Bypass to the intracranial internal carotid artery

doi:10.1054/jocn.2002.1127

Journal of Clinical Neuroscience

Volume 9, Issue 4, July 2002, Pages 418-424

https://doi.org/10.1054/jocn.2002.1127 Get rights and content

Abstract

Extracranial to intracranial internal carotid artery bypass surgery with vein is well described for a number of diverse conditions. They provide high blood flow with good initial patency. However, long term patencies for specific graft types remains unknown. This is an analysis of consecutive interposition saphenous vein bypass cases between the common carotid artery (CCA) and the intracranial internal carotid artery (ICA) where the distal anastomosis was placed end-to-end immediately proximal to the posterior communicating artery in 55 patients undergoing 57 bypass procedures (bilateral in 2 cases). Twenty-five patients underwent grafting for planned vessel obliteration where the pathology required vessel sacrifice. Twenty-eight patients had bypass grafting for stroke risk reduction in the setting of threatening stroke and 4 patients had bypass grafts for emergency revascularisation in the setting of stroke in evolution. Patients were assessed preoperatively and at follow-up with modified Rankin scores. Procedural related complications included a 7% mortality and 7% functional decline. Early graft occlusion occurred in 5% of grafts leading to death in each case. A further patient died of rupture at the distal anastomosis site. In surviving patients, patency was present in 100% at last follow-up (mean 5 years and maximum 11 years) with no patient sustaining new hemispheric ischemic events. One patient developed a delayed asymptomatic stenosis within the vein graft requiring stenting. Because of the high initial management risks this technique of common carotid to intracranial internal carotid artery saphenous vein bypass surgery should be reserved for patients at considerable risk by alternate management. However, once the acute postoperative period is past the bypass appears to be robust and capable of supplying the entire distribution of a normal internal carotid artery.

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Cited by (32)

Temporo-Sylvian anastomosis in the management of internal carotid system occlusions: Patient series
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Extracranial-intracranial bypass (EC-IC) procedures have played an important role in the treatment of cerebrovascular disease since their development in the 1960s.
The aim of our work is to evaluate the results of temporo-sylvian anastomosis in internal carotid occlusions in a retrospective study of a series of six descriptive cases.
The mean age of our patients was 55.16 years. An arterial hypertension was found in 4 cases and atherosclerosis in 3 cases. An embolization of an arteriovenous malformation of the oral floor was reported in one patient. Likewise, a cavernous sinus meningioma had been the subject of radiotherapy in 02 other patients. The symptomatology leading to the diagnosis consisted of a recurrent TIA (transient ischemic attack) or minor stroke in all of our patients. An asymmetry of the cerebral perfusion was objectified on the perfusion MRI (Magnetic resonance imaging) in all our patients. The follow-up was favorable, with an mRS (modified Rankin score) between 0 and 2 at three months. A control perfusion MRI was performed in all patients, showing better perfusion in the affected area.
Temporal-sylvian anastomosis is a surgical technique that is effective in the short and medium term in carotid occlusions responsible for ischemic hemodynamic attacks.
Superficial Temporal Artery–Middle Cerebral Artery Bypass Ex Vivo Hybrid Simulator: Face, Content, Construct, and Concurrent Validity
2020, World Neurosurgery
Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on “flat” models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills.
Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models.
The fidelity grade was ranked as low (Linkert scale score, 1–2), medium (score, 3), and high (score, 4–5). The face and content validity of the model showed high fidelity to superficial temporal artery–middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present.
The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.
Bony Dehiscence of the Horizontal Petrous Internal Carotid Artery Canal: An Anatomic Study with Surgical Implications
2018, World Neurosurgery
The cervical carotid segment is used routinely as donor site for high-flow bypass procedures. The horizontal petrous segment would offer a shorter graft distance, complete graft protection intracranially, and avoid the need for surgical neck exposure. In a morphometric cadaveric study, we aimed to investigate variations of the petrous carotid anatomy, especially the incidence of bony dehiscence of the roof of the horizontal petrous carotid segment canal, which may facilitate exposure of the vessel and thereby potentially lower the morbidity of high-flow bypass procedures.
A subtemporal approach was used to expose the horizontal petrous internal carotid artery (ICA) on each side of 4 alcohol-embedded, silicone-injected human cadaver heads to perform a morphometric analysis of the vessel segment and surrounding bony anatomy.
The following measurements were obtained of the horizontal petrous ICA (millimeters): long axis mean 9.6 (standard deviation [SD] 4.4, MIN 4.2, MAX 19.5), diameter mean 4.9 (SD 0.6, MIN 4, MAX 5.7), thickness of canal roof mean 2.1 (SD 1.7, MIN 0, MAX 5), and distance from temporal squama mean 22.5 (SD 6, MIN 17, MAX 35). Dehiscence of the bony roof of the horizontal petrous carotid canal was found in 25% of specimen investigated.
A dehiscent bony roof of the horizontal petrous carotid canal potentially facilitates exposure of the vessel for high-flow bypass procedures and was observed in 25% of specimens. This feature could be identified on preoperative high-resolution imaging and thus aid in patient selection.
Hemodynamic effect of bypass geometry on intracranial aneurysm: A numerical investigation
2018, Computer Methods and Programs in Biomedicine
Citation Excerpt :
In addition, coil embolization is not preferred in aneurysms with wide neck regions [5]. Extracranial–intracranial (EC–IC) arterial bypass is commonly used in such cases [6,7]. Cerebral bypass surgery is performed to correct or revascularize the blood flow via conventional extracranial to intracranial (EC–IC) or intracranial to intracranial (IC–IC) methods in the brain [8–12].
Hemodynamic analyzes are used in the clinical investigation and treatment of cardiovascular diseases. In the present study, the effect of bypass geometry on intracranial aneurysm hemodynamics was investigated numerically. Pressure, wall shear stress (WSS) and velocity distribution causing the aneurysm to grow and rupture were investigated and the best conditions were tried to be determined in case of bypassing between basilar (BA) and left/right posterior arteries (LPCA/RPCA) for different values of parameters.
The finite volume method was used for numerical solutions and calculations were performed with the ANSYS-Fluent software. The SIMPLE algorithm was used to solve the discretized conservation equations. Second Order Upwind method was preferred for finding intermediate point values in the computational domain. As the blood flow velocity changes with time, the blood viscosity value also changes. For this reason, the Carreu model was used in determining the viscosity depending on the velocity.
Numerical study results showed that when bypassed, pressure and wall shear stresses reduced in the range of 40–70% in the aneurysm. Numerical results obtained are presented in graphs including the variation of pressure, wall shear stress and velocity streamlines in the aneurysm.
Considering the numerical results for all parameter values, it is seen that the most important factors affecting the pressure and WSS values in bypassing are the bypass position on the basilar artery (L_b) and the diameter of the bypass vessel (d). Pressure and wall shear stress reduced in the range of 40–70% in the aneurysm in the case of bypass for all parameters. This demonstrates that pressure and WSS values can be greatly reduced in aneurysm treatment by bypassing in cases where clipping or coil embolization methods can not be applied.
Efficacy of Early Superficial Temporal Artery–Middle Cerebral Artery Double Anastomoses for Atherosclerotic Occlusion in Patients with Progressing Stroke
2017, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
This procedure, in particular STA–MCA bypass, has been widely used to augment CBF and has been shown to be effective in the treatment of ischemic atherosclerotic disease. However, the indications and timing of this surgery for acute ischemic stroke are still controversial.1,2,7-13 Previously, it has been reported that an STA–MCA bypass within the first week after an acute stroke results in a high risk of conversion from a bland infarct into a hemorrhagic infarction or an increase in the size of the ischemic area and presents very high operative risks.
We investigated the efficacy of early superficial temporal artery–middle cerebral artery (STA–MCA) double anastomoses for patients with progressing stroke due to atherosclerotic occlusion.
Nine consecutive patients who underwent early STA–MCA double anastomoses were enrolled. All patients presented with progressing stroke despite maximal medical treatment. Cerebral blood flow in 7 patients was analyzed by single-photon emission tomography. Clinical outcomes were investigated postoperatively, and we evaluated the utility of early STA–MCA double anastomoses.
Nine patients in the present study included those with middle cerebral artery occlusion (n = 6) and internal carotid artery occlusion (n = 3). The mean age was 58.4 years. Subjects comprised 1 female (11.1%) and 8 males (88.9%). The cause was low perfusion ischemia due to atherosclerotic occlusion with a small infarct. The mean regional cerebral blood flow (rCBF) ratio in the middle cerebral artery territory compared to the normal side was 69.6 ± 5.3%. The duration from onset to surgery was 1-8 days (median, 3.11 days). All patients underwent early STA–MCA double anastomoses, and no reperfusion-induced hemorrhage occurred. All of them slowly achieved obvious remission compared to symptoms on admission and achieved a good functional outcome.
Early STA–MCA double anastomoses were safe and effective, and early revascularization resulted in rapid neurological improvement. We recommend this procedure for patients with progressive ischemia due to main trunk artery occlusion, when the rCBF flow ratio with the normal side was 70 ± 10%, even at the subacute stage.
Multimodality Treatment of Cerebral Arteriovenous Malformations
2014, World Neurosurgery
Citation Excerpt :
We have found that, qualitatively, an AVM after embolization is more easily manipulated intraoperatively. We believe that the major benefit of embolization is the elimination of deep feeding arteries, which have been suggested to be the limiting factor in the morbidity and surgical resectability for Spetzler-Martin grade IV–V lesions (34). Embolization for the elimination of deep feeding arteries helps both because of the sensitive location of these deep feeding arteries and because they have little smooth muscle in their wall and are difficult to coagulate (21).
Many arteriovenous malformations (AVMs) can be treated with one modality, but with increasing complexity a combination of techniques, including surgical excision, embolization, and radiosurgery, may be beneficial. The 2 senior authors' experience in the multimodal management of AVMs from 1980–2008 is reported, including the results in all patients with rehemorrhage while awaiting treatment or after partial initial treatment has begun. The series contains a disproportionately high number of Spetzler-Martin grade IV and V lesions, owing to the nature of the referral practice.
Data were collected prospectively. Only patients who were managed until treatment options were exhausted were included; this entailed either treatment to the point of AVM obliteration or inability to treat further using any or all modalities. Patients who presented with intracranial hemorrhage (ICH) in extremis in whom the AVM was excised during the first operation were also included.
Of the 290 patients, 265 underwent treatment, and 25 were managed conservatively. An unruptured AVM was present in 48% of patients. Cure was achieved in 233 (88%) of treated patients. Cure was achieved in 25 of 37 patients undergoing radiosurgery only, 56 of 57 undergoing surgery, 100 of 101 undergoing embolization and microsurgical excision, 20 of 34 undergoing embolization alone, 12 of 17 undergoing embolization and radiosurgery, 5 of 5 undergoing surgery and radiosurgery, and 14 of 14 patients undergoing all 3 modalities. Spetzler-Martin grade was found to correlate negatively with cure (P < 0.001). There was a good outcome in 210 patients (72%), moderate disability in 40 patients (14%), severe disability in 22 patients (8%), vegetative state in 1 patient, and 17 patients (6%) died. There was a favorable outcome (no or only moderate deficits) in 93% of patients with Spetzler-Martin grade I–III lesions. The outcome was favorable in 13 of 25 patients (52%) having no treatment, 32 of 37 (86%) having radiosurgery only, 30 of 34 (88%) having embolization only, 54 of 57 (95%) having surgery only, 87 of 101 (86%) having embolization and surgery, 16 of 17 (94%) having embolization and radiosurgery, 5 of 5 (100%) having surgery and radiosurgery, and 13 of 14 (93%) having all 3 modalities. These outcomes included morbidity from initial presenting symptoms, from treatment, and from rehemorrhage. Good recovery was more likely in patients who were treated with surgery as one of the treatments (P = .025). Considering only new deficits related to treatment, 9 patients (3%) incurred severe neurologic deficits, 11 patents died after treatment, 2 patients died of postoperative hematomas, and 6 died of rehemorrhage from residual AVM. Increasing age, Spetzler-Martin grade, and rehemorrhage were correlated with a poorer Glasgow Outcome Scale score (P < 0.05).
These data suggest a higher risk of hemorrhage after partial obliteration of AVM. One should ascertain an acceptably high likelihood of complete obliteration before embarking on treatment. Using a multimodality approach, the authors were able to cure 92% of treated Spetzler-Martin grade I–IV lesions but only 53% of treated Spetzler-Martin grade V lesions. A major neurologic deficit, disabling to the patient, was incurred in 3% of cases, and 11 patients died.

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^f1: Correspondence to: Professor M. K. Morgan, Sydney Aneurysm and AVM Neurosurgical Centre Level 8, 193 Macquarie St, Sydney, NSW 2000, Australia. Tel.: +61-2-92236500; Fax: +61-2-92236855.

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Clinical studyBypass to the intracranial internal carotid artery

Abstract

Common carotid to intracranial internal carotid bypass venous graft: technical note

J Neurosurg

Treatment of inoperable carotid aneurysms with endovascular carotid occlusion after extracranial-intracranial bypass surgery

Neurosurgery

Revascularization and aneurysm surgery: current techniques, indications, and outcome

Neurosurgery

Extracranial – intracranial saphenous vein bypass for carotid or vertebral artery dissection: report of 6 case

Journal of Neurosurgery

Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease

J Neurosurgery

N Engl J Med

Was the international randomized trial of extracranial-intracranial arterial bypass representative of the population at risk?

N Engl J Med

Extracranial-intracranial bypass for ischaemic cerebrovascular disease refractory to maximal medical therapy

Neurosurgery

Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion

JAMA

Improvement of cerebrovascular reserve capacity by EC-IC bypass surgery in patients with ICA occlusion and hemodynamic cerebral ischemia

J Neurosurg

An assessment of cavernous carotid artery bypass grafting during surgery for tumors of the cavernous sinus

Crit Rev Neurosurg

Hunterian proximal arterial occlusion for giant aneurysms of the carotid circulation

J Neurosurg

Long term follow up of occlusive cervical carotid dissection

Stroke

Late complications of carotid ligation in the treatment of intracranial aneurysms

J Neurosurg

Changes in intracranial stenotic lesions after extracranial-intracranial bypass surgery

J Neurosurg

Clinical study
Bypass to the intracranial internal carotid artery