Extracranial-intracranial bypass surgery using a radial artery interposition graft for cerebrovascular diseases

Extracranial-intracranial bypass using a cephalic vein graft for iatrogenic internal carotid artery injury during functional endoscopic sinus surgery: illustrative case

BACKGROUND

Injury to the internal carotid artery (ICA) during functional endoscopic sinus surgery is a rare but potentially fatal complication. Although treatment algorithms have been developed, guidelines for effectively managing iatrogenic ICA injury have not been established. A case of ICA perforation during functional endoscopic sinus surgery treated with cerebral bypass utilizing a cephalic vein graft is presented.

OBSERVATIONS

A woman in her late 50s presented with a left cavernous ICA injury that had occurred during endoscopic nasal polypectomy at an outside hospital. Hemostasis was achieved with intranasal Foley catheter placement. Left common carotid artery angiography revealed a high-flow carotid-cavernous fistula. Cerebral revascularization was chosen as the optimal procedure. The initial intent was to use a radial artery graft, but the radial artery was found to be occluded intraoperatively. Postoperatively, the patient experienced decreased vision and left eye movement but was otherwise neurologically intact. Postoperative angiography showed complete resolution of the fistula.

LESSONS

In cases involving ICA injury and carotid-cavernous fistula formation, microsurgical trapping with high-flow bypass is a favorable treatment option. The cephalic vein is a viable graft option when unexpected challenges arise with a radial artery graft. https://thejns.org/doi/10.3171/CASE24222.

Extracranial-Intracranial Microsurgical Bypass Using a Y-Shaped Vein Graft From the Hand

While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons' expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.

How we do it? Performing a protective superficial temporal artery-middle cerebral artery bypass with endoscopic transnasal cavernous sinus lesion operation

BACKGROUND

To describe the concept of a protective superficial temporal artery-middle cerebral artery (STA-MCA) bypass performed prior to endoscopic transnasal cavernous sinus (CS) lesion resection in order to reduce the risk of perioperative cerebral ischemia due to internal carotid artery (ICA) vasospasm, occlusion, and even injury.

METHOD

We illustrated the procedure of a 14-year-old female accepting a protective STA-MCA bypass with endoscopic transnasal CS lesion resection.

CONCLUSION

A protective bypass may be a prophylactic strategy in selected endoscopic transnasal CS surgery cases, particularly where the diagnosis is uncertain, or the risk of ICA injury or occlusion is high.

Management of Internal Carotid Artery Injury During Transsphenoidal Surgery: A Case Series and Suggestion for Optimal Management

OBJECTIVE

Internal carotid artery (ICA) injury during transsphenoidal surgery is a rare but serious complication. We analyzed a series of ICA injuries that occurred during a transsphenoidal approach to suggest an optimal management strategy.

METHODS

Between January 2015 and May 2020, we enrolled 10 cases of ICA injury at our institution.

RESULTS

Among the 10 patients enrolled, 5 had pituitary adenoma, 2 had craniopharyngioma, and 1 each had skull base chondrosarcoma, tuberculum sellae meningioma, and nasopharyngeal cancer; 4 were revision surgery cases. The cavernous segment of the ICA was the most commonly injured area. The most common reason for ICA injury was a drill injury at the sellar floor opening. A direct repair was performed using a clip in only 1 patient. In the others, bleeding control of the injured ICA was achieved by packing multiple cotton pads. After angiography, 6 patients underwent immediate endovascular sacrifice of the injured ICA. In 3 patients who showed poor collateral flow from the anterior communicating and posterior communicating arteries, revascularization surgery was performed before endovascular trapping. After 6 postoperative months, 6 patients showed favorable functional outcomes, and 4 patients showed poor functional outcomes.

CONCLUSIONS

Prompt control of bleeding, endovascular management of injured ICA, and consideration of revascularization surgery based on collateral flow may prevent catastrophic neurological sequelae.

Giant Aneurysm Management

The treatment of giant aneurysms has always been a challenge in the field of neurovascular disease. Giant aneurysms are larger in size and are associated with thrombosis development and the calcification of the aneurysmal wall and neck, which often interfere with direct clipping. Most giant aneurysms have a wide neck with an incomplete thrombus, making complete embolization almost impossible. Giant aneurysms of different sites have entirely different hemodynamic characteristics. Moreover, aneurysms at the same site may exhibit very different hemodynamics among different individuals. Therefore, careful assessment of each case is required before and during treatment to develop and carry out an individualized treatment plan.

Extra-intracranial bypass surgery using the orifice of maxillary artery in a patient with middle cerebral artery aneurysm. Case report and literature review

OBJECTIVE

To present the technique of extra-intracranial bypass surgery using the orifice of maxillary artery bypass, to evaluate the advantages and disadvantages of this and alternative revascularization options.

MATERIAL AND METHODS

Radial artery graft harvesting was performed at the 1st stage. Simultaneously, the second team of surgeons performed a combined (submandibular and anterior) access to the donor artery (mandibular segment of maxillary artery behind the ramus of the mandible). Craniotomy and mobilization of potential recipient arteries (M2-M3 segments of the middle cerebral artery) were performed at the 2nd stage. Distal anastomosis in end-to-side fashion was formed with M3 segment of the middle cerebral artery. At the 3rd stage, radial artery was passed through a subcutaneous tunnel in zygomatic region. The orifice of maxillary artery was resected together with distal external carotid artery (ECA) and orifice of superficial temporal artery. After transposition of ECA and orifice of maxillary artery, proximal end-to-end anastomosis was performed with radial artery. After that, the main surgical stage was performed, i.e. exclusion of M3 segment of the middle cerebral artery together with aneurysm.

RESULTS

Harvesting of mandibular segment of the maxillary artery as a donor vessel reduces the length of bypass graft to 12-14 cm since this branch is localized close to the skull base. You can also form optimal proximal end-to-end anastomosis for intracranial redirecting blood flow maxillary artery.

CONCLUSION

The described method makes it possible to form anastomosis with a short bypass graft and reduce the risk of thrombosis. This procedure is effective for cerebral bypass in patients with skull base tumors, complex aneurysms, and occlusive-stenotic lesions of carotid arteries.

Radial artery access for neuroendovascular procedures: safety review and complications

Although enthusiasm for transradial access for neurointerventional procedures has grown, a unique set of considerations bear emphasis to preserve safety and minimize complications. In the first part of this review series, we reviewed anatomical considerations for safe and easy neuroendovascular procedures from a transradial approach. In this second part of the review series, we aim to (1) summarize evidence for safety of the transradial approach, and (2) explain complications and their management.

Efficacy and Safety of Emergency Extracranial-Intracranial Bypass for Revascularization within 24 Hours in Resolving Large Artery Occlusion with Intracranial Stenosis

BACKGROUND

Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke.

METHODS

The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale.

RESULTS

The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P < 0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cm³) than in the MMT group (68.0 cm³) but was not significantly different from that of the PTA/S group (14.0 cm³; P < 0.05). The proportion of patients with a modified Rankin scale score of 0-2 at 6 months after surgery was significantly higher in the EC-IC bypass group (80%) than in the PTA/S (59%) and MMT (14%) groups (P < 0.05).

CONCLUSIONS

Emergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.

Controversies and Advances in Adult Intracranial Bypass Surgery in 2020

Cerebral revascularization utilizing a variety of bypass techniques can provide either flow augmentation or flow replacement in the treatment of a range of intracranial pathologies, including moyamoya disease, intracranial atherosclerotic disease, and complex aneurysms that are not amenable to endovascular or simple surgical techniques. Though once routine, the publication of high-quality prospective evidence, along with the development of flow-diverting stents, has limited the indications for extracranial-to-intracranial (EC-IC) bypass. Nevertheless, advances in imaging, assessment of cerebral hemodynamics, and surgical technique have changed the risk-benefit calculus for EC-IC bypass. New variations of revascularization surgery involving multiple anastomoses, flow preserving solutions, IC-IC constructs, and posterior circulation bypasses have been pioneered for otherwise difficult to treat pathology including giant aneurysms, dolichoectasia, and medically refractory intracranial atherosclerosis. This review provides a practical update on recent advances in adult intracranial bypass surgery.

Cerebrovascular bypass for ruptured aneurysms: A case series

In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.

Subclavian Artery to Internal Carotid Artery Interpositional Bypass for Carotid Artery Occlusion: Technical Case Report

BACKGROUND AND IMPORTANCE

Conventional microsurgical treatment for symptomatic internal carotid artery (ICA) occlusion is revascularization with superficial temporal artery (STA) to middle cerebral artery bypass. However, in rare cases where the common carotid artery, external carotid artery (ECA), or both are also occluded, other microsurgical treatment options must be considered.

CLINICAL PRESENTATION

We present the case of a 52-yr-old woman with common carotid artery occlusion and weak ICA flow from collateral connections between the vertebral artery, occipital artery, and ECA. She had ischemic symptoms and a history of stroke. The patient's STA was unsuitable as a donor vessel due to its small caliber and poor flow, and we instead performed an interpositional bypass from the subclavian artery to the ICA using a radial artery graft.

CONCLUSION

This case illustrates the successful use of the subclavian artery to ICA bypass technique with an interpositional radial artery graft. The surgical anatomy of the subclavian arteries is reviewed, and the technical details of subclavian artery to radial artery graft to ICA interpositional bypass are presented.

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.

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

OBJECTIVE

We investigated the use of high-flow superficial temporal artery trunk-to-radial artery-to-middle cerebral artery (STAt-RA-MCA) bypass to prevent ischemic stroke in patients with symptomatic internal carotid artery occlusion (SICAO).

METHODS

We retrospectively analyzed the data from patients with SICAO who had undergone high-flow STAt-RA-MCA bypass in our center from October 2014 to November 2017. The incidence of ischemic stroke, changes in cerebral blood flow, characteristics of perioperative complications, and related factors determining the blood flow rate in the graft were analyzed.

RESULTS

From October 2014 to November 2017, we treated 21 patients with SICAO using high-flow STAt-RA-MCA bypass. A total of 42 ischemic stroke events had been reported within 6 months before surgery. The ipsilateral/contralateral mean transit time (I/C MTT) ratio before surgery was 1.24 ± 0.10 (range, 1.14-1.51). During a median follow-up period of 692 days (range, 212-1114), 3 transient ischemic attacks occurred in 3 patients; 18 patients (85.7%) did not experience recurrent stroke. The patency rate of the bypass graft was 95.2% (20 of 21). The I/C MTT ratio was 1.06 ± 0.11 on postoperative day 1 in all patients and was significantly different from the preoperative I/C MTT ratio (P < 0.001). The surgical complication rate was 9.5% (2 of 21), and no reoperation was required.

CONCLUSION

Our results suggest that high-flow STAt-RA-MCA bypass can effectively reduce the risk of stroke in patients with SICAO. Moreover, the surgical procedure is a highly safe procedure. Further randomized controlled studies are required to draw more precise conclusions.

Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge

Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization

BACKGROUND

Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch.

OBJECTIVE

To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization.

METHODS

Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients.

RESULTS

Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization.

CONCLUSION

The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option.

Complete Cavernous Sinus Resection: An Analysis of Complications

BACKGROUND

Complete cavernous sinus resection has been described for patients with malignant or recurrent cavernous sinus tumors without other therapeutic options but has been associated with high morbidity and mortality rates. We reviewed the complications associated with complete cavernous sinus resection to gain insights for future complication avoidance.

METHODS

A retrospective analysis of a prospective, single-institution database was performed to identify patients who had undergone complete cavernous sinus resection from July 2014 to October 2017. Patient- and disease-specific data, surgical complications, and clinical outcomes were recorded.

RESULTS

Two male patients underwent complete cavernous sinus resection (aged 60 and 47 years) for recurrent maxillary tumors with secondary cavernous sinus extension. Revascularization was performed based on balloon test occlusion (BTO) results, with extracranial-to-intracranial bypass performed in 1 patient with a concerning hemispheric flow pattern found during BTO. Vascularized free flaps were used in both patients to assist with closure of the resulting skull base defect. Three complications related to surgery occurred in 1 patient (thigh hematoma, recurrent cerebrospinal fluid leak, and meningitis). One patient died of pneumonia approximately 2 weeks postoperatively, and the other experienced an acceptable neurologic and oncologic outcome.

CONCLUSIONS

Despite the high peri- and postoperative risks, complete cavernous sinus resection can be considered for select patients with tumors involving the cavernous sinus without other treatment options. Familiarity with cerebral bypass and free flap reconstruction of skull base defects is critical for complication avoidance and management.

Extracranial to intracranial by-pass anastomosis: Review of our preliminary experience from a low volume center in Egypt

Background:

Cerebral revascularization is a useful microsurgical technique for the treatment of steno-occlusive intracranial ischemic disease, complex intracranial aneurysms that require deliberate occlusion of a parent artery and invasive skull base tumors. We describe our preliminary experience with extracranial-to-intracranial by-passes at a low volume center; and discuss clinical indications and microsurgical techniques, challenges in comparison to large advanced referral centers.

Materials and Methods:

Twenty-seven patients with hemodynamic ischemia or complex aneurysms or skull base tumors were operated at Cairo University Hospitals in the period between May 2009 and June 2014. All patients operated by a low flow by-pass were operated through a superficial temporal artery to middle cerebral artery (MCA) anastomosis. All patients chosen for a high flow by-pass were operated using a radial artery graft interposed between the MCAs distally and the common or the external carotid artery proximally. Patency was confirmed at the end of surgery using appearance on the table and confirmed after surgery by transcranial color-coded duplex or computed tomography angiography. All patient data were prospectively collected and retrospectively analyzed at the end of surgery.

Results:

Nineteen patients (70.4%) were operated upon for flow augmentation and eight patients (29.6%) were operated upon for flow replacement. A total of 30 anastomoses were performed. All except one were patent which gives a patency rate of 96.3%. There was one death in the present series resulting from a hyperperfusion syndrome. 89.5% of patients with hemodynamic ischemia stopped having symptoms after surgery. All but one patient operated for hemodynamic ischemia showed a considerable cognitive improvement after surgery. None of the patients operated upon for flow replacement showed improvement of oculomotor nerve function in spite of adequate intraoperative decompression. All patients treated for flow replacement showed the absence of recurrence on follow-up.

Conclusion:

Our initial results for both low and high flow by-pass procedures in our low volume center indicate that such complex surgical procedures are possible with results comparable to those obtained in other larger referral centers throughout the world. This procedure not only represents a more definitive treatment when compared to other endovascular or radiation treatments but is also much less costly when compared to other treatment modalities.