Microsurgical Clipping of Residual Ophthalmic Artery Aneurysm After Initial Treatment With Pipeline Embolization Device: 2-Dimensional Operative Video

Flow diversion has become the predominant treatment modality for aneurysms of the ophthalmic segment of the internal carotid artery. Although highly effective, some aneurysms do not occlude at long-term follow-up, particularly when the ophthalmic artery arises from the aneurysm neck.(1,2)Although microsurgical clipping of previously coiledaneurysm has been well-documented, clipping of aneurysms previously treated withflow diversion has been rarelydescribed.3,4We present the case of a patient with an ophthalmic artery aneurysm which did not occlude at 10-monthfollow-up after flow diversion. Although continued observation or implantation of a secondflow diverter was rec-ommended, the patient had significant anxiety from the ongoing presence of the aneurysm and requested a definitiveprocedure for obliteration. Therefore, after the patient consented to the procedure, we performed a craniotomy forresidual ophthalmic artery clipping. The video illustrates the intraoperative appearance of an ophthalmic aneurysm with a flow diverter in situ. The aneurysm was successfully occluded with clipping, andflow in the ophthalmic artery was preserved as demonstrated on indocyanine green video angiography. We review the fundamental principles of clippingparaclinoid aneurysms, which is now a rare procedure in the era offlow diversion