Right-Angled Fenestrated Picket Fence Clipping Technique for an Anterior Communicating Artery Aneurysm

Anterior communicating artery (AComm) aneurysms account for approximately 25% of all cerebral aneurysms.^1-3 Their management remains challenging due to significant anatomic and morphologic variability, and a high recurrence rate after primary endovascular coiling.⁴ Recurrence is often due to coil compaction and thrombus incorporation into the aneurysm wall, necessitating more complex treatments such as stenting, flow diversion, or microsurgical clip reconstruction. The picket fence clipping technique is a strategy for treating large or recurrent aneurysms when conventional clipping across the neck is not feasible.⁵ In this report, we present a modified picket fence clipping technique using multiple right-angled fenestrated clips for a recurrent AComm aneurysm. The patient is a 42-year-old man with a history of subarachnoid hemorrhage from a ruptured large AComm aneurysm previously treated with coiling (Video 1). He presented with worsening intractable headaches, and follow-up imaging revealed coil compaction and residual aneurysm filling at the base. Due to the aneurysm's wide neck and complex morphology, a right orbital pterional skull base approach was recommended for clip reconstruction, with intraoperative angiography, and possible bypass. Intraoperatively, nine clips were used to reconstruct the aneurysm neck while preserving flow in all branch vessels. The patient recovered without complication and was discharged on postoperative day four. This case highlights the utility of right-angled fenestrated clips in a modified picket fence construct, providing a versatile and effective solution for managing complex, recurrent AComm aneurysms with residual coils and thrombus.