傍鞍部を含む内頚動脈瘤に対する頚動脈直接穿刺によるsuction decompression法の有用性

抄録

Introduction: Surgical clipping of a paraclinoid aneurysm can be very difficult because strong adhesion may hinder the dissection of the perforators and surrounding anatomical structures from the aneurysm dome. We describe our experience of performing retrograde suction decompression during the clipping of paraclinoid internal carotid artery (ICA) aneurysms, and discuss the advantages and pitfalls of the technique.
Materials and methods: In this retrospective study, we enrolled 22 consecutive patients, 20 females and 2 males aged 37-78 years (mean, 64 years), including 13 patients with large and 4 patients with giant intracranial aneurysms treated with clipping surgery through suction decompression assistance between March 2004 and August 2013. Direct puncture of the common carotid artery was performed using a 20-gauge needle. The aneurysm was trapped by clamping the common carotid and external carotid arteries followed by temporary clipping of the intracranial ICA distal to the aneurysm neck. Blood was then gently aspirated through a catheter introduced into the cervical ICA, resulting in the collapse of the aneurysm. The aneurysm dome was detached from the perforators and surrounding structures during blood flow interruption, which could be maintained for up to 5 min. This procedure was repeated until the dissection and clipping of the aneurysm were completed. Control angiography was usually performed to confirm complete clipping of the aneurysm and the restoration of blood flow in the intracranial ICA.
Results: The admitted patients included 6 patients with a ruptured aneurysm resulting in subarachnoid hemorrhage, 11 with an asymptomatic unruptured aneurysm, and 5 with a symptomatic unruptured aneurysm. The aneurysms were located in the paraclinoid ICA in 14 patients, the posterior communicating artery bifurcation in 6, the ICA bifurcation in 1, and the anterior wall of the ICA in 1. No patient had any complication related to the puncture of the common carotid artery. The surgical outcomes were as follows: good recovery in 12 patients, moderate disability in 4, severe disability in 4, and vegetative state in 1. One patient died of re-rupture of the aneurysm resulting from incomplete dome clipping. Two patients developed cerebral infarction—in 1 patient, this was due to an anterior choroidal artery infarction.
Conclusion: Retrograde suction decompression through direct puncture of the common carotid artery is a useful adjunct technique for the clipping of ICA aneurysms.