Radial Artery Fascial Flow-Through Free Flap for Complex Cerebral Revascularization: Technical Notes and Long-Term Neurologic and Radiographic Outcomes

BACKGROUND

Surgical innovation is critical for the management of challenging cerebrovascular pathology. Flow-through free flaps are versatile composite grafts that combine viable tissue with a revascularization source. Neurosurgical experience with these flaps is limited.

OBJECTIVE

To provide an in-depth technical description of the radial artery fascial (and fasciocutaneous) flow-through free flap (RAFF and RAFCF, respectively) for complex cerebral revascularizations.

METHODS

An Institutional Review Board-approved, prospective database was retrospectively reviewed to identify patients that underwent extracranial-to-intracranial cerebral bypass with a RAFF or RAFCF. Patient demographics, underlying pathology, surgical treatment, complications, and outcomes were recorded.

RESULTS

A total of 4 patients were treated with RAFFs or RAFCFs (average age 40 ± 8.8 yr). Two patients with progressive moyamoya disease involving multiple vascular territories with predominantly anterior cerebral artery (ACA) symptoms and flow alterations underwent combined direct ACA and indirect middle cerebral artery (MCA) bypass with a RAFF. The third patient with moyamoya disease and concomitant proximal fusiform aneurysms requiring internal carotid artery sacrifice underwent dual direct ACA and MCA bypass and indirect MCA revascularization with posterior tibial artery and RAFF grafts. The fourth patient with a large MCA bifurcation aneurysm and recurrent wound complications underwent a direct MCA bypass and complex wound reconstruction using a RAFCF. Good neurologic outcomes (Glasgow Outcomes Scale score ≥4 at discharge) were achieved in all patients. There were no perioperative surgical complications, and graft patency was confirmed on long-term follow-up.

CONCLUSION

The RAFF and RAFCF are versatile grafts for complex cerebral revascularizations.

Extracranial-to-Intracranial Bypass for Refractory Vertebrobasilar Insufficiency

BACKGROUND

Vertebrobasilar insufficiency (VBI) is associated with high rates of morbidity and mortality, especially after failure of first-line medical and/or endovascular therapies. Although the optimal therapeutic strategy for refractory VBI remains unclear, surgical bypass represents a potentially life-saving treatment in this patient subset.

METHODS

A multi-institution retrospective database review was performed to identify patients with symptomatic refractory VBI over a 4-year period (July 2014 to July 2018). Surgical treatments, as well as clinical and neurologic outcomes were recorded.

RESULTS

Five patients were identified with refractory VBI (average age 55 ± 11.0 years). All 5 patients had clinically significant posterior circulation strokes on presentation. Three patients underwent superficial temporal artery-to-superior cerebellar artery bypass based on significant acute perfusion mismatches or progressive strokes despite maximal medical therapy; 1 surgical patient (33%) experienced punctate perioperative strokes and there were no significant bypass related complications. Functional outcomes in the 3 surgical patients were correlated with preoperative stroke burden. The remaining 2 patients experienced rapid neurologic declines after presentation that precluded bypass, and died shortly thereafter.

CONCLUSIONS

Refractory VBI has high morbidity, with cerebral bypass representing a safe and potentially efficacious treatment for selected patients. Long-term post-bypass outcomes are dependent on the level of irreversible preoperative neurologic injuries.