Portal de Periódicos da CAPES

Cotton-Clipping Technique

2011; Lippincott Williams & Wilkins; Volume: 69; Issue: 5 Linguagem: Inglês

10.1227/neu.0b013e31822ed4b4

1524-4040

Tomas Menovsky, Joost de Vries, J. André Grotenhuis,

Vascular Procedures and Complications

To the Editor: We read with great interest the technical note on the cotton-clipping technique to manage an aneurysm neck rupture by Drs Barrow and Spetzler, the highly respected and renowned neurovascular surgeons.1 The number of surgical techniques and/or materials to stop bleeding from an aneurysmal neck tear is limited owing to the nature, strength, and usually deep site of the bleeding and the narrow surgical corridor through which one operates. When a neck tear is present, methods such as bipolar coagulation or applying hemostatic products are usually not very successful. Thus, any new technique or material facilitating "easy" and effective hemostasis in such situations is more than welcome, and the cotton-clipping technique presented by Barrow and Spetzler is a very elegant one. We would like to suggest an alternative for the cotton piece placed between the aneurysm and the clips, ie, a small piece of smashed muscle. It is our experience that such a piece of muscle has very strong hemostatic properties. Skeletal muscle tissue is very well vascularized and has a high density of bloodvessels and capillaries.2 It is known that arterioles and capillaries are capable of holding and releasing several procoagulative factors after tissue trauma.3 Whena piece of muscle is smashed or crushed, coagulation tissue factors are massively released.4 Subsequently, these mediators, together with attracted platelets, initiate, amplify, and propagate the natural hemostasis process at the point of injury.5 This, combined with a mechanical tamponade resulting from the muscle piece itself, results in a strong hemostatic plug. Sometimes just placing the piece of muscle against the bleeding point for 2 minutes may be sufficient to stop the bleeding (in case of a small aneurysmal neck tear). The use of a piece of autologous muscle does not lead to complications related to foreign body reactions to the implanted materials such as cotton.6 The size and shape of the muscle can be cut as desired, depending on the size of the bleeding and the clips used (Figure 1). The small piece of muscle is taken from the temporal muscle or, in the case of a posterior fossa aneurysm and approach, from one of the neck muscles.FIGURE 1: A small piece of temporal muscle is smashed and cut as needed.We use an atraumatic suction tip (Atraumatic Suction Tip, Circle Medical BV, Wijchen, the Netherlands) to keep the piece of muscle on its place before clipping. This suction tip has a concave shape, a fine filter at the top, and small openings at the side acting as air vents (Figure 2), permitting suction of the blood through the lateral openings and keeping the muscle in its place without losing it in the tube.7,8FIGURE 2: Atraumatic suction tip mounted on a regular 6F suction tube. The fenestrated tip prevents suctioning the piece of muscle into the suction tube.Alternatively, the muscle may already be positioned on an aneurysm clip before clipping (Figure 3) and applied with the clip on the neck tear.FIGURE 3: The piece of muscle may already be positioned on an aneurysm clip to facilitate easy application.A literature search for articles related to the muscle-clipping technique revealed only 1 publication by Andrade and Braga in 20029 describing more or less the same technique using a piece of muscle that we discuss in this letter; however, the article is less accessible because it is in Portuguese. In other surgical disciplines, a piece of muscle has occasionally been used for a difficult-to-achieve hemostasis in the pelvic region10,11 or for a leaking microvascular anastomosis.12,13 In conclusion, we are of opinion that a small piece of smashed muscle is a good alternative to the cotton-clipping technique for an aneurysm neck tear. Once again, the authors are to be congratulated for sharing this very useful technique.