J Cerebrovasc Endovasc Neurosurg.  2025 Mar;27(1):50-59. 10.7461/jcen.2024.E2023.11.003.

“Picket fence” an alternative clipping technique for wide necked and large aneurysms: technical nuances in a case series

• Parra-Romero G
• Ugalde-Hernández Y
• García-López R

• KMID: 2567043
• DOI: http://doi.org/10.7461/jcen.2024.E2023.11.003

Abstract

Complex aneurysms are a therapeutic challenge in contemporary neurosurgery. Several microsurgical and endovascular techniques have been proposed for their treatment. The picket fence clipping technique uses fenestrated clips, that are stacked not to reconstruct the neck of the aneurysm, but to create a duct to normalize the cerebral flow by reconstructing the dome. We present four illustrative cases using the picket fence clipping technique. The aneurysms considered were of different locations (ICA, MCA, AComA), of large or giant size with wide necks, in which clipping attempt with a conventional technique was not possible, so that the use of non-conventional clipping techniques had to be applied with favorable results. In our experience we found this technique useful in large and giant, wide-necked aneurysms by reconstructing the parent vessel according to the concept of the ideal closure line in these previously unreported locations, thereby restoring normal cerebral circulation. The use of non-conventional techniques for clipping complex aneurysms can be used alone or in combination for adequate treatment, preserving cerebral circulation without compromising adequate exclusion of the aneurysm. The Picket fence technique is a feasible clipping technique that can be used as a less morbid option in large and giant aneurysms with wide necks.

Keyword

Case reports; Cerebral aneurysm; Clipping technique; Ideal closure line; Microsurgery

Figure

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  Fig. 1. Case 1 (A) Axial CT shows a Fisher 4 SAH in the basal cisterns. (B) Angio-CT showing a giant M1 bifurcation aneurysm with dome dependent M2 frontal and temporal branches. (C) Posterior view of a digital reconstruction showing a fusiform ATA aneurysm. (D) Operative view of a trans- sylvian approach after dissection of the M1 bifurcation-dependent aneurysm. (E) To reduce the volume of the dome and identify the closure line, the aneurysm was trapped and aspirated. (F) A clip is then placed to modify the geometry of the dome and (G) the remaining clips are stacked to reconstruct the parent artery and its efferent branches. (H) Postoperative DSA shows adequate patency of the distal vessels and complete exclusion of the aneurysm from the cerebral circulation (I). CT, computed tomography; ATA, anterior temporal artery; DSA, digital subtraction angiography

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  Fig. 2. Case 2 (A) Digital reconstruction of AngioCT, (B) DSA and (C) digital reconstruction of DSA showing a giant paraclinoid aneurysm with ventral projection. (D) Operative view after dissection of the basal cisterns showing the aneurysm and the ICA with its terminal branches ACA and MCA. (E) Operative view after clinoidectomy and opening of the distal dural ring for proximal control. (F) First attempt of conventional clipping with a fenestrated clip angled at 90°, which under proximal control shows patency of the distal branches (MCA, ACA and AChoA), but after removal of the temporary clip, (G) the flow of the aneurysm displaces the clip from its original position. (H), (I) The reverse picket fence technique is started from proximal to distal with placement of straight fenestrated clips from the neck to the dome. (J) To verify the adequate exclusion of the aneurysm, puncture and aspiration are performed, observing permeability of aneurysm, so reconstruction is continued. (K) Reconstruction of the dome with placement of clips preserving the AChoA (L). In the post-operative, frontal view (M), oblique view (N) and lateral view (O) of the DSA, in which the distal cerebral circulation is observed without residual aneurysm. CT, computed tomography; DSA, digital subtraction angiography; ICA, internal carotid artery; ACA, anterior cerebral artery; MCA, middle cerebral artery; AChoA, anterior choroidal artery

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  Fig. 3. Case 3 Posterior (A), anterior (B), and superior view (C) of digital reconstruction of an Angio CT showing an aneurysm of the M1 bifurcation which shares the neck with the M2 temporal branch. (D) Operative view after dissection of the Sylvian valley showing the aneurysm with atheroma plaque in the neck. (E) Dissection of the aneurysm shows involvement of the M2 temporal branch by continuity of the neck. (F) Under proximal control of M1, a first clip is placed perpendicular to the neck in the center of the dome to reduce the volume and identify the line of ideal occlusion. (G) Stacked clips are placed on the ideal closure line, obliterating the neck of the bifurcation. (H) The remnant is observed in the neck attached to the temporal M2. (I) Finally, a curved miniclip is placed to complete the remodeling of the parent vessel and distal M2 branches. (J) Final surgical view after removal of the temporal clip with adequate patency of the distal branches. (K) Posterior oblique view and (L) and posterior AngiCT reconstruction showing patency of the anterior and temporal M2 branches with adequate exclusion of the aneurysm. CT, computed tomography

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  Fig. 4. Case 4 (A), (B) Superior and lateral view of the AngioCT reconstruction showing aneurysms in the AComA, AChoA, ICA and M1 bifurcation. (C) Operative view of the anterior communicating complex showing an AComA-dependent aneurysm sharing the neck with the A2 branch. (D) Reconstruction from the dome to the neck is started by dividing the neck portion of A2. (E) Reconstruction is continued with fenestrated clips to exclude atheroma plaque in the dome. (F) More clips are stacked to reconstruct the AComA. (G) Operative view of the M1 bifurcation aneurysm. (H) A first clip is placed in the center of the dome to modify the shape of the aneurysm. (I) Clips are stacked from the dome to the neck to complete the reconstruction of the frontal and temporal M2 branches. (J) Post-operative lateral view in Angio CT reconstruction, (K) superior oblique and (L) superior view showing adequate exclusion of aneurysms with distal vessels patency. CT, computed tomography; AComA, anterior communicating artery; AChoA, anterior choroidal artery; ICA, internal carotid artery

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