抄録
A postoperative iatrogenic aneurysm following repeated temporary clipping procedures at the same site is reported. Simultaneously pitfall of the angled fenestrated clip application to the intracranial internal carotid artery is mentioned. A 51-year-old female was involved in an SAH episode with severe headache. Her Hunt & Hess grade was II. Right CAG showed a right paraclinoid aneurysm, pointing in the medio-inferior direction. Surgery was carried out on March 19th, 1984. A right optic canal decompression was made. During careful retraction of the right optic nerve premature rupture occurred. After temporary clipping of the proxymal internal carotid artery with a Scoville clip, neck clipping was done with a Sugita angled fenestrated clip. The right supraclinoid portion of the internal carotid artery became stenotic in diameter by the clip. Then EC-IC bypass procedures were initiated. At this time the Sugita clip was forced out by the torque of the released brain, and massive bleeding from the Sylvian fissure and the frontal base was observed. A Scoville clip was again applied to the right internal carotid artery. Next a Heifetz encircled clip was applied, but hemorrhage could not be controlled. Unavoidably a third temporary clipping was done. Finally a Sugita angled fenestrated clip was again applied and bleeding was controlled. Just after removing the Scoville clip, a pinhole laceration at the clipped site was revealed. But the bleeding was easily controlled by compression with Gelfoam. In addition, Aron-alpha was applied to the surface of the bleeding area. For prevention of Sugita clip slipping, a small piece of lyodura was laid between the handle of the clip and sphenoid ridge with Aron-alpha coating. Then the STA-MCA bypass was completed. On the 26th day after the operation bloody cerebrospinal fluid was obtained during a ventriculoperitoneal shunting operation. Urgent right CAG showed an iatrogenic aneurysm at the pinhole laceration during operation. It was judged that due to film coating by Aron-alpha direct operation would be difficult. Selverstone clipping was carried out at the cervical internal carotid artery. Postoperative digital subtraction angiography revealed no iatrogenic aneurysm and patency of the EC-IC bypass. The patient has returned to work and shows no neurological deficit.
Conclusions are as followings: 1, It is possible that frequent and repeated temporary clippings against the main arterial trunk might induce minimal laceration of the arterial wall and cause development of an iatrogenic aneurysm postoperatively. In order to prevent occurrence of traumatic aneurysms, sufficient and careful repair is necessary, even with a very small laceration of the arterial wall. 2, Main trunk stenosis by clipping and slipping out of a clip caused torque force are pitfalls of Sugita angled fenestrated clip application. Prophylactic procedures for slipping out of the clip should be considered.
