Microsurgical Clip Ligation of a Large Anterior Communicating Artery Aneurysm Previously Treated With Woven Endobridge Device: 2-Dimensional Operative Video

Abstract

The Woven Endobridge (WEB) intrasaccular flow diversion device (Microvention, Inc.) is commonly used to treat both unruptured and ruptured wide-necked bifurcation aneurysms. 1 Despite its relative safety and comparable rates of aneurysm occlusion, the device may compress over time resulting in aneurysm recurrence. 2 In this video, we demonstrate the microsurgical retreatment of a large anterior communicating artery (ACoA) aneurysm previously treated with WEB. A 53-year-old patient with hypertension and current tobacco use presented with a ruptured ACoA aneurysm measuring 8.4 mm × 8 mm × 7 mm. She was urgently treated with a 9 mm × 5 mm WEB SL and made a full recovery. At 6 months, cerebral angiography showed a significant recurrence secondary to WEB compression. We considered both endovascular and microsurgical approaches; however, the anatomy was unfavorable for endovascular treatment. 3 Although previous reports have documented clipping as a retreatment strategy, a minority of these aneurysms were ACoA aneurysms. 4-7 The patient consented to the surgical procedure. This operative video illustrates the in vivo appearance of the WEB device and the surgical technique used to treat this unusual situation. The WEB device was firm and not as compressible as previously reported, but clipping was still possible. 4,6 We highlight the use of temporary clipping, fenestrated clips, and intraoperative angiography in treatment. The aneurysm was occluded, and the patient remained without deficits. In summary, clip ligation can be an excellent option for ACoA aneurysms in the setting of WEB recurrence. The patient consented to this report; Institutional Review Board/ethics committee approval was not required.