Reverse Suction Decompression Using the Superior Thyroid Artery During Clipping of a Complex Anterior Choroidal Artery Aneurysm.

Direct aneurysmal suction decompression was first described by Dr. Flamm in 1981 to improve safety and ease clipping of complex aneurysms by deflating their dome. This technique evolved over the following decade, from direct aneurysmal puncture to indirect-reverse-suction decompression (RSD). The conventional technique for RSD involves a cannulation of the internal (ICA) or common (CCA) carotid arteries. Direct puncture of either the CCA or ICA carry risk of arterial wall damage (e.g., dissection), which may result in significant morbidity. We routinely cannulate the superior thyroidal artery (SThA) as the vascular access to perform RSD. This subtle technical nuance prevents dissection of either the CCA or ICA while providing a reliable source for RSD. In this operative video, the SThA was cannulated to apply reverse suction decompression, which allowed releasing perforating arteries from the dome of an anterior choroidal artery aneurysm in a 68-year-old lady. The patient tolerated the procedure well, was discharged without neurologic deficits, and resumed normal life with no aneurysm remnant. The patient consented to the procedure and video/photography publication. RSD is an optimal technique to enhance efficiency and safety when dissecting around the dome of a complex intradural ICA aneurysm. The use of the SThA avoids the risk of ICA or CCA wall damage due to access, which defeats the protective purpose of RSD itself. Video 1 provides an educational example of the SThA cannulation technique for RSD during dissection and clipping of a complex anterior choroidal artery aneurysm.