gms | German Medical Science

Complex aneurysms are those not suitable for endovascular treatment nor for clip reconstruction. They include aneurysms with a large and complex neck, blister aneurysms, dissecting aneurysms, aneurysms which present a branch vessel (s) originating from the aneurysm sac, recurrent aneurysms in which microsurgical clipping or endovascular treatment had failed as well as giant aneurysm. With the term of giant aneurysm we mean to describe those aneurysms having a major diameter superior to 25 mm. Definitive treatment of the above-mentioned pathologies may require an extra-intracranial by-pass. Cerebral by-pass can be classified according to different criteria. On the basis of the kind of vessel selected to build the by-pass, two kinds of graft can be distinguished: arterial and venous graft. According to the flow guaranteed by the different grafts three main kinds of by-pass can be identified: low flow by-pass (15-25 ml min, STA-MCA), medium flow by-pass (40-70 ml, radial artery) and high flow by-pass (70-140 ml min, saphenous vein). Our experience taught us that every single giant aneurysm is characterized by a peculiar hemodynamic flow requiring the planning of a tailored treatment for each single case. In some cases patients have been operated in awake surgery with the aim of better evaluating the integrity of eloquent areas. Following the criteria established by the modified universal revascularization algorhythm, it is clearly appreciable how, in aneurysms not suitable for endovascular treatment nor for clip reconstruction (as may occur in giant aneurysms), the gold standard treatment for patients younger than 70 and in good general conditions (ASA < 2) is high flow extra-intracranial by-pass with saphenous vein graft. Between 1985 and 2014, 84 aneurysms were treated with high flow extracranial-intracranial by-pass applying these criteria. A great percentage of the patients of our series had giant aneurysms and were treated with high flow extracranial-intracranial by-pass with saphenous graft. Results in terms of survival, quality of life and graft patency have been analyzed. In consideration of our results we can state that, nowadays, the execution of high flow extra-intracranial by-pass plays a pivotal role in the management of giant aneurysms.