1200. Revascularization Strategies in the Management of Complex Anterior Cerebral Artery Aneurysms

Authors: Mohamed Labib, MD; Sirin Gandhi, MD; Claudio Cavallo, MD; Oliver Tang; Michael Mooney; Joshua Catapano, MD; Michael Lang, MD; Tsinsue Chen, MD; Michael Lawton, MD (Phoenix, AZ)

Introduction: Anterior Cerebral Artery (ACA) bypass is a technically demanding procedure owing to its intricate vascular anatomy and its location in the depth of the interhemispheric fissure. ACA bypasses usually favor an intracranial-intracranial (IC-IC) constructs. The current study aims to report the senior author’s (MTL) experience regarding revascularization strategies for complex ACA aneurysms based on the aneurysm location, morphology and the native intracranial vascular anatomy of the patient. Methods: All patients with an ACA aneurysm requiring a bypass were included in this retrospective cohort. A comprehensive chart review was conducted to gather clinical, radiological and perioperative outcome data. Three types of anastomoses used were: end-to-end, end-to-side, side-to-side with or without an interposition graft. Bypass patency was evaluated using the microdoppler and indocyanine green videoangiography. The definitive management of the aneurysm was achieved by proximal occlusion, distal occlusion, trapping or a staged-endovascular occlusion. Results: Seventeen patients were identified to have 17 ACA aneurysms requiring revascularization over a 30-year period. There were 7 males and 10 females with the mean age of 55.6 ± 18.6 years. The aneurysms were subdivided as 4 pre-communicating, 6 communicating and 7 post-communicating aneurysms. Five different bypass strategies were utilized across all these patients including – 1 reanastomosis, 3 reimplantation, 8 in-situ side-to-side bypass, 3 IC-IC with interposition and 2 combination bypasses. Total aneurysm obliteration was achieved in 82% patients. Improvement or stable neurological function was noted in 82% patients. At last follow-up, favorable outcome (mRS<2) was observed in 65% patients. Conclusion: This study emphasizes the importance of direct revascularization with clip reconstruction or coiling in the management of selective giant or dolichoectatic complex ACA aneurysms. IC-IC bypasses can be beneficial in improving clinical outcomes and achieving complete aneurysm obliteration in such difficult cases than with clipping or endovascular occlusion alone.