.0 mm, is secured by right-angle clip holder; clip is applied 180 degrees away from primary projection of aneurysm to minimize premature rupture.

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    Repair of anterior communicating aneurysm projecting posteriorly by use of right-angle clip holder and clip-graft. The placement of burr holes for the usual bifrontal craniotomy is indicated at the left; the lateral projection of the clip holder illustrates its usual position when applying the clip-graft. To the right, magnification views typical of those through the operating microscope demonstrate: (A) initial incision in arachnoid overlying chiasm prior to identification of aneurysm, (B) clip-graft applied from normal vessel side of anterior communicating artery aneurysm (the dome of the aneurysm and distal extent are not necessarily exposed), (C) clip-graft in place, anterior communicating artery is still patent, base of aneurysm is sealed in jaws of clip-graft, the A-1 and A-2 segments of both anterior cerebral arteries are visualized to confirm patency.

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    Gravity release mechanism of clip holder is illustrated prior to final approach to anterior communicating artery aneurysm. For repair of both anterior communicating artery aneurysms and carotid artery aneurysms the author prefers to “prerelease” the clip and hold the clip in an open position. This minimizes movements necessary at the time of application and in certain positons for carotid aneurysms the position of the clip holder is such that the gravity release mechanism will not function.

References

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Botterell EHLougheed WMScott JWet al: Hypothermia, and interruption of carotid, or carotid and vertebral circulation in the surgical management of intracranial aneurysms. J Neurosurg 13:1421956Botterell EH Lougheed WM Scott JW et al: Hypothermia and interruption of carotid or carotid and vertebral circulation in the surgical management of intracranial aneurysms. J Neurosurg 13:1–42 1956

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Pool JL: Aneurysms of the anterior communicating artery: bifrontal craniotomy and routine use of temporary clips. J Neurosurg 18:981111961Pool JL: Aneurysms of the anterior communicating artery: bifrontal craniotomy and routine use of temporary clips. J Neurosurg 18:98–111 1961

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Scoville WB: Surgical lesions of the brain affecting human behavior with especial reference to psychosurgery in: Proceedings of the Second International Conference on PsychosurgeryCopenhagen, DenmarkAugust 24–26, 1970. Springfield, IllCharles C Thomas (In press)Scoville WB: Surgical lesions of the brain affecting human behavior with especial reference to psychosurgery in: Proceedings of the Second International Conference on Psychosurgery Copenhagen Denmark August 24–26 1970. Springfield Ill Charles C Thomas (In press)

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Sundt TM JrMurphey F: Clip-grafts for aneurysm and small vessel surgery. Part 3: Clinical experience in intracranial internal carotid artery aneurysms. J Neurosurg 31:59711969Sundt TM Jr Murphey F: Clip-grafts for aneurysm and small vessel surgery. Part 3: Clinical experience in intracranial internal carotid artery aneurysms. J Neurosurg 31:59–71 1969

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VanderArk GDKempe LC: Classification of anterior communicating aneurysms as a basis for surgical approach. J Neurosurg 32:3003031970VanderArk GD Kempe LC: Classification of anterior communicating aneurysms as a basis for surgical approach. J Neurosurg 32:300–303 1970

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