• Sotaro Oshida, Hiroshi Kashimura, Taro Suzuki, Kenta Aso, and Yosuke Akamatsu.
• Department of Neurosurgery, Iwate Prefectural Chubu Hospital, Kitakami, Iwate, Japan.
• World Neurosurg. 2018 Aug 1; 116: 230-233.

BackgroundUsing angled fenestrated clips for posteromedially projecting internal carotid artery (ICA) aneurysms may allow the surgeon to simultaneously obliterate the aneurysmal neck and preserve the branching artery by applying the blade of the clip parallel to the ICA. However, using these clips when the aneurysm neck involves the branching artery may have a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm.Case DescriptionA 52-year-old woman developed a subarachnoid hemorrhage. Three-dimensional computed tomography angiography showed a saccular aneurysm arising from the left ICA-posterior communicating artery (PCoA) bifurcation. The aneurysmal fundus projected posteromedially, and the PCoA was larger than the ipsilateral P1 segment, in which its origin involved the aneurysmal neck. Tandem straight fenestrated clips were applied across the ICA, followed by reconstruction of the ICA wall with preservation of the PCoA and obliteration of the aneurysm.ConclusionWhen using angled fenestrated clips is unsuitable because of a risk of branching artery stenosis, occlusion, or incomplete obliteration of the aneurysm, using multiple straight fenestrated clips may be a useful alternative.Copyright © 2018 Elsevier Inc. All rights reserved.

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