What are the current roles of temporary clipping in the surgical treatment of arteriovenous malformations?

OBJECTIVE

Temporary clipping consists of a well-defined technique applied during the surgical treatment of cerebral aneurysms. However, little has been described regarding the use of transient clipping during the surgical treatment of arteriovenous malformations (AVMs). In this study, we aim to describe the use of temporary clipping and how it may aid the surgical resection of AVMs, as well as to report a case series to exemplify its application.

MATERIALS AND

METHODS

A case series of 28 patients submitted to microsurgical resection of AVM in which a temporary clip was applied was described and 4 illustrative surgical cases were reported.

RESULTS

In most of the cases, the temporary clip was applied in the arterial feeders, during nidus dissection, under neurophysiological monitoring and observing the indocyanine green angiography (ICGA) study intraoperatively, and it facilitated the coagulation and reduced the occurrence of bleeding from these vessels, besides reducing the turgidity of the nidus and draining vein during its dissection; in addition, it may aid the identification of residual nidus. In the cases which the transient clip was applied in the draining veins, it usually was applied to reduce the caliber of the vein and facilitate its coagulation, to verify, with the aid of ICGA, if the AVM was completely dearterialized, and in cases with venous drainage to multiple sites for the ICGA study of the main draining vein. The percentage of postoperative complications was low.

CONCLUSION

The use of temporary clipping, combined with intraoperative ICGA and neurophysiological monitoring, consists of a useful tool during the steps of the AVM microsurgical resection, from the coagulation of arterial feeders and nidus dissection to studying the flow pattern and aiding the decision when to remove the venous outflow.