Treatment of a Fusiform Anterior Cerebral Artery Aneurysm With an A3-A3 Bypass: 2-Dimensional Operative Video

Distal anterior cerebral artery (ACA) aneurysms remain a relatively rare and challenging entity for both open microsurgical and endovascular treatments. These lesions provide a significant surgical challenge because of the narrow interhemispheric surgical field, limited proximal control, common fixation of the aneurysm to the adjacent cingulate gyrus, and possible involvement of an unpaired azygos A2. These challenges result in a known association between distal ACA aneurysms and higher operative morbidity. This video demonstrates indirect obliteration of a prior ruptured fusiform right A2 aneurysm utilizing an A3-to-A3 side-to-side anastomotic bypass with aneurysm trapping. An anterior interhemispheric approach was used for exposure of bilateral ACAs, arteriotomies, microanastomosis, and trapping of the aneurysmal right A2 segment. Postoperatively, the patient's neurological status returned to baseline, and imaging demonstrated evidence of bypass patency with no residual filling of the fusiform aneurysmal segment. This video verifies the feasibility and efficacy of the A3-to-A3 anastomotic bypass for treatment of distal ACA aneurysms. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.