Salvage Maneuvers for Occluded Bypass in Cerebral Revascularization Procedures

OBJECT

Cerebral revascularization is an effective measure for dealing with complicated intracranial aneurysms and ischemic cerebro-vascular disease. Intra-operative thrombosis causing bypass occlusion is a severe issue that cause devastating consequences for complication in revascularization. We report our experiences regarding salvage maneuvers for intraoperative thrombosis in cerebral revascularization procedures and discuss the characteristics and culprits.

METHODS

We investigated 720 consecutive patients who underwent cerebral revascularization at the First Affiliated Hospital of Soochow University from January 2013 to October 2021, including 688 patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and 32 patients who underwent extracranial artery-radial artery (ECA-RA)-MCA bypass. Forty-one patients experienced intracranial aneurysms, and the remaining 679 patients was involved in moyamoya disease (MMD), skull base tumors, intracranial occlusive vascular diseases, or other cerebrovascular diseases. All clinical characteristics, clinical imaging examinations and neurological outcomes were studied pre- and postoperatively. The patency of bypasses was confirmed by intraoperative doppler ultrasonography and indocyanine green (ICG) videoangiography.

RESULTS

Seven intraoperative thromboses, which were confirmed by intraoperative doppler ultrasonography and ICG videoangiography, including STA-MCA bypass (n=5) and ECA-RA-MCA bypass (n=2), were observed in 720 patients who underwent cerebral revascularization. The anastomotic stoma remained patent in 6 of 7 patients with intraoperative thrombosis after treatment. One case in STA-MCA bypass failed to be salvaged. Of the four intraoperative thrombosis in STA-MCA bypass for MMD being successfully saved, two were salvaged by applying gelfoam around the site of the anastomosis to relieve the downward compression effect of the donor vessel(STA) on the recipient vessel(M4 segment of MCA).One case in ECA-RA-MCA bypass were salvaged by thrombectomy through donor arteriotomy (radial artery) and reanastomosis. The other case was salvaged by complete reanastomosis. All seven patients who experienced intraoperative thrombosis achieved favorable outcomes at discharge and the 6-month follow-up.

CONCLUSION

Various factors are responsible for intraoperative thrombosis in cerebral revascularization. Relieving the downward compression effect of the donor vessel STA on the recipient vessel M4 segment of MCA by applying gelfoam around the site of the anastomosis stoma, can be recommend to salvage the intraoperative thrombosis in cerebral revascularization.

Role of multimodal monitoring in the management of patients undergoing complex intracranial bypass procedures - A case series and literature review

Patients undergoing complex intracranial neurovascular procedures continue to have a high mortality rate. Individualised goal-directed cerebral resuscitation employing multimodality neuromonitoring may impact these patients' treatment and prognosis. Advanced monitoring methods aid in the early identification of secondary brain insults and serve as endpoints for goal-directed therapy in the perioperative period. Unfortunately, there is a paucity of literature exploring the impact of multimodality monitoring and its outcome in these patients. We aim to present this case series wherein the patients had a favourable outcome post-intracranial complex bypass procedure, owing to goal-directed management guided by multimodality monitoring in the perioperative period.

Extracranial-Intracranial Cerebral Revascularization for Atherosclerotic Vessel Occlusion: An Updated Systematic Review of the Literature

BACKGROUND

Atherosclerotic steno-occlusive cerebrovascular disease includes extracranial carotid occlusive and intracranial atherosclerotic disease. Despite the negative findings in Carotid Occlusion Surgery Study (COSS), many large centers continue to report favorable results for revascularization surgery in select groups of patients. The aim of our study was to perform an updated systematic review to investigate the role of revascularization surgery for atherosclerotic steno-occlusive patients in the modern era.

METHODS

Five independent reviewers performed Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature searches in October 2022 to identify articles reporting clinical outcomes in adult patients undergoing bypass for atherosclerotic steno-occlusive disease. Primary endpoints used were perioperative and long-term ischemic strokes, intracerebral hemorrhage, bypass patency, and favorable clinical outcomes. Study quality was evaluated with Newcastle-Ottawa, JADAD, and the Oxford Center for Evidence-Based Medicine scales.

RESULTS

A total of 6709 articles were identified in the initial search. Of these articles, 50 met the inclusion criteria and were included in the systematic review. A notable increase in the proportion of articles published over the past 10 years was observed. There were 6046 total patients with 4447 bypasses performed over the period from 1978 to 2022. The average length of follow-up was 2.75 ± 2.71 years. The average Newcastle-Ottawa was 6.23 out of 9 stars. There was a significant difference in perioperative stroke (odds ratio [OR], 0.65 [0.48-0.87]; P = 0.004), long-term ischemia (OR, 0.32 [0.23-0.44]; P < 0.0001), overall ischemia (OR, 0.36 [0.28-0.44]; P < 0.0001), and favorable outcomes (OR, 3.63 [2.84-4.64]; P < 0.0001) when comparing pre-COSS to post-COSS time frames in favor of post-COSS.

CONCLUSIONS

Based on a systematic review of 50 articles, the existing literature indicates that long-term stroke rates and favorable outcomes for surgical revascularization for steno-occlusive disease have improved over time and are lower than previously reported. Improved patient selection, perioperative care, and surgical techniques may contribute to improved outcomes.