Self-closing U-clips for intracranial microanastomoses in high-flow arterial bypass : technical case report

OBJECTIVE: Self-closing nitinol U-clips (Medtronic, Inc., Minneapolis, MN) have been used to create vascular microanastomoses by vascular surgeons. This device eliminates the need for suture management and knot tying. Therefore, a high-quality interrupted microvascular anastomosis can be obtained in a shorter period of time. This is the first report of a U-clip intracranial arterial microanastomosis for a high-flow extracranial-intracranial bypass using a radial artery graft. CLINICAL PRESENTATION: A 24-year-old woman with a history of chronic headache was admitted to the National Neurological Institute Carlo Besta after a brain computed tomographic scan revealed a giant serpentine aneurysm of her right middle cerebral artery. Magnetic resonance angiography and four-vessel angiography confirmed the diagnosis and ruled out other lesions. INTERVENTION: A radial artery graft was used to create a high-flow bypass between the external carotid artery and the postaneurysmal M2 segment of the right middle cerebral artery. Nitinol self-closing U-clips were used for the interrupted intracranial microanastomosis. After intraoperative near-infrared indocyanine green video angiography confirmed the bypass patency, the aneurysm could be trapped. CONCLUSION: The postoperative course was uneventful. The patient was discharged on the seventh postoperative day and was neurologically intact. Postoperative angiography documented the successful exclusion of the aneurysm and the presence of revascularization of the distal branches of the right middle cerebral artery through the bypass. This case demonstrates the efficacy of U-clips for intracranial microanastomoses.