Rapid ventricular pacing for clip reconstruction of complex unruptured intracranial aneurysms: results of an interdisciplinary prospective trial
- 1 June 2018
- journal article
- research article
- Published by Journal of Neurosurgery Publishing Group (JNSPG) in Journal of Neurosurgery
- Vol. 128 (6), 1741-1752
- https://doi.org/10.3171/2016.11.JNS161420
Abstract
OBJECTIVE To date, treatment of complex unruptured intracranial aneurysms (UIAs) remains challenging. Therefore, advanced techniques are required to achieve an optimal result in treating these patients safely. In this study, the safety and efficacy of rapid ventricular pacing (RVP) to facilitate microsurgical clip reconstruction was investigated prospectively in a joined neurosurgery, anesthesiology, and cardiology study. METHODS Patients with complex UIAs were prospectively enrolled. Both the safety and efficacy of RVP were evaluated by recording cardiovascular events and outcomes of patients as well as the amount of aneurysm occlusion after the surgical clip reconstruction procedure. A questionnaire was used to evaluate aneurysm preparation and clip application under RVP. RESULTS Twenty patients (mean age 51.6 years, range 28-66 years) were included in this study. Electrode positioning was easy in 19 (95%) of 20 patients, and removal of electrodes was easily accomplished in all patients (100%). No complications associated with the placement of the pacing electrodes occurred, such as cardiac perforation or cardiac tamponade. RVP was applied in 16 patients. The mean aneurysm size was 11.1 +/- 5.5 mm (range 6-30 mm). RVP proved to be a very helpful tool in aneurysm preparation and clip application in 15 (94%) of 16 patients. RVP was used for a mean duration of 60 +/- 25 seconds, a mean heart rate of 173 +/- 23 bpm (range 150-210 bpm), and a reduction of mean arterial pressure to 35-55 mm Hg. RVP leads to softening of the aneurysm sac facilitating its mobilization, clip application, and closure of the clip blades. In 2 patients, cardiac events were documented that resolved without permanent sequelae in both. In every patient with successful RVP (n = 14) a total or near-total aneurysm occlusion was documented. In the 1 patient in whom the second RVP failed due to pacemaker electrode dislocation, additional temporary clipping was required to secure the aneurysm, but was not as sufficient as RVP. This led to an incomplete clipping of the aneurysm and finally a remnant on postoperative digital subtraction angiography. A pacemaker lead dislocation occurred in 3 (19%) of 16 patients, but intraoperative repositioning requires less than 20 seconds. Outcome was favorable in all patients according to the modified Rankin Scale. CONCLUSIONS To the best of the authors' knowledge this is the first prospective interdisciplinary study of RVP use in patients with UIAs. RVP is an elegant technique that facilitates clip reconstruction in complex UIAs. The safety of the procedure is good. However, because this procedure requires extensive preoperative cardiological workup of the patient and an experienced neurosurgery and neuroanesthesiology team with much cerebrovascular expertise, actually it remains reserved for selected elective cases and highly specialized centers.This publication has 45 references indexed in Scilit:
- Rapid Ventricular Pacing for Flow Arrest During Cerebrovascular SurgeryOperative Neurosurgery, 2012
- Exclusively intradural exposure and clip reconstruction in complex paraclinoid aneurysmsActa Neurochirurgica, 2011
- Predictors of Clinical and Angiographic Outcome After Surgical or Endovascular Therapy of Very Large and Giant Intracranial AneurysmsNeurosurgery, 2011
- Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia?Clinical Neurology and Neurosurgery, 2011
- Adenosine-induced Transient Asystole for Intracranial Aneurysm SurgeryJournal of Neurosurgical Anesthesiology, 2011
- Results of Microsurgical Treatment of Large and Giant ICA Aneurysms Using the Retrograde Suction Decompression (RSD) Technique: Series of 92 PatientsWorld Neurosurgery, 2010
- Adenosine-Induced Flow Arrest to Facilitate Intracranial Aneurysm Clip LigationAnesthesia & Analgesia, 2010
- Adenosine-induced cardiac arrest during intraoperative cerebral aneurysm ruptureWorld Neurosurgery, 2010
- ENDOVASCULAR RETROGRADE SUCTION DECOMPRESSION AS AN ADJUNCT TO SURGICAL TREATMENT OF OPHTHALMIC ANEURYSMSOperative Neurosurgery, 2009
- Rapid right ventricular pacing is an alternative to adenosine in catheter interventional procedures for congenital heart diseaseHeart, 2004