Tandem angled fenestrated clipping is a technique using multiple angled fenestrated clips applied sequentially with the blade tips aligned in the same direction across a broad aneurysm neck projecting away from the neurosurgeon. Tandem counter clipping techniques align the blade tips in opposite directions, and can be facing toe-to-toe or cross-wise heel-to-heel. This case demonstrates cross-wise counter clipping of an aneurysm of the intradural vertebral artery (V4-VA) located in the corridor of the vagoaccessory triangle between the lateral edge of the medulla medially, the vagus nerve superiorly, and the accessory nerve laterally.1,2 A 75-yr-old woman with right leg weakness had a large dolichoectatic left VA aneurysm compressing the medulla. Endovascular options were considered but the patient opted for open surgery to decompress the medulla. The aneurysm was exposed through a far-lateral approach, dissected away from the cranial nerves through the vagoaccessory triangle, and softened with a proximal temporary clip. The aneurysm was obliterated with 2 cross-wise 45-degree angled fenestrated clips that overlapped at their interface to completely close the neck, and was then deflated to decompress the medulla. Indocyanine-green and fluorescein angiography intraoperatively, and catheter angiography postoperatively, confirmed aneurysm occlusion and perforator preservation. The patient recovered from surgery without any complications and her weakness improved at 3-mo follow-up evaluation. Cross-wise counter clipping enables clip reconstruction of complex aneurysms in confined spaces like the vagoaccessory triangle. Overlapping heel-to-heel clips enable clip application from one central point along the neck, whereas overlapping toe-to-toe clips require application from both ends of the neck. The variable lengths and angles of the blades allow for customized reconstructions.
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Disclosure
The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES
1. Abla AA, Benet A, Lawton MT. The far lateral transpontomedullary sulcus approach to pontine cavernous malformations: technical report and surgical results. Neurosurgery2014;10(Suppl 3):472-480.
2. Rodriguez-Hernandez A, Lawton MT. Anatomical triangles defining surgical routes to posterior inferior cerebellar artery aneurysms. J Neurosurg. 2011;114:1088-1094.
COMMENTS
This is a beautiful video of an elegant and clever clipping technique to exclude a wide necked aneurysm from the circulation that was causing mass effect on the brainstem. This provides a nice example of the versatility of microsurgical clipping to efficiently and durably eliminate mass effect caused by aneurysms.
Daniel L. Barrow
Atlanta, Georgia
It is helpful for an aneurysm surgeon to view aneurysm clipping as parent artery reconstruction. Fenestrated clips can create opportunities for creative closure of wide necked aneurysms in a step-wise fashion. In this case the fenestrations allowed the surgeon to reconstruct the parent artery in an elegant manner without subjecting the adjacent cranial nerves to undue manipulation. More traditional clips would have been much more difficult to apply in this case. Modern 3-dimensional printing and computer simulation should allow residents and surgeons to experiment with various clipping strategies prior to the actual surgery. This case illustrates the utility of fenestrated clips and some nuances of safe and anatomically enlightened microsurgery. While posterior circulation aneurysms have become labeled unfairly at times as high risk for microsurgery, vertebral aneurysms like this are in fact easier to treat than some anterior circulation aneurysms. While stent assisted coiling and flow diversion may be alternatives for this type of aneurysm it is important for any aneurysm team to keep all options on the table when counseling patients. Only when all options are vetted carefully by an experienced team can patients receive high quality care.
Bernard R. Bendok
Phoenix, Arizona
