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
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.
ABBREVIATIONSDSA = 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.
AblaAAZaidiHACrowleyRWBritzGWMcDougallCGAlbuquerqueFC: 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 Pediatr14:31–372014
AlbertFKForstingMAschoffAKriegerDKunzeS: Clipping of proximal paraclinoid aneurysm with support of the balloon-catheter “trapping-evacuation” technique. Technical note. Acta Neurochir (Wien)125:138–1411993
BatjerHHFrankfurtAIPurdyPDSmithSSSamsonDS: Use of etomidate, temporary arterial occlusion, and intraoperative angiography in surgical treatment of large and giant cerebral aneurysms. J Neurosurg68:234–2401988
DehdashtiARLe RouxABacigaluppiSWallaceMC: Long-term visual outcome and aneurysm obliteration rate for very large and giant ophthalmic segment aneurysms: assessment of surgical treatment. Acta Neurochir (Wien)154:43–522012
EliavaSSFilatovYMYakovlevSBShekhtmanODKheireddinASSazonovIA: Results of microsurgical treatment of large and giant ICA aneurysms using the retrograde suction decompression (RSD) technique: series of 92 patients. World Neurosurg73:683–6872010
FulkersonDHHornerTGPaynerTDLeipzigTJScottJADenardoAJ: Endovascular retrograde suction decompression as an adjunct to surgical treatment of ophthalmic aneurysms: analysis of risks and clinical outcomes. Neurosurgery64 (3 Suppl):ons107–ons1122009
GaoXYuCWangXZhangHLiZZhuT: Microsurgical treatment of large and giant paraclinoid carotid aneurysms using a revised endovascular suction decompression technique with Invatec Mo.Ma device. J Clin Neurosci33:264–2682016
GiacominiLPiskeRLBaccinCEBarrosoMJoaquimAFTedeschiH: Neurovascular reconstruction with flow diverter stents for the treatment of 87 intracranial aneurysms: clinical results. Interv Neuroradiol21:292–2992015
GriessenauerCJPiskeRLBaccinCEPereiraBJAReddyASThomasAJ: Flow diverters for treatment of 160 ophthalmic segment aneurysms: evaluation of safety and efficacy in a multicenter cohort. Neurosurgery80:726–7322017
HohDJLarsenDWElderJBKimPEGiannottaSLLiuCY: Novel use of an endovascular embolectomy device for retrograde suction decompression-assisted clip ligation of a large paraclinoid aneurysm: technical case report. Neurosurgery62 (5 Suppl 2):ONSE412–ONSE4142008
KallmesDFHanelRLopesDBoccardiEBonaféACekirgeS: International retrospective study of the Pipeline Embolization Device: a multicenter aneurysm treatment study. AJNR Am J Neuroradiol36:108–1152015 (Erratum in AJNR Am J Neuroradiol 36:E39–E40 2015)
KanPSiddiquiAHVeznedarogluELiebmanKMBinningMJDumontTM: Early postmarket results after treatment of intracranial aneurysms with the Pipeline embolization device: a U.S. multicenter experience. Neurosurgery71:1080–10882012
LjunggrenBSharmaSFodstadH: History and epidemiology of SAH and cerebrovascular malformaitons in PasqualinADa PianR (eds): New Trends in Management of Cerebrovascular Malformations. Vienna: Springer Vienna1994 pp 3–15
LylykPMirandaCCerattoRFerrarioAScrivanoELunaHR: Curative endovascular reconstruction of cerebral aneurysms with the pipeline embolization device: the Buenos Aires experience. Neurosurgery64:632–643 N62009
MattinglyTKoleMKNicolleDBoultonMPelzDLownieSP: Visual outcomes for surgical treatment of large and giant carotid ophthalmic segment aneurysms: a case series utilizing retrograde suction decompression (the “Dallas technique”). J Neurosurg118:937–9462013
OtaniNWadaKToyookaTFujiiKUenoHTomuraS: Usefulness of suction decompression method combined with extradural temporopolar approach during clipping of complicated internal carotid artery aneurysm. World Neurosurg90:293–2992016
ParkinsonRJBendokBRGetchCCYasharPShaibaniAAnkenbrandtW: Retrograde suction decompression of giant paraclinoid aneurysms using a No. 7 French balloon-containing guide catheter. Technical note. J Neurosurg105:479–4812006
RouchaudALeclercOBenayounYSalemeSCamilleriYD’ArgentoF: Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms. AJNR Am J Neuroradiol36:330–3362015
SaatciIYavuzKOzerCGeyikSCekirgeHS: Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol33:1436–14462012
SahleinDHFouladvandMBecskeTSaatciIMcDougallCGSzikoraI: Neuroophthalmological outcomes associated with use of the Pipeline Embolization Device: analysis of the PUFS trial results. J Neurosurg123:897–9052015