Orthogonal Dome First Tandem Clipping Technique for the Reconstruction of Giant Ophthalmic Artery Aneurysm: A Single-Surgeon Operative Experience

Introduction: Surgical management of giant ophthalmic artery aneurysms is a challenge due to adjacent bony anatomy, dural rings, and proximity to the optic nerve. Commonly, right-angled fenestrated clips are applied parallel to the internal carotid artery (ICA) for large and giant aneurysms. There is a possibility of kinking of the ICA as multiple right-angled fenestrated clips are applied in tandem. This aspect has been noted by several authors. We describe an alternative orthogonal clipping technique that is useful in atherosclerotic and wide (transverse) neck aneurysms.

Methods: We retrospectively analyzed 22 patients with giant ophthalmic artery aneurysm from January 1994 to August 2011 operated on by the senior author (AN).

Microsurgical Technique: A standard pterional craniotomy along with cranial base modification, cervical ICA exposure, and clinoidectomy was used in all cases. Mobilization of the falciform ligament, dural ring sectioning, and optic canal roof drilling were done in some cases. The following clipping techniques were used: For Group A, orthogonal clipping was done. The dome was handled first with multiple straight tandem clips (perpendicular to the long axis of the ICA). Dog-ear formation and kinking of the ICA was avoided by partial coagulation of the dome and clipping with curved clips or straight fenestrated clips. Seven patients with Barami type II/IV aneurysms were treated by this technique. These patients had atherosclerotic and wide (transverse) neck. For Group B, parallel clipping was done. Nine patients underwent parallel clipping to the ICA long axis. A combination of interlocking right-angled fenestrated and straight fenestrated clips was used. Group C patients were classified as “others.” Six patients could be managed by meticulous placement of curved and side-curved clips.

Results: The average age of the patients was 60.5 years, and the female:male ratio was 3:1. The most common presentation was visual loss, which was seen in 13/22 patients. Headache was the next, affecting 6/22 patients. The mean follow-up was 24.45 months. Of the 22 patients, 1 died and 2 were lost in follow-up. The clinical outcome was good (GOS score 5 or 4) in the majority (77.27%) of patients. Of the 14 patients who presented with visual problems before surgery, 78.5% showed improvement after surgical clipping. There was no significant difference between the outcomes and complications among different groups. Postoperative angiography analysis found a small residual neck in two patients, one in Group A and one in Group B. Serial angiogram in follow-up did not show any increase in size. No kinking of ICA or dog ears was seen in Group A patients.

Conclusion: Traditionally “parallel” clip placement is advocated, especially for giant ICA aneurysms. The technique of orthogonally placed tandem clips with fenestrated or curved clips gives an additional armament to a surgeon, especially in elderly patients with atherosclerosis or wide (transverse) neck aneurysms. The fear of kinking of the ICA and dog ear formation is uncalled for when this technique is used meticulously, and a predominantly good outcome can be expected.