Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms

Abstract

BackgroundComplex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms.MethodsBetween 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years.ResultsAfter successful STA–MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA–MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0–2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up.ConclusionsThe combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.

Extracranial-intracranial bypass surgery for intracranial aneurysm of the anterior cerebral circulation: A systematic review and meta-analysis

“…After identification, 21 studies were included in this review, involving a total of 22 cohorts and 915 patients (13,14,(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38). The study of Abdulrauf et al (31) included a prospective cohort of 30 patients and a retrospective cohort of 110 patients.…”

“…The study of Abdulrauf et al (31) included a prospective cohort of 30 patients and a retrospective cohort of 110 patients. The study by Dodie et al (38) included one patient with a failed intraoperative bypass, so a total of 40 bypasses were performed. We evaluated a total of 1,100 unique publications and 1,079 were excluded (Figure 1).…”

Flow diversion for compressive unruptured internal carotid artery aneurysms with neuro-ophthalmological symptoms: a systematic review and meta-analysis

“…We included series reporting on ≥10 patients with (1) an unruptured intracranial aneurysm of the ICA, with (2) a compressive effect on the oculomotor nerves and/or the optic pathway, considered responsible for ocular symptoms-that is, (3) cranial neuropathy affecting the CN III, IV, and VI (alone or in combination) and/or (4) visual impairment due to compressive optic neuropathy. Treatment was (5) with flow diversion alone or in conjunction with coil embolization.…”

“…Aneurysms inducing compression-related symptoms are often large and/or rapidly growing lesions 1. Intrasaccular coil embolization, parent artery occlusion (PAO)—either with or without extracranial–intracranial bypass surgery—or aneurysm clipping have been studied for the management of these lesions 2–5. Flow diverters (FD) promote aneurysm collapse and healing, thus reducing the mass effect, while preserving the vessel patency 6.…”

“…1 Intrasaccular coil embolization, parent artery occlusion (PAO)-either with or without extracranial-intracranial bypass surgery-or aneurysm clipping have been studied for the management of these lesions. [2][3][4][5] Flow diverters (FD) promote aneurysm collapse and healing, thus reducing the mass effect, while preserving the vessel patency. 6 To date, the literature on the use of FD in internal carotid artery (ICA) aneurysms causing compressive NOS is still scarce.…”