SAPHENOUS-VEIN GRAFT RECONSTRUCTION OF AN UNCLIPPABLE GIANT BASILAR ARTERY ANEURYSM PERFORMED WITH THE PATIENT UNDER DEEP HYPOTHERMIC CIRCULATORY ARREST - TECHNICAL CASE-REPORT

OBJECTIVE AND IMPORTANCE: Effective treatment for unclippable giant ve rtebrobasilar aneurysms remains unclear. We present the first reported case of a giant vertebrobasilar aneurysm being successfully treated w ith trapping of the aneurysm and internal carotid artery to basilar ar tery bypass with a saphenous vein graft that was performed with the pa tient under hypothermic circulatory arrest. CLINICAL PRESENTATION: A 1 5-year-old female patient with a history of probable subarachnoid hemo rrhage and chronic headaches presented with a relatively acute exacerb ation of her headache, nausea, vomiting, and weakness. Imaging studies revealed a 4 x 4 x 3-cm vertebrobasilar aneurysm, supplied by an angi ographically dominant right vertebral artery and causing significant b rain stem compression. INTERVENTION: Initially, a petrosal approach wi th a hearing-preserving partial labyrinthectomy was used to perform a right external carotid artery to posterior cerebral artery bypass with saphenous vein. Delayed occlusion of the right vertebral artery with an intraluminal balloon was planned; however, intraoperative angiograp hy revealed poor graft flow, presumably because of the small size of t he posterior cerebral artery. Postoperative graft occlusion was antici pated. During this same time interval, the patient deteriorated neurol ogically. Brain imaging failed to reveal evidence of cerebral infarcti on. The patient underwent subsequent surgery. After a total petrosecto my, the aneurysm was trapped, an aneurysmectomy was performed, and, wi th the patient under deep hypothermic circulatory arrest, a new interp osition saphenous vein graft was inserted between the internal carotid and basilar arteries. Excellent flow was observed angiographically. A t her 4-month follow-up examination, the patient had improved to near baseline. CONCLUSION: We present a technically challenging but safe an d definitive treatment option for an unclippable giant vertebrobasilar aneurysm. Using cranial base approaches and hypothermic circulatory a rrest techniques, aneurysmal trapping and successful bypass grafting d irectly into the basilar artery was performed.