Balloon-assisted clipping of a large paraclinoidal aneurysm: A salvage procedure

OBJECTIVE: Surgical clipping and parent vessel reconstruction of wide-neck paraclinoid aneurysms can be very challenging. We report a case of a ruptured paraclinoid aneurysm which failed standard clipping techniques. We were able to reconstruct this aneurysm while providing proximal and distal control using an adjuvant endovascular balloon. CLINICAL PRESENTATION: We report the case of a 45-year-old woman presenting with a ruptured large paraclinoidal aneurysm, which involved a significant portion of the internal carotid artery wall. INTERVENTION: Repeated attempts at fenestrated clip placement resulted in slipping of the clip and occlusion of the parent artery. Ultimately, the aneurysm ruptured at the neck, and, despite trapping and direct aneurysmal suction decompression, significant bleeding was encountered. The bleeding point was packed, and, subsequently, endovascular access was obtained. A balloon was navigated and then inflated across the neck of the aneurysm using C-arm fluoroscopic guidance. The aneurysm was successfully clipped, and intraoperative angiography demonstrated no parent vessel stenosis. CONCLUSION: This case demonstrates a salvage procedure in the event of intraoperative rupture and inadequate interruption of local blood flow. Balloon inflation resulted in adequate hemostasis and provided intraluminal support for optimal clip placement while preserving the parent artery.