Overcoming End-to-End Vessel Mismatch During Superficial Temporal Artery–Radial Artery–M2 Interposition Grafting for Cerebral Ischemia: Tapering Technique

doi:10.1016/j.wneu.2017.10.162

World Neurosurgery

Volume 110, February 2018, Page 85

https://doi.org/10.1016/j.wneu.2017.10.162 Get rights and content

Cerebral revascularization procedures, such as the external carotid–internal carotid bypass, have been used in the clinical management of cerebral ischemic states. Among the most commonly performed bypasses is the superficial temporal artery–middle cerebral artery (STA-MCA) bypass to restore cerebral blood flow. In cases of a foreshortened STA donor vessel, a radial artery (RA) graft is often used as an interposition graft between the STA and MCA. However, addressing the vessel size mismatch between the radial artery and donor can be problematic and challenging.

We present the case of an 80-year-old male presenting with positional-onset expressive aphasia and right-sided hemiparesis. Computed tomography perfusion demonstrated a diffusion-perfusion mismatch in a left MCA distribution. Angiography showed a complete left internal cerebral artery occlusion and poor distal filling of the STA. We performed an external carotid artery–to–internal carotid artery bypass through interposing an RA graft to the STA proximally with an end-to-end anastomosis and to the MCA distally using an end-to-side anastomosis. The mismatch between 2 bypass vessel sizes was corrected by removing a small piece from the RA graft at 1 margin and suturing it to itself to reduce the size of the RA vessel diameter opening on the side used to sew to the STA.

The patient did well clinically with improved right-sided strength, a patent graft, and no postoperative complications.

Addressing vessel mismatch when using RA interposition grafts for bypass is challenging. Various operative approaches to address mismatch should be individualized on the basis of the particular vascular anatomy and needs of the case. Nevertheless, our method of cutting and suturing 1 side of the RA graft into a semiblind end to match donor vessel diameter may be of use to cerebrovascular surgeons in select cases.

Section snippets

Supplementary Data

References (0)

Cited by (7)

Safety and efficacy of microsurgery for complex cranial pathologies in the ultra-geriatric population
2022, Clinical Neurology and Neurosurgery
Citation Excerpt :
In our study, three EC-IC bypass surgeries were done for COD patients, with all remaining patent at all follow-ups (Table 4: Cases #7–9, and Case illustration #2). We believe that neurosurgeons will increasingly encounter COD, and that age alone should not preclude the opportunity for cerebral revascularization to treat complex life-threatening pathologies in this growing brittle population [7]. Neurosurgeons should consider microsurgery for the UG in collaboration with anesthesiologists to optimize preoperative physical status in non-emergent and emergent cases.
The global increase in the “ultra-geriatric” population (aged 80 years and older) has led to higher demand for neurosurgical procedures in this vulnerable population. The objective was to evaluate the safety and efficacy of advanced microsurgical procedures on ultra-geriatric patients, in our modern era of neurosurgery, anesthesiology, and advanced medical care.
The study examined 66 complex cranial procedures, performed on 65 ultra-geriatric patients, who constituted 3.8% of the 4461 consecutive neurosurgical procedures performed by a single neurosurgeon over 14-years in a tertiary care university hospital. Excluded from this study were intra- or extra-axial spontaneous hematomas or traumatic brain injuries, infections, biopsy-only cases and carotid endarterectomies.
The most common indication for surgery for the 66 complex cranial procedures were meningiomas (23.9%), followed by gliomas (17.9%), and metastatic brain tumors (17.9%). Postoperative complications occurred in seven procedures (10.60%). No patient deaths were directly caused by intra- or postoperative events, and only one 30-day mortality occurred. All deceased patients had a statistically significant higher American Society of Anesthesiologists (ASA) class (p = 0.024). However, there was no significant correlation between ASA class and modified Rankin scale at discharge (p = 0.238).
With the aging global population and increasing life expectancy, the number of ultra-geriatric patients with complex pathologies seeking advanced microsurgical treatment is growing. Therefore, neurosurgeons are confronting a growing number and variety of complex pathologies in ultra-geriatric patients in their daily practice. Regardless of advanced age, microsurgery provides safe and effective treatment, with age alone not being a barrier to proper neurosurgical treatment when other risk factors are adequately modified.
Rare origin of the brachioradial artery - A case found on a historical specimen prepared by Ludwik Karol Teichmann
2021, Translational Research in Anatomy
Citation Excerpt :
As stressed by Vergara-Garcia et al. [17], p. 5, the brachioradial artery is one of the most frequently encountered anatomical variations of the upper limb, and “The presence of such may alter the success rate of neurovascular diagnostic procedures and therapeutic strategies.” Anatomical variations of the radial and brachioradial arteries might influence radial artery cannulation, surgical procedures, as well as trauma repair [18–22]. For instance, catheterization of the radial artery (so-called transradial access) may be altered by the vessel's abnormal origin and course.
Historical sources can serve as an important point of reference for anatomical research. In this report, we present an atypical origin of the brachioradial artery from the distal fourth of the arm. The radial recurrent artery originated from the ulno-interosseous trunk and crossed the brachioradial artery posteriorly at the level of the neck of the radius. This case reported herein was observed during a review of the historical specimens collection prepared in the 19th century by the prominent Polish anatomist Ludwik Karol Teichmann and his collaborators and exhibited in the Anatomy Museum of Jagiellonian University Medical College. The goal of this study was to provide data on the course and branching pattern of a rare variant of the brachioradial artery.
Surgical Strategies for Cerebral Revascularization in Patients with Limited Bypass Conduit Options and Unexpected Intraoperative Difficulties
2020, World Neurosurgery
Citation Excerpt :
For example, using cephalic veins as an interposition graft in peripheral bypass procedures was described in 197112 and successfully used in peripheral bypass13 and CABG procedures14; however, its first application by neurosurgeons was not reported until 2016,15 with no other reports that we could find until the present study. In the absence of available STA frontal and/or parietal branches, or when the flow of these branches is not adequate for the desired revascularization, the STA trunk can be used as a higher flow-carrying capacity donor as previously described,16 and as also shown in case 8 in Table 1.8 Furthermore, when an ipsilateral donor artery is totally absent, a Bonnet bypass7,17 may be used to exploit contralateral donor options, as presented in cases 6, 7,7 and 12 (Table 1).
Cerebral bypass procedures are complex and require substantial experience and skills and thorough preoperative planning. Cerebrovascular surgeons face increasingly complex bypass cases because most routine cases are managed by endovascular means, and because increasing numbers of patients have complex medical problems that affect available and suitable bypass conduit options. We report the cases of several patients undergoing cerebral bypass with limited bypass conduit alternatives, in whom there were unexpected intraoperative difficulties requiring complex solutions.
The neurological surgery department database was reviewed to identify patients who had undergone cerebral bypass procedures during a 13-year period in whom there were limited available bypass conduits, and in whom unexpected intraoperative difficulties were encountered during cerebral bypass.
Patient outcomes and graft patency were evaluated for 13 patients including 6 with ischemia, 3 with giant aneurysms, 2 with mycotic aneurysms, 1 with dissecting aneurysm, and 1 with gunshot-induced pseudoaneurysm. Median duration of follow-up was 43 months. In 12 of 13 patients, bypass graft/grafts were patent on the last computed tomography angiogram. In 1 patient, a prophylactic bypass procedure, the graft was not filling, probably because of lack of demand. Two patients died during follow-up of unrelated causes.
Cerebrovascular surgeons should be versatile in dealing with patients with complex bypass. When there are limited available conduit options, we find that collaboration with other surgical specialties (e.g., plastics and vascular) is helpful. In patients in whom extreme intraoperative difficulties are expected, thorough preoperative planning with multiple backup plans should be exercised, as described in this report.
Combined Double-Barrel Superficial Temporal Artery to M4 Bypass and Parent Artery Occlusion for the Treatment of Complex Intracranial Aneurysms in Internal Carotid Artery and Middle Cerebral Artery: A Retrospective Case Series
2023, Operative Neurosurgery
Subclavian artery to internal carotid artery interpositional bypass for carotid artery occlusion: Technical case report
2021, Operative Neurosurgery
Persistent median artery as an unusual finding in the carpal tunnel: Its contribution to the blood supply of the hand and clinical significance
2019, Medical Science Monitor

View all citing articles on Scopus

: 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.

View full text

Video ArticleOvercoming End-to-End Vessel Mismatch During Superficial Temporal Artery–Radial Artery–M2 Interposition Grafting for Cerebral Ischemia: Tapering Technique

Section snippets

Supplementary Data

Video Article
Overcoming End-to-End Vessel Mismatch During Superficial Temporal Artery–Radial Artery–M2 Interposition Grafting for Cerebral Ischemia: Tapering Technique