Complex Aneurysm: The Unpredictable Pathological Entity

Background. Surgical treatment of complex aneurysms often requires the execution of a revascularization procedure. Even if avoiding the concomitant trapping of the aneurysm during the bypass procedure (waiting for the subsequent endovascular or spontaneous closure) permits one to verify the graft's patency and patient's adaptation to increased flow, the hemodynamic changes induced by the bypass may cause the aneurysmal rupture. Whether or not to perform the concomitant trapping of the aneurysm still remains a dilemma. Here we illustrate our management protocol through the critical analysis of some illustrative cases of our series. Materials and methods. Between 1990 and 2016, 48 of 157 patients affected by complex aneurysms underwent a revascularization procedure. In 19 cases (1990-1997) only a bypass procedure was performed. Spontaneous or endovascular closure was obtained within the first postoperative week once the graft patency had been verified (staged revascularization strategy). In the remaining 29 cases (1997-2016) the revascularization procedure and the closure of the aneurysm were performed simultaneously during the same surgical procedure (single-stage strategy). Results. In the staged revascularization era, one patient died because of the rupture of the aneurysm before its closure. In the single-stage era no further cases of rebleeding were observed. Neurologic status of this group was unvaried or improved. Conclusions. Given the unpredictable response of complex aneurysms to the hemodynamic changes induced by the revascularization, in our opinion it is always preferable to perform complete or at least incomplete trapping of the aneurysm during the bypass procedure.