Peer-Review ReportUniversal Extracranial-Intracranial Graft Bypass for Large or Giant Internal Carotid Aneurysms: Techniques and Results in 38 Consecutive Patients
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.
References (47)
- et al.
Surgical bypass for intracranial aneurysms: navigating around a changing paradigm
World Neurosurg
(2011) - et al.
Extracranial-intracranial bypass: resurrection of a nearly extinct operation
J Vasc Surg
(2012) - et al.
Training of A3-A3 side-to-side anastomosis in a deep corridor using a box with 6.5-cm depth: technical note
Surg Neurol
(2006) - et al.
The role of cerebral revascularization in patients with intracranial aneurysms
Neurosurg Clin N Am
(2001) Extracranial-intracranial bypass to reduce the risk of ischemic stroke in intracranial aneurysms of the anterior cerebral circulation: a systematic review
J Stroke Cerebrovasc Dis
(2008)- et al.
Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment
Lancet
(2003) - et al.
De novo aneurysm formation after carotid artery occlusion for cerebral aneurysms
Skull Base
(2010) Carotid endarterectomy saphenous vein patch rupture revisited: selective use on the basis of vein diameter
J Vasc Surg
(1996)- et al.
De novo large fusiform posterior circulation intracranial aneurysm presenting with subarachnoid hemorrhage 7 years after therapeutic internal carotid artery occlusion: case report and review of the literature
Neurosurgery
(2012) - et al.
Surgical treatment of giant intracranial aneurysms: current viewpoint
Neurosurgery
(2008)
Aneurysm rupture following treatment with flow-diverting stents: computational hemodynamics analysis of treatment
AJNR Am J Neuroradiol
Simulation of the natural history of cerebral aneurysms based on data from the International Study of Unruptured Intracranial Aneurysms
J Neurosurg
Bypass or not? Adjustment of surgical strategies according to motor evoked potential changes in large middle cerebral artery aneurysm surgery
World Neurosurg
Detection of ischemia in endovascular therapy of cerebral aneurysms: a perspective in the era of neurophysiological monitoring
Neurosurg Rev
Failure of the hypotensive provocative test during temporary balloon test occlusion of the internal carotid artery to predict delayed hemodynamic ischemia after therapeutic carotid occlusion
Surg Neurol
Hypotensive endovascular test occlusion of the carotid artery in head and neck cancer
Neurosurg Focus
Long-term 3T MR angiography follow-up after therapeutic occlusion of the internal carotid artery to detect possible de novo aneurysm formation
AJNR Am J Neuroradiol
Temporary arterial occlusion in the repair of ruptured intracranial aneurysms: an analysis of risk factors for stroke
J Neurosurg
Cerebral perfusion long term after therapeutic occlusion of the internal carotid artery in patients who tolerated angiographic balloon test occlusion
AJNR Am J Neuroradiol
Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial
JAMA
Training in microvascular surgery using a chicken wing artery
Neurosurgery
Microsurgical technique without pial injury for transsylvian approach
Surg Cereb Stroke
Double-insurance bypass for internal carotid artery aneurysm surgery
Neurosurgery
Cited by (0)
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.
Supplementary digital content available online.