Yonsei Med J.  2014 Mar;55(2):401-409.

Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping Strategies for Unclippable Cerebral Aneurysms

• Kim YB
• Hong CK
• Chung J
• Joo JY
• Huh SK

Abstract

PURPOSE
To evaluate the efficacy and stability of the wrap-clipping methods as a reconstructive strategy in the treatment of unclippable cerebral aneurysms.
MATERIALS AND METHODS
Twenty four patients who had undergone wrap-clipping microsurgery were retrospectively reviewed. Type and morphology of the treated aneurysm, utilized technique for wrap-clip procedure, and clinical outcome with angiographic results at their last follow-up were evaluated.
RESULTS
Of 24 patients, eleven patients had internal carotid artery (ICA) blister-like aneurysms, three had dissecting type aneurysms, and ten had fusiform aneurysms. The follow-up period for the late clinical and angiographic results ranged from 10 to 75 months (mean 35 months). Wrap-clipping was performed in eleven, wrap-holding clipping was in ten, and combination of wrap-clip and wrap-holding clip was in three cases. At the last angiographic follow-up study, twelve aneurysms (50%) were found to have completely healed, and nine aneurysms (38%) were at least stable. However, wrap-holding clip for the elongated blister type of ICA aneurysm was found failed, leading to fatal rebleeding in one case, and two cases of combination of wrap-clip-wrap-holding clip revealed delayed branch occlusion and marked regrowing, respectively.
CONCLUSION
Wrap-clipping strategy could be an easy and safe alternative for unclippable aneurysms. The wrapped aneurysm mostly disappeared, or at least remained stationary, after a long-term period. However, surgeons should be aware of that the wrapped aneurysm might become worse. Therefore, follow-up surveillance for an extended period should be mandatory.

Keyword

Cerebral aneurysms; unclippable; wrap-clipping; follow-up

MeSH Terms

Aneurysm
Blister
Carotid Artery, Internal
Follow-Up Studies
Humans
Intracranial Aneurysm*
Methods
Microsurgery
Retrospective Studies

Figure

• 

  Fig. 1 Schematic diagram of wrap-clip, wrap-holding clip, and combination of two. (A) After enveloping the entire aneurysm segment of the parent artery with a cotton strip, the portion of the aneurysm body that appears acceptable to approximate is clip-ligated as much as possible over the wrapped material (Wrap-Clip). (B) If the clip ligation to the aneurysm body is deemed difficult and risky in such a case with laterally projecting aneurysm or thick atherosclerosis of the parent artery, the free ends of cotton wrapping are secured with a clip to tighten the wrapped construct (Wrap-Holding Clip). (C) Occasionally, the two techniques can be used in combination. The most vulnerable portion of the lesion is wrap-clipped first, and the remainder is double reinforced by a second wrap-holding clipping (Wrap-Clip-Wrap-Holding Clip).

• 

  Fig. 2 Illustrative case 6. (A) Catheter angiography revealing a 3-mm-sized tit-like aneurysm at the left ICA (arrow). (B) Intraoperative photo of the aneurysm covered with a localized clot. (C) Wrap-Holding Clipping of the aneurysmal segment of the ICA. (D) Catheter angiography taken after 13 months showed the remaining aneurysm without significant changes (arrow). ICA, internal carotid artery.

• 

  Fig. 3 Illustrative case 7. (A) Catheter angiography showed a 3-mm-sized sessile aneurysm arising at the non-branching site of the right ICA (arrow). (B) The ICA segment containing a clot-capped aneurysm. (C) The aneurysm was wrapped with a holding clip. (D) Catheter angiography taken 14 months later showed no preexisting aneurysm (arrow) and normal appearance of the ICA (arrow). ICA, internal carotid artery.

• 

  Fig. 4 Illustrative case 22. (A) Catheter angiography showed diffuse aneurysmal bulging without an identifiable neck measuring 7 mm at the inferior MCA branch. (B) Intraoperative photo of the fusiform aneurysm. (C) Wrap-Clipping for most of the aneurysmal dilatation with reconstruction of adequate lumen for normal blood flow. (D) An additional Wrap-Holding Clipping over theWrap-Clipped construct. (E) Immediate postoperative angiography showing satisfactory obliteration of the original fusiform dilatation and satisfactory reconstruction of the parent artery (arrow). (F) After 36 months, an angiography revealed total occlusion of the previously wrap-reconstructed parent artery (arrow). MCA, middle cerebral artery.

• 

  Fig. 5 Illustrative case 23. (A) Catheter angiography revealing a globe-shaped fusiform aneurysm at the right MCA main trunk. (B) Intraoperative photo showing aneurysmal dilatation without a clippable neck. (C) Wrap-Clipping plus subsequent Wrap-Holding Clipping using two fenestrated angled clips. (D) Postoperative angiography showing good reconstruction of the MCA. (E) Ten months later, catheter angiography revealed a giant-sized fusiform dilatation of the right MCA proximal to the wrap-reconstructed segment. (F) Computed tomographic angiography showing radial artery graft bypass between the cervical external carotid artery and distal MCA. MCA, middle cerebral artery.

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