Superficial Temporal Artery Trunk-to-Middle Cerebral Artery Bypass with Short Radial Artery Interposition Graft for Symptomatic Internal Carotid Artery Occlusion

Comparison Of The Treatment Strategies For Symptomatic Chronic Internal Carotid Artery Occlusion

BACKGROUND

The best management of symptomatic chronic internal carotid artery occlusion (CICAO) has been controversial. This systematic review and meta-analysis were to compare the outcomes of different treatment strategies for symptomatic CICAO.

METHODS

Two independent researchers conducted a search of articles on the treatment of CICAO published between January 2000 and October 2023 in PubMed, Web of Science, Embase, and The Cochrane Library. Twenty-two articles were eligible for meta-analysis using a random effects model to combine and analyze the data for the pooled rates of stroke and death, and the rates of procedural success and significant restenosis/occlusion.

RESULTS

Total of 1193 patients from 22 publications were included in this study. 6 of them had bilateral internal carotid artery occlusion. The 30-day stroke and death rates were 1.1% (95%CI: 0%-4.4%) in the best medical treatment (BMT) group, 4.1% (95%CI: 0.7%-9.3%, I2=71.4%) in the extracranial-intracranial (EC-IC) bypass group, 4.4% (95%CI: 2.4% - 6.8%, I2 = 0%) in the carotid artery stenting (CAS) group, and 1.2% (95% CI: 0% - 3.4%, I2 = 0%) in the combined carotid endarterectomy and stenting (CEA+CAS) group. During follow-up of 16.5 (±16.3) months, the stroke and death rates were 19.5%, 1.2%, 6.6%, and 2.4% in BMT, EC-IC, CAS and CEA+CAS groups respectively. The surgical success rate was 99.7% (95%CI: 98.5%-100%, I2=0%) in EC-IC group, 70.1% (95%CI: 62.3%-77.5%, I2=64%) in CAS group, and 86.4% (95%CI: 78.8%-92.7%, I2=60%) in CEA+CAS group. The rate of post-procedural significant restenosis or occlusion was 3.6% in EC-IC group, 18.7% in CAS group, and 5.7% in CEA+CSA group. The surgical success rate was negatively associated by the length of internal carotid artery (ICA) occlusion. Surgical success rate was significantly higher in the patients with occlusive lesion within C1 to C4 segments, comparing to those with occlusion distal to C4 segment (OR:11.3, 95%CI: 5.0-25.53, P<0.001). A proximal stump of ICA is a favorable sign for CAS. The success rate of CAS was significantly higher in the patients with an ICA stump than that in the patients without (OR=11.36, 95%CI:4.84-26.64, P<0.01). However, the success rate of CEA+CAS was not affected by the proximal ICA stump.

CONCLUSIONS

For the management of symptomatic CICAO, BMT alone is associated with the highest risk of mid- and long-term stroke and death. EC-IC bypass surgery and CEA+CAS should be considered as the choice of treatment based on operator's expertise and patient's anatomy. CAS may be employed as an alternative option in high surgical risk patients, especially when proximal ICA stump exists.

The interpositional bypass with a parietal branch of superficial temporal artery graft for symptomatic atherosclerotic anterior cerebral artery stenosis or occlusion

Background

For nonmoyamoya patients with anterior cerebral artery (ACA) stenosis or occlusion, whether direct revascularization of the ACA territory can prevent stroke is still unclear. The objective of this study was to investigate the efficacy and safety of a parietal branch of superficial temporal artery-interposed superficial temporal artery-to-ACA bypass (PISAB) for preventing stroke in patients with symptomatic atherosclerotic ACA stenosis or occlusion (SAASO).

Methods

We retrospectively analyzed the data from patients with SAASO who had undergone PISAB in our center between April 2016 and November 2021. The rates of patency, satisfaction (revascularization grades A and B) of bypass, perioperative complications, recurrence of ischemic stroke, changes in bypass flow, and improvements in cerebral blood perfusion were analyzed.

Results

A total of 19 SAASO patients were involved in this study. Sixteen out of 19 (84.2%) patients were free from any cerebral ischemic events after surgery. Only 3 patients (15.8%) had recurrent stroke postoperatively. Two (10.5%) surgery-related complications occurred, including hyperperfusion syndrome and minor stroke. No skin ischemic complications occurred. The average follow-up period was 50.6 ± 18.3 months. The flow rate of the bypass was significantly increased half a year after surgery (56.2 ± 8.0 mL/min vs. 44.3 ± 5.3 mL/min, p < 0.001). The ratio of ipsilateral/contralateral mean transit time in the superior frontal gyrus was decreased significantly after bypass (1.08 ± 0.07 vs. 1.23 ± 0.05, p < 0.001) and continued to decrease 6 months after surgery (1.05 ± 0.04 vs. 1.08 ± 0.07, p = 0.002). The patency rate of PISAB was 94.7% (18/19) 2 years after surgery. The satisfaction rate of bypass was 89.5% (17/19).

Conclusion

The results of this study indicate that PISAB, as a safe superficial bypass, can effectively reduce the risk of stroke in SAASO patients. More precise conclusions will require randomized control studies.

Superficial temporal artery interposition bypass for the treatment of complex intracranial aneurysms: Flexible and creative options for flow preservation bypass

PURPOSE

Flow-preservation bypass is a treatment option for complex intracranial aneurysms (IAs) that cannot be managed with microsurgical clipping or endovascular treatment. Various bypass methods are available, including interposition grafts such as the radial artery or saphenous vein. Size discrepancy, invasiveness, and procedure complexity must be considered when using interposition grafts. We describe our experience of treating complex IAs using a superficial temporal artery (STA) interposition bypass.

METHODS

We retrospectively reviewed the medical records and operative videos of all patients who were treated for complex IAs at our center from January 2009 to December 2021 using cerebral revascularization. Clinical, radiological, and surgical findings of the cases that underwent STA interposition bypass were investigated.

RESULTS

Seventy-six bypass procedures were performed of which seven (9.2%) complex IAs were managed using STA interposition bypass. Of these 5 cases were of anterior cerebral artery, 1 of middle cerebral artery, and 1 of posterior inferior cerebellar artery aneurysm. There were no postoperative ischemic complications. Revision surgery for postoperative pseudomeningocele was performed in one case. The long-term bypass patency rate was 85.7% (6 out of 7) and good long-term aneurysm control was achieved in all cases, with a mean follow-up of 64 months.

CONCLUSIONS

When treating complex IAs, creative revascularization strategies are needed in selective cases for favorable outcomes. STA interposition graft bypass which can reduce the size discrepancy between the donor and recipient may be a less invasive, flexible, and practical option for treating complex IAs.

Comparison Between the Efficacy of a Flow Diverter and Interventional Trapping with Bypass in the Treatment of Unruptured Large- or Giant-Sized ICA Aneurysms

OBJECTIVE

Management of large- or giant-sized internal carotid artery aneurysms (LICAAs) remains challenging. Whether a flow diverter device (FDD) or interventional trapping with extracranial-intracranial bypass (ITB) is better, remains unclear.

METHODS

We conducted a multicenter retrospective analysis of unruptured LICAA patients treated with FDD or ITB at 3 medical centers. Both the effectiveness and safety results of FDD and ITB were compared.

RESULTS

In total, 101 aneurysms in 95 patients treated with FDDs and 36 aneurysms in 36 patients managed with ITBs were included (September 2014-June 2021). There was no significant difference between the groups in the complete obliteration rate 1 year after surgery (P = 0.101). There were 2 relapse cases (2.0%) and 4 retreated cases (4.0%) in the FDD group and 1 relapse case (2.8%) and 2 retreated cases (5.6%) in the ITB group. Neither the relapse rates nor retreat rates between groups were significantly different. The neurological morbidity rates were 4.0% (4/101) and 2.8% (1/36) in the FDD group and ITB group, respectively, and were not significantly different. There was 1 mortality case in each group, and the mortality rates were not significantly different (P = 0.443). Both the perioperative and overall (perioperative plus long-term) complication rates in the FDD group were significantly lower than those in the ITB group (P = 0.033, P = 0.039).

CONCLUSIONS

FDD had comparable surgical efficacy and a significantly lower postoperative complication rate to traditional ITB. FDD might be preferable to ITB as a treatment modality for LICAA.

Clinical importance of the superficial temporal artery in neurovascular diseases: A PRISMA-compliant systematic review

The superficial temporal artery (STA) plays a very important role in neurovascular diseases and procedures. However, until now, no comprehensive review of the role of STA in neurovascular diseases from a neurosurgical perspective has ever been published. To review research on the clinical importance of STA in neurovascular diseases, a literature search was performed using the PubMed database. Articles were screened for suitability and data relevance. This paper was organized following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. According to the literature, STA is one of the terminal branches of the external carotid artery and can give off scalp, muscle, and transosseous branches. STA-middle cerebral artery (MCA) bypass is very useful for intracranial ischemic diseases, including moyamoya disease, chronic ICA and MCA insufficiency, and even acute ischemic stroke. For intracranial complex aneurysms, STA bypass remains a major option that can serve as flow replacement bypass during aneurysmal trapping or insurance bypass during temporary parent artery occlusion. Occasionally, the STA can also be involved in dural AVFs (DAVFs) via to its transosseous branches. In addition, the STA can be used as an intraoperative angiography path and the path to provide endovascular treatments. Therefore, STA is a very important artery in neurovascular diseases.