"Reverse Picket Fence" Technique for Clipping of a Large, Anterior Communicating Artery Aneurysm: 2-Dimensional Operative Video.

The "picket fence" technique is a clipping technique used for large, wide-neck complex aneurysms not suitable for conventional clipping.1 With this technique, simple or fenestrated straight clips are stacked side-by-side perpendicular to the neck rather than the conventional parallel placement. In complex aneurysms projecting away from the surgeon, the picket fence technique is impossible. Instead, fenestrated clips are applied in a reverse direction from neck-to-dome, using the blade heels to close the neck. This fenestration tube transmits the bifurcation. This video demonstrates a "reverse picket fence" clipping technique of an incidental, large anterior communicating artery (ACoA) aneurysm in a 52-yr-old woman. Bilaterally adherent A2-anterior cerebral artery (ACA) segments led to abortion of a prior clipping attempt at an outside hospital. After obtaining patient consent, a modified orbitozygomatic craniotomy was performed with gyrus rectus removal. Temporary clips were applied to A1-ACA for freeing the adherent A2-ACA segments from the dome. The aneurysm was clipped using a "reverse picket fence" technique transmitting the A1-A2-A2 bifurcation through the fenestration tube. Bilateral recurrent artery of Heubner was preserved. Indocyanine angiography demonstrated parent vessel patency with complete aneurysm exclusion. Postoperatively, the patient experienced short-term memory loss, which resolved over 6 mo with cognitive rehabilitation. The "reverse picket fence" technique can be considered for large aneurysms directed away from the surgeon, obviating the need for difficult dissection of adherent efferent arteries from aneurysmal sac. Adjusting the heel position of each fenestrated clip in this construct allows the patency of hidden perforators behind the aneurysm to be maintained. Video © Barrow Neurological Institute. Used with permission.