J Cerebrovasc Endovasc Neurosurg.  2023 Mar;25(1):62-68. 10.7461/jcen.2022.E2022.01.003.

Trapping and A4-A4 end-to-side anastomosis for the treatment of a ruptured A3 fusiform aneurysm: Potential risk of in-situ bypass

• Kim YR
• Lee SH
• Bae JW
• Choi YH
• Ha EJ
• Kim KM
• Cho WS
• Kang HS
• Kim JE

• KMID: 2540808
• DOI: http://doi.org/10.7461/jcen.2022.E2022.01.003

Abstract

The treatment of complicated anterior cerebral artery aneurysms remains challenging. Here, the authors describe a case of ruptured complicated A3 aneurysm, which was treated with trapping and in-situ bypass. A 47-year-old man presented to the emergency department with severe headache and vomiting. Computed tomography illustrated acute intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) confirmed a ruptured fusiform A3 aneurysm with lobulation and a daughter sac. Trapping of the ruptured fusiform A3 aneurysm and distal end-toside A4 anastomosis was performed. DSA on postoperative day 7 showed mild vasospasm to the afferent artery. However, 2 months later, DSA demonstrated that the antegrade flow through the anastomosis site had recovered. Thus, surgeons should be aware of the possibility of postsurgical vasospasm of anastomosed arteries, especially in cases of ruptured aneurysms.

Keyword

End-to-side anastomosis; In-situ bypass; Vasospasm; Complicated ACA aneurysm

Figure

• 

  Fig. 1. (A) Computed tomography demonstrates intracerebral hemorrhage, intraventricular hemorrhage, and a small amount of subarachnoid hemorrhage. (B) and (C) Digital subtraction angiography (both anteroposterior views and a lateral view) shows a right A3 fusiform aneurysm. (D) Three-dimensional reconstruction illustrates the fusiform aneurysm and the distal portion of ACA with an ectatic change. ACA, anterior cerebral artery

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  Fig. 2. Microscopic view. (A) Aneurysm revealed after arachnoid dissection via an interhemispheric approach (inlet: interactive three-dimensional angiography). (B) After trapping the aneurysm, end-to-side anastomosis was performed by using ipsilateral A4 as the donor artery (black arrow) and contralateral A4 (white arrow) as the recipient artery. (C) Anastomosis was performed in a continuous manner for the deep plane and an interrupted manner for the superficial plane. (D) Indocyanine green angiography shows patent flow to both ACAs and the disapperance of the aneurysm. ACA, anterior cerebral artery

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  Fig. 3. (A) Immediate postoperative perfusion CT demonstrates symmetrical flow to the bilateral ACA region. (B) CT angiography illustrates that the bilateral ACAs can be visualized distal to the anastomosis site and that the aneurysm has disappeared. (C) Schematic illustration of the trapping and A4-A4 end-to-side in situ bypass techniques. CT, computed tomography, ACA, anterior cerebral artery

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  Fig. 4. (A) and (B) Angiography one week after surgery. Faint flow is shown from the left-sided internal carotid artery (ICA) to the right-sided anterior cerebral artery (ACA) distal to the anastomosis site. A mild degree of vasospasm of the left A1 and A2 is visualized. Right ICA angiography demonstrates prominent leptomeningeal collaterals of the middle cerebral artery to the right anterior cerebral artery territories. (C) and (D) Angiography two months postoperatively. Left ICA angiography shows disappeared vasospasm and restored flow to the right ACA through the anastomosis site. Right ICA angiography illustrates the absence of collateral flow from the middle cerebral artery to the ACA territory.

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