Booster clips for giant and thick-based aneurysms

Restricted access

✓ The authors describe their experience using booster clips to secure the closure of primary clips in the repair of giant and other thick-walled aneurysms. These clips were used for 21 aneurysms in 20 patients, comprising 12% of all aneurysms operated on during the 15-month period of the report, but representing about 50% of all giant aneurysms operated on during the same time frame. These clips are designed to encircle the primary clip and have fixation “shoes” to close upon the jaws of the primary clip. All aneurysms were opened for decompression and thrombectomy when necessary following temporary major vessel occlusion before placement of the primary clip. Cerebral blood flow measurements and continuous electroencephalographic monitoring were utilized to predict the brain's tolerance to temporary ligation of the internal carotid artery (ICA) in those cases with a giant aneurysm arising from that vessel. There were no complications attributable to the periods of intracranial or cervical ICA occlusion; these periods varied but did not exceed 8 minutes for the former nor the tolerance period for the latter, which was calculated as from 5 to 30 minutes. It was necessary to reoperate on two patients and reposition clips because of stenoses or occlusions identified on immediate postoperative angiography. Fifteen patients had normal neurological function at the time of discharge. Three patients had minor deficits which did not prevent employment; two of these were related to a preoperative deficit and one was a complication of delayed ischemia. There were two deaths: one from bleeding complications and probable damage to perforating vessels in a patient operated on under profound hypothermia (the only case in the series so managed), and one from respiratory complications in a patient with severe pulmonary problems.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Left: Diagram showing the mechanism of a typical booster clip. Right: Photograph showing the various sizes and shapes of booster clips used to date. The clips are manufactured at different lengths and with the “shoes” available at angles of 0°, 30°, 60°, and 90° to the long axis of the clip.

  • View in gallery

    Case 4. Preoperative angiograms demonstrating a large aneurysm elevating the A1 segments of both anterior cerebral arteries and compressing the optic nerves.

  • View in gallery

    Operative drawings in Case 4. A: The aneurysm is exposed through a standard pterional approach after the internal carotid artery (ICA) has been isolated in the neck for temporary ligation. ECA = external carotid artery. B: The dura overlying the anterior clinoid process is cauterized and incised. C: The anterior clinoid process is resected with an air drill, exposing the dural sheath surrounding the ICA, which is then incised. D: The ICA is temporarily ligated in the neck and intracranially proximal to the origin of the anterior choroidal artery. The aneurysm is then opened with the tip of a No. 11-blade knife. E: The thrombus is removed from the aneurysm, converting the base of the aneurysm to a pliable sac which will accept an aneurysm clip. F: A McFadden or heavy Drake clip is placed across the base of the aneurysm leaving a small cuff of aneurysm to prevent constriction of the parent artery. G and H: The aneurysm clip is reinforced with two booster clips, and the temporary clips are removed. One of the booster clips encircles the optic nerve and closes on the tip of the primary aneurysm clip.

  • View in gallery

    Case 4. Postoperative angiogram demonstrating good flow through the site of the aneurysm repair after the clips had been repositioned.

  • View in gallery

    Case 7. Lateral (left) and anteroposterior (right) angiograms indicating a large internal carotid artery aneurysm projecting medially.

  • View in gallery

    Case 7. Postoperative angiograms, lateral view (left) and magnified oblique view (right), demonstrating repair of the aneurysm with two booster clips in a manner similar to that delineated in Fig. 3.

  • View in gallery

    Case 13. Preoperative angiogram, lateral view, of a giant aneurysm arising from the internal carotid artery. The aneurysm is projecting medially and inferiorly.

  • View in gallery

    Case 13. Left: Immediate postoperative angiogram with the patient still under anesthesia demonstrating occlusion of the internal carotid artery (ICA) by aneurysm clips. She was returned immediately to surgery and the aneurysm clips repositioned. She awoke from the operative procedure with no focal neurological deficits. Right: Postoperative angiogram taken prior to discharge demonstrating good filling of the ICA complex through the site of aneurysm repair.

  • View in gallery

    Case 5. Preoperative angiograms, lateral (left) and anteroposterior (right) views.

  • View in gallery

    Case 5. Left: Operative sketch of a giant aneurysm arising from the internal carotid artery (ICA) and projecting inferiorly. The configuration of the aneurysm required a slightly different approach from that used for aneurysms projecting medially. Right: The aneurysm is repaired with a heavy-duty McFadden clip reinforced with a booster clip on the tips of the clip jaws, with a secondary aneurysm clip occluding a portion of the sac not included in the primary clip.

  • View in gallery

    Case 5. Postoperative subtraction angiograms, lateral (left) and anteroposterior (right) views, illustrating good flow through the internal carotid artery at the site of aneurysm repair.

  • View in gallery

    Case 11. Left: Computerized tomography scans demonstrating a large mass in the left middle fossa which appears to be a giant aneurysm. Right: Only a portion of the aneurysm fills on the preoperative angiogram.

  • View in gallery

    Case 11. A: The aneurysm is approached through the Sylvian fissure. The base of the aneurysm is dissected away from the limbs of the middle cerebral artery (MCA), and a plane of dissection is created for the aneurysm clip. ACA = anterior cerebral artery. B: A temporary clip is applied to the MCA. C: The aneurysm is occluded with a McFadden clip reinforced with a booster clip. D: Blood flow is restored (arrows).

  • View in gallery

    Case 11. Immediate postoperative angiogram demonstrating good flow through the site of aneurysm repair.

  • View in gallery

    Case 2. Anteroposterior (left) and lateral (right) preoperative angiograms showing a giant aneurysm arising from the anterior communicating artery. Only a portion of the aneurysm appeared filled on angiography; the lesion was bigger on computerized tomography and appeared to be largely thrombosed.

  • View in gallery

    Case 2. A: Giant aneurysm arising from the anterior communicating artery in an anomalous circle, with a single A1 segment supplying both anterior cerebral arteries (ACA's). B: The A1 segment is temporarily occluded and the aneurysm opened for thrombectomy. C: After the thrombus in the base of the aneurysm is removed, the aneurysm clip is applied to the base. Thrombus in the dome of the aneurysm is not removed until after the aneurysm has been clipped, in order to shorten occlusion time. D: The aneurysm clip is reinforced with a booster clip, and the temporary clip on the A1 segment is removed. Occlusion time was 5 minutes. ICA = internal carotid artery, MCA = middle cerebral artery.

  • View in gallery

    Case 2. Anteroposterior (left) and lateral (right) postoperative angiograms demonstrating good filling of the anterior cerebral artery complex through the site of aneurysm repair.

References

  • 1.

    Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:12951979Drake CG: Giant intracranial aneurysms: experience with surgical treatment in 174 patients. Clin Neurosurg 26:12–95 1979

  • 2.

    Ferguson GGDrake CG: Carotid-ophthalmic aneurysms: the surgical management of those cases presenting with compression of the optic nerves and chiasm alone. Clin Neurosurg 27:2633081980Ferguson GG Drake CG: Carotid-ophthalmic aneurysms: the surgical management of those cases presenting with compression of the optic nerves and chiasm alone. Clin Neurosurg 27:263–308 1980

  • 3.

    Gelber BRSundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1101980Gelber BR Sundt TM Jr: Treatment of intracavernous and giant carotid aneurysms by combined internal carotid ligation and extra- to intracranial bypass. J Neurosurg 52:1–10 1980

  • 4.

    Silverberg GDReitz BAReam AK: Hypothermia and cardiac arrest in the treatment of giant aneurysms of the cerebral circulation and hemangioblastoma of the medulla. J Neurosurg 55:3373461981Silverberg GD Reitz BA Ream AK: Hypothermia and cardiac arrest in the treatment of giant aneurysms of the cerebral circulation and hemangioblastoma of the medulla. J Neurosurg 55:337–346 1981

  • 5.

    Sugita KKobayashi SInoue Tet al: New angled fenestrated clips for fusiform vertebral artery aneurysms. J Neurosurg 54:3463501981Sugita K Kobayashi S Inoue T et al: New angled fenestrated clips for fusiform vertebral artery aneurysms. J Neurosurg 54:346–350 1981

  • 6.

    Sugita KKobayashi SKyoshima Ket al: Fenestrated clips for unusual aneurysms of the carotid artery. J Neurosurg 57:2402461982Sugita K Kobayashi S Kyoshima K et al: Fenestrated clips for unusual aneurysms of the carotid artery. J Neurosurg 57:240–246 1982

  • 7.

    Sundt TM JrPiepgras DG: Surgical approach to giant intracranial aneurysms. Operative experience with 80 cases. J Neurosurg 51:7317421979Sundt TM Jr Piepgras DG: Surgical approach to giant intracranial aneurysms. Operative experience with 80 cases. J Neurosurg 51:731–742 1979

  • 8.

    Sundt TM JrSharbrough FWPiepgras DGet al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy. With results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:5335431981Sundt TM Jr Sharbrough FW Piepgras DG et al: Correlation of cerebral blood flow and electroencephalographic changes during carotid endarterectomy. With results of surgery and hemodynamics of cerebral ischemia. Mayo Clin Proc 56:533–543 1981

  • 9.

    Sundt TM JrWhisnant JP: Subarachnoid hemorrhage from intracranial aneurysms. Surgical management and natural history of disease. N Engl J Med 299:1161221978Sundt TM Jr Whisnant JP: Subarachnoid hemorrhage from intracranial aneurysms. Surgical management and natural history of disease. N Engl J Med 299:116–122 1978

  • 10.

    Weir B: Value of immediate postoperative angiography following aneurysm surgery. Report of two cases. J Neurosurg 54:3963981981Weir B: Value of immediate postoperative angiography following aneurysm surgery. Report of two cases. J Neurosurg 54:396–398 1981

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 49 49 3
Full Text Views 205 205 0
PDF Downloads 115 115 0
EPUB Downloads 0 0 0

PubMed

Google Scholar