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Wang C, Li H, Dong Y, Wang H, Li D, Zhao C, Cao L, Sun K, Geng J, Yang B. Risk factors for wound healing complications after revascularization for MMD with complete Y-shaped incision. Sci Rep 2023; 13:3251. [PMID: 36828875 PMCID: PMC9958019 DOI: 10.1038/s41598-022-18709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/18/2022] [Indexed: 02/26/2023] Open
Abstract
Moyamoya disease (MMD) is a chronic occlusive cerebrovascular disease that can be treated with revascularization. Surgery increases the risk of poor wound healing (PWH) due to the impact on the blood supply to the flap. We aimed to analyze risk factors for PWH in MMD with a complete Y-shaped incision. A total of 125 patients with MMD were enrolled in this prospective observational study. The wounds were assessed and measured on the third and seventh days after surgery. The mean age of these patients was 43.3 ± 10.0 years. The ratio of male to female was 1:1.3. 15 (12.0%) patients had incision complications. 5 patients (4.0%) had redness; 2 patients (1.6%) had swelling; 2 patients (1.6%) had fat necrosis; 3 patients (2.4%) had incision infection; and 3 patients (2.4%) had flap necrosis. Student's t test showed significant differences in BMI (P = 0.040) and fever time (P = 0.050). The standard chi-squared test showed significant differences in incision infection (P = 0.010), suture mode (P = 0.047), and cutting off large branch vessels in the flap (P < 0.001). Multivariate logistic regression analysis suggested that incision infection (P = 0.026, OR 12.958), using a skin stapler (P = 0.030, OR 4.335), cutting off large branch vessels in the flap (P = 0.009, OR 5.227), and BMI (P = 0.027, OR 1.204) were risk factors. The area under the curve for risk factors for PWH on a receiver operating characteristic curve was 0.853. Incision infection, using a skin stapler, higher BMI, and cutting off large branch vessels in the flap are risk factors for PWH.
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Affiliation(s)
- Chenchao Wang
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Hongwei Li
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Yang Dong
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Hao Wang
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Dongpeng Li
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Chengbin Zhao
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Lei Cao
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Kaiwen Sun
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Jiefeng Geng
- grid.412633.10000 0004 1799 0733Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053 Henan China
| | - Bo Yang
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, No. 1, Jianshe East Road, Erqi District, Zhengzhou, 450053, Henan, China.
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See AP, Charbel FT. Bypass for flow-augmentation in atherosclerotic carotid occlusion: a review of the literature and career experience. J Neurosurg Sci 2021; 65:305-321. [PMID: 33709658 DOI: 10.23736/s0390-5616.21.05094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atherosclerosis of the internal carotid artery and intracranial vessels can compromise cerebral hemodynamics and cause stroke. Cerebral bypass has a half-century history in augmenting or replacing blood flow the brain. Several trials have investigated various applications of cerebral bypass in flow augmentation for atherosclerotic disease. This review discusses the clinical science of cerebrovascular atherosclerosis to provide the context in which cerebral bypass is currently applied. This includes prior clinical trials, ongoing clinical trials, and consensus guidelines, and is complemented by studies in the physiologic science of cerebrovascular flow. The scientific background is supplemented by the description of the technical art of bypass surgery based on a three-decade experience. Successful application of cerebral bypass to augment flow in atherosclerotic cerebrovascular disease requires correct diagnosis of compromised hemodynamic reserve refractory to medical optimization and an appropriate matching of bypass flow with cerebral demand.
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Lukyanchikov VA, Orlov EA, Oganesyan MV, Gordeeva AA, Pavliv MP. [Anatomical bases of brain revascularization: choosing an extra-intracranial bypass option]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2021; 85:120-126. [PMID: 34951769 DOI: 10.17116/neiro202185061120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Surgical brain revascularization is an important treatment for acute or chronic ischemia, intracranial aneurysms and skull base tumors. Individual anatomy of brain vessels should be clearly understood for this procedure. Variants of collateral cerebral blood flow in patients with cerebrovascular diseases depend on individual characteristics of circle of Willis and reserve mechanisms of collateral circulation. These anatomical variations require careful preoperative planning to choose the optimal revascularization option.
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Affiliation(s)
- V A Lukyanchikov
- University's Hospital of the Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
- Russian People's Friendship University, Moscow, Russia
| | - E A Orlov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M V Oganesyan
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Gordeeva
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M P Pavliv
- Sechenov First Moscow State Medical University, Moscow, Russia
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Acker G, Schlinkmann N, Fekonja L, Grünwald L, Hardt J, Czabanka M, Vajkoczy P. Wound healing complications after revascularization for moyamoya vasculopathy with reference to different skin incisions. Neurosurg Focus 2020; 46:E12. [PMID: 30717062 DOI: 10.3171/2018.11.focus18512] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMoyamoya vasculopathy (MMV) is a steno-occlusive cerebrovascular disease that can be treated by a surgical revascularization. All the revascularization techniques influence the blood supply of the scalp, with a risk for wound healing disorders. The authors' aim was to analyze the wound healing process in the patients who underwent a direct or combined bypass surgery with a focus on different skin incisions.METHODSThe authors retrospectively identified all the patients with MMV who were treated surgically in their institution. Subsequently, they analyzed demographic data, clinical symptoms, surgical treatment, and detailed history of complications. Based on the evolution of their surgical techniques and the revascularization strategy to be used, the authors applied the following skin incisions: linear incision, curved incision, incomplete Y incision, and complete Y incision. Group comparisons regarding wound healing disorders were performed with significance testing using Fisher's exact test.RESULTSThe authors identified 172 patients with MMV (61.6% moyamoya disease, 7% unilateral moyamoya disease, 29.7% moyamoya syndrome, and 1.7% unilateral moyamoya syndrome), of whom 124 underwent bilateral operations. One-quarter of the patients were juveniles. A total of 236 hemispheres were included in the analysis, of which 27.9% were treated by a combined procedure with encephalomyosynangiosis. Overall, 5.1% major and 1.7% minor wound complications occurred. The overall wound complication rate was lower in direct revascularization compared to combined revascularization (3% vs 15.2%). The lowest incidence of wound healing disorders was found in the linear incision group for the parietal superficial temporal artery branch (1.6%), followed by the incomplete Y incision group for the frontal branch of the superficial temporal artery (3.8%) in the direct bypass group. In the combined revascularization cohort, major or minor wound disorders appeared in 14.3% and 4.8%, respectively, in the complete Y incision group and in 4.2% (for both major and minor) in the curved incision group. The complete Y incision caused significantly more wound healing disorders compared to the remaining incision types (17.1% vs 3.1%, p = 0.007).CONCLUSIONSWound healing disorders are one of the major complications of revascularization surgery. Their incidence depends on the revascularization strategy and skin incision applied, with a complete Y incision giving the worst results.
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Affiliation(s)
- Güliz Acker
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin.,2Berlin Institute of Health, Berlin
| | - Nicolas Schlinkmann
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin
| | - Lucius Fekonja
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin.,3Cluster of Excellence: "Image Knowledge Gestaltung: An Interdisciplinary Laboratory," Humboldt University, Berlin
| | - Lukas Grünwald
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin
| | - Juliane Hardt
- 4Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin; and.,5Clinical Research Unit, Berlin Institute of Health, Berlin, Germany
| | - Marcus Czabanka
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin
| | - Peter Vajkoczy
- 1Department of Neurosurgery and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin (corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health), Berlin
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Gutierrez-Avila O, Moroi J, Ishikawa T. Dissection of the Superficial Temporal Artery: Significance and Performance with Bipolar Forceps. World Neurosurg 2019; 134:94-97. [PMID: 31678315 DOI: 10.1016/j.wneu.2019.10.145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adequate bypass harvesting of the superficial temporal artery (STA) is a standard procedure for every neurosurgeon, so mastery of techniques for its management and care is mandatory. METHODS Here, we report the effectiveness of using the bipolar forceps as a novel procedure. RESULTS This procedure improves safety, efficiency, and bleeding compared to the usual dissection. CONCLUSIONS In cases requiring an STA donor, this technique may be as useful as the traditional method and could become part of the neurosurgeon's armamentarium.
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Affiliation(s)
- Oscar Gutierrez-Avila
- Department of Surgical Neurology Research, Institute for Brain & Blood Vessels - Akita, Akita, Japan.
| | - Junta Moroi
- Department of Surgical Neurology Research, Institute for Brain & Blood Vessels - Akita, Akita, Japan
| | - Tatsuya Ishikawa
- Department of Surgical Neurology Research, Institute for Brain & Blood Vessels - Akita, Akita, Japan
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Torihashi K, Ogura T, Hosoya T, Nakajima S, Sakamoto M, Kurosaki M. Usefulness of the Lone Star Retractor System for harvesting the superficial temporal artery: technical note. Br J Neurosurg 2019:1-4. [DOI: 10.1080/02688697.2019.1672857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Koichi Torihashi
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Takafumi Ogura
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomohiro Hosoya
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Sadao Nakajima
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Makoto Sakamoto
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Masamichi Kurosaki
- Division of Neurosurgery, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, Yonago, Japan
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Chung Y, Lee SH, Choi SK. Fundamental Basis of Scalp Layering Techniques to Protect Against Wound Infection: A Comparative Study Between Conventional and In-to-Out Dissection of the Superficial Temporal Artery. World Neurosurg 2016; 97:304-311. [PMID: 27742506 DOI: 10.1016/j.wneu.2016.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/28/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is associated with several surgical problems. Despite the vascular patency and hemodynamic changes after the anastomosis, wound problems can be a major surgical complication. METHODS In a review of 41 surgical cases of STA-MCA bypass for moyamoya disease or cerebral occlusive vascular disease, we compared the conventional (out-to-in) dissection method for STA (n = 23) with the in-to-out (ITO) dissection method (n = 18) and evaluated the surgical results with respect to wound problems. RESULTS The incidence of skin maceration was significantly higher in the conventional dissection group than the ITO dissection group (34.8% vs. 5.5%; P < 0.01). Skin necrosis also showed a higher incidence in the conventional dissection group (39.1%) than the ITO group (22.2%). CONCLUSIONS These data suggest that the simple layering technique of the ITO dissection method can protect against contamination from bacteria and reduce postoperative surgical wound problems. Sealing of the galea aponeurotica (first protective barrier), including fibrous septa and loose areolar tissues, including the periosteal layer (second protective barrier), is an important factor to decrease the rate of scalp wound infection.
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Affiliation(s)
- Yeongu Chung
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Seok Keun Choi
- Department of Neurosurgery, College of Medicine, Kyung Hee University, Seoul, Korea.
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Esposito G, Burkhardt JK, Bozinov O, Regli L. Indocyanine green videoangiography for the identification of superficial temporal artery branches in EC-IC bypass surgery. Acta Neurochir (Wien) 2016; 158:565-70. [PMID: 26783025 DOI: 10.1007/s00701-016-2703-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/06/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass remains an essential tool for managing complex cerebrovascular conditions. A crucial surgical step is the identification and safe dissection of the bypass donor artery. If the frontal branch of the STA is used, a curvilinear fronto-temporal scalp flap generally allows for a clean dissection from the underside of the scalp flap. This dissection is sometimes tedious, since the frontal branch is not always easily visible and due to variability of its anatomy. With this article, we report on the feasibility and effectiveness of a simple indocyanine green videoangiography (ICG-VA)-assisted technique for the identification of the STA branches from the underside of a fronto-temporal scalp flap in bypass surgery. METHODS The technique is based on the analysis of the difference in timing of filling of scalp vessels illuminated via ICG-VA from the underside of a scalp flap. Three illustrative cases are reported. RESULTS ICG-VA permitted the correct identification and safe dissection of the donor vessels (STA branches) in all three patients. There were no complications due to the ICG-VA. CONCLUSIONS This technique allows reliable visualization of the STA and its branches at once before microsurgical dissection. The information provided by ICG-VA enables precise mapping and preparation of the STA. The simplicity and safety of this technique make it an effective tool for intraoperative identification of the STA and its branches.
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Affiliation(s)
- Giuseppe Esposito
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland, Frauenklinikstrasse 10, 8091.
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland, Frauenklinikstrasse 10, 8091.
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland, Frauenklinikstrasse 10, 8091.
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland, Frauenklinikstrasse 10, 8091.
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Duckworth EAM, Rao VY, Patel AJ. Double-barrel bypass for cerebral ischemia: technique, rationale, and preliminary experience with 10 consecutive cases. Neurosurgery 2014; 73:ons30-8; discussion ons37-8. [PMID: 23313980 DOI: 10.1227/neu.0b013e318285b587] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In selected patients, extracranial-intracranial bypass remains an important treatment for the prevention of stroke. Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass uses 1 STA branch. We have adopted a "double-barrel" technique in which both branches are joined with MCA recipients in distinct vascular territories. OBJECTIVE To assess the feasibility of routinely using both branches of the STA for cerebral revascularization. METHODS Ten consecutive patients underwent double-barrel bypass. Patients were selected if they demonstrated symptomatic MCA hypoperfusion resistant to medical therapy or had symptomatic moyamoya disease. Flow-directed bypass was performed to augment flow to the territories most at risk in each case, based on preoperative and intraoperative data. Computed tomography perfusion was routinely performed to evaluate baseline deficits and postoperative augmentation. Clinical data were analyzed to assess patient demographics and outcomes. RESULTS The double-barrel bypass was no more difficult technically than the traditional approach, with the second branch harvested through a small satellite incision. By isolating temporary occlusion to each territory, there was no additional ischemia to each brain region. No intraoperative complications or wound-healing issues occurred. Postoperative computed tomography perfusion studies all showed improvement, and delayed vascular imaging demonstrated universal graft patency. Nine of 10 patients have been asymptomatic since surgery, whereas 1 patient demonstrated symptoms in a separate vascular distribution. CONCLUSION Double-barrel STA-MCA bypass is both feasible and potentially advantageous. In our series, both bypass branches remained patent, augmenting flow to the territories most at need.
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Affiliation(s)
- Edward A M Duckworth
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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