Elsevier

World Neurosurgery

Volume 82, Issues 1–2, July–August 2014, Pages 130-139
World Neurosurgery

Peer-Review Report
Universal Extracranial-Intracranial Graft Bypass for Large or Giant Internal Carotid Aneurysms: Techniques and Results in 38 Consecutive Patients

https://doi.org/10.1016/j.wneu.2013.02.063Get rights and content

Objective

To present indications, surgical techniques, and outcomes of extracranial-intracranial (EC-IC) graft bypass.

Methods

Between January 1996 and June 2011, 38 patients with large or giant internal carotid artery (ICA) aneurysms were treated using graft bypass, employing the radial artery (RA) or the saphenous vein (SV) as a graft. Preoperative balloon test occlusions were not performed in any of the cases. In 17 patients, the external carotid artery (ECA)-RA-M2 segment of the middle cerebral artery bypass was used for treatment, and ECA-SV-M2 bypass was used in 21 patients.

Results

All aneurysms were completely trapped, and there were no subarachnoid hemorrhages or recanalizations of aneurysms during the follow-up period (8–170 months). Of the 38 bypasses, 36 (94.7%) remained patent, and there were no permanent neurologic deficits. Hyperperfusion syndrome was not experienced in this series. There were 2 temporary neurologic deficits. In 1 case using the RA, graft vasospasm occurred, and kinking occurred in 1 case using the SV. Another patient with a SV graft had to undergo an emergent revision of the graft 8 hours after the initial operation. One patient with a SV graft underwent a second operation to control an epidural abscess.

Conclusions

Universal EC-IC graft bypass is a safe and effective method for treating large or giant ICA aneurysms.

Introduction

Large or giant aneurysms of the intracranial internal carotid artery (ICA) can lead to severe morbidity or death secondary to progressive disability from mass effect, ischemia, or subarachnoid hemorrhage (SAH). The risk of rupture of intracranial ICA aneurysms >25 mm in diameter is 40% within 5 years according to ISUIA (International Study of Unruptured Intracranial Aneurysms) (46). Although most extradural cavernous carotid aneurysms are considered benign, 6.4% of aneurysms >25 mm in diameter bleed and cause difficult-to-treat carotid cavernous fistula within 5 years according to ISUIA (46). Progressive mass effect of the aneurysm dome on the cavernous sinus can induce symptoms associated with cranial nerves. In cases of giant aneurysms or symptomatic cases, not only intracranial ICA but also extracranial cavernous carotid aneurysms can be considered for treatment. Cerebral revascularization is often used to treat these aneurysms to compensate for the temporal or permanent occlusion of the affected artery. Graft bypass using the radial artery (RA) or saphenous vein (SV) is promising to replace the ICA (24) but is considered technically challenging (26).

Our policy for these complex aneurysms is first to make a graft bypass with RA or SV graft in all cases that potentially need ICA occlusion. We have termed this procedure “universal extracranial-intracranial (EC-IC) graft bypass” (23). In this report, we present surgical techniques and the outcomes of our 38 consecutive cases.

Section snippets

Clinical Material

Between January 1996 and June 2011, 38 consecutive patients with large or giant ICA aneurysms were treated using graft bypass. Of these patients, 17 underwent external carotid artery (ECA)-RA-M2 bypass, and 21 underwent ECA-SV-M2 bypass. The clinical features are listed in Table 1.

Surgical Technique

Video 1 demonstrates the surgical technique of graft bypass. The ipsilateral cervical common carotid artery, ICA, and ECA were exposed by making an incision along the anterior margin of the sternocleidomastoid muscle

Graft Patency

The graft-to-M2 anastomosis procedure took an average of 19.4 minutes ± 4.1 (Table 2). During a mean radiographic follow-up period of 46.7 months (range, 8–170 months), 36 of the 38 graft bypasses remained patent (94.7%) as confirmed by serial magnetic resonance arteriography (MRA) or computed tomographic angiography (CTA) (Table 3). There was no SAH or recanalization of the aneurysm during the follow-up period.

Graft occlusion occurred in 2 patients with SV graft bypass. One of the patients was

Management of Large or Giant ICA Aneurysms

Large and giant aneurysms of the intracranial ICA frequently involve the parent artery and critical neighboring branches, and direct surgical clip reconstruction is difficult in many cases (39). ISUIA found >20% major morbidity in clipping these aneurysms (46), and individual risk increased with age, especially for patients >70 years, possibly exceeding the lifetime risk of rupture (6).

A flow-diverting stent for these aneurysms is available in many countries, and it can reduce blood flow in the

Conclusions

Universal EC-IC graft bypass is a safe, effective way to treat large and giant ICA aneurysms.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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