Endovascular Retrograde Suction Decompression-Assisted Clipping of Large Paraclinoid Aneurysm in Hybrid Operating Room: 2-Dimensional Operative Video.

Surgical treatment of large paraclinoid aneurysms remains technically challenging due to the adjacent bony anatomy and neurovascular structures. Endovascular retrograde suction decompression using a double-lumen balloon catheter facilitates clip ligation of the aneurysm. Video 1 demonstrates a large paraclinoid aneurysm that was treated with endovascular balloon occlusion and retrograde suction decompression in a hybrid operating room. A 49-year-old woman presented with progressively worsening headache. Computed tomography angiography demonstrated a large 16-mm left paraclinoid aneurysm. Neurologic examination showed no deficits. Angiography with compression of the left carotid artery showed the collateral blood flow through the posterior communicating artery. The aneurysm was exposed via the pterional transsylvian approach. A double-lumen balloon guide catheter was placed in the left internal carotid artery. Considering the risk of ischemic complications, the "trapping-evacuation" technique was not used. After balloon inflation, a temporary clip was placed on the posterior communicating artery. Retrograde suction through the guide catheter decreased the intra-aneurysmal pressure. Tandem clipping with fenestrated clips was used to occlude the aneurysm and reconstruct the parent artery. Postoperative angiography confirmed complete obliteration of the aneurysm, and the patient recovered without any neurologic deficits. Endovascular balloon occlusion obviated the need for cervical dissection of the internal carotid artery. Retrograde suction decompression and intraoperative angiography facilitated surgical clipping for large and giant paraclinoid aneurysms.