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Management of Complex Aneurysms:
Role of Arterial Reconstruction
Neil A. Martin, MD
Geisinger Health
Danville, Pa
Techniques for Aneurysm Occlusion
• Simple neck clipping
• Clip reconstruction of parent artery
• Clipping under hypothermic cardiac arrest
• Parent artery occlusion (balloon, coil, clip)
• Endosaccular coils
• Stent plus coils
• Wrapping
• Parent artery occlusion with bypass
Bypass for Aneurysms: Advantages
• Parent artery occlusion generally provides
simple, complete, permanent treatment
• Bypass prevents distal ischemia, and collateral
flow stress (de novo aneurysm formation)
• No need to reconstruct calcified,
atherosclerotic, or thombosed neck region
• Avoids risk of cardiac arrest
Bypass
Types
Type II
Patient HB: 48 yo woman with headaches
and diplopia
Problem: No cross-filling, rapid failure of BTO
Saphenous vein graft from ICA to MCA
Pre-op Post-op
Type II Bypass: Saphenous Vein Interposition
Fusiform MCA Aneurysm
Saphenous vein from ECA
Type III
Failed BTO at
9 minutes
STA vs Saphenous Vein
STA
• One anastomosis
• Acute occlusion: 2-5%
• Late occlusion: 5-10%
• One incision
Vein
• Two anstomoses
• Acute occlusion: 5-
10%
• Late occlusion: 25-
30%
• Three incisions
• Hyperperfusion
STA vs Saphenous Vein
STA
• Cavernous aneurysm
with small
communicating
arteries
• Aneurysm involving
one branch vessel
(MCA, PICA)
Vein
• Cavernous aneurysm
with no
communicating
arteries
• Aneurysm involving
major trunk (MCA
M1)
30 y.o. photographer with headaches, episodic aphasia,
and right side weakness
40 yo woman, progressive headaches, decreased visual
acuity
ICA aneurysm extends to include Pcom origin - persistent
aneurysm filling post op
Pre opPost op
Bypass Patency
• Superficial temporal artery : 96%
• Saphenous vein grafts : 95%
• Cerebral artery anastomoses : 100%
135761Spetzler ‘96
9779
(83%)
95Martin ‘07
433946Drake ‘94
242531Ausman ‘90
542029Sundt ‘86
DeadFair-PoorExc-Goodn
Revascularization for Aneurysms: Results
END
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