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  • Title: Salvage of Intraoperative Rupture of a Wide-Necked Middle Cerebral Artery Bifurcation Aneurysm: The Felt-Fenestrated Clipping Technique.
    Author: Housley SB, Monteiro A, Cappuzzo JM, Khawar WI, Levy EI.
    Journal: Oper Neurosurg (Hagerstown); 2023 Feb 01; 24(2):e57-e60. PubMed ID: 36637307.
    Abstract:
    BACKGROUND: Intraoperative aneurysm rupture during microsurgical clipping can be managed with different salvage techniques. In an aneurysm with a very wide neck that is located at a bifurcation, repairing an iatrogenic tear can be challenging and carry the risk of branch occlusion and infarction. OBJECTIVE: To describe a variation of the cotton-clipping technique modified to better fit the bifurcation anatomy, which we call "felt-fenestrated clipping." METHODS: An illustrative case of intraoperative rupture of a wide-necked middle cerebral artery bifurcation aneurysm is presented. Radiological imaging, operative video, and technique illustration were obtained and prepared for this report. RESULTS: A middle-aged woman underwent microsurgical clipping of a wide-necked middle cerebral artery bifurcation aneurysm. A right-angle clip became dislodged from the clip applier and snapped across the aneurysm causing a small rupture at the base. This was later determined to be the result of improper placement of a standard clip onto a mini-clip applier. After a few salvage attempts, a small piece of Teflon felt was placed over the rupture site and held in place using a straight, fenestrated clip. Then, the right-angle clip was applied over the true neck of the aneurysm and the edge of the rupture site, covering the Teflon felt to obtain true hemostasis. CONCLUSION: We demonstrate a technically successful felt-fenestrated clipping technique for treatment of an intraoperative rupture not amenable to other salvage options. This technique is useful to achieve hemostasis while preserving branches in wide-necked bifurcation aneurysms.
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