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

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.¹ This technique evolved over the following decade, from direct aneurysmal puncture to indirect-reverse-suction decompression (RSD).^2,3 The conventional technique for RSD involves a cannulation of the internal (ICA) or common (CCA) carotid arteries.^2-9 Direct puncture of either the CCA or ICA carry risk of arterial wall damage (e.g., dissection), which may result in significant morbidity.^10,11 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.¹² 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.