How I do it: superficial temporal artery-middle cerebral artery bypass for flow augmentation and replacement

Interrupted Versus Running Sutures for Superficial Temporal Artery to Middle Cerebral Artery Cranial Bypass

BACKGROUND AND OBJECTIVES

Superficial temporal artery to middle cerebral artery (STA-MCA) bypass is the workhorse for flow augmentation surgery. Although either interrupted or running sutures can be used to complete the anastomosis with high intraoperative patency rates, no previous study in the cranial bypass literature has compared long-term patency and maturity of end-to-side STA-MCA anastomoses. We compared STA-MCA anastomoses performed with running vs interrupted sutures by evaluating bypass flow and anastomotic maturation on follow-up vascular imaging.

METHODS

Ninety-six STA-MCA anastomoses were performed from 1/2019 to 6/2024. Forty-seven anastomoses (40 patients) with long-term vascular imaging were retrospectively analyzed. All anastomoses were intraoperatively patent on initial revascularization. Patient demographics, clinical course, and imaging were reviewed. All images were reviewed by a neuroradiologist or a cerebrovascular neurosurgeon.

RESULTS

Twenty-five anastomoses were performed with interrupted sutures and compared with 22 anastomoses performed with running sutures. All patients underwent a preoperative perfusion assessment confirming a significant hypoperfusion state. There were no significant differences between cohorts in demographics, bypass indication, or time to follow-up. Formal digital subtraction angiography was performed for 35 anastomoses (21 interrupted, 14 running). On digital subtraction angiography follow-up, there was no difference in STA caliber between cohorts (P = .204), but there was a difference in anastomotic growth (P = .014), with 5/21 (23.8%) anastomoses stable or enlarged in the interrupted cohort vs 9/14 (64.3%) stable or enlarged in the running cohort. Notably, of the 47 total anastomoses, there was no difference in long-term bypass patency between interrupted and running anastomoses (22/25 (88.0%) vs 22/22 (100.0%), respectively, P = .380).

CONCLUSION

No significant differences in patency or STA caliber on follow-up imaging were observed between STA-MCA anastomoses performed with interrupted vs running sutures although a difference in anastomotic maturity was observed, with the running suture cohort having a higher proportion of enlarged or stable anastomoses. Further studies are needed for validation.

How I do it: superficial temporal artery to middle cerebral artery bypass for moyamoya disease

BACKGROUND

Moyamoya disease (MMD) is a chronic progressive disease leading to recurrent stroke due to occlusion of the terminal internal carotid arteries. Surgical revascularization for symptomatic MMD is an effective treatment for preventing further stroke. However, direct revascularization of advanced MMD remains challenging due to small caliber of the recipient vessel and perforators.

METHODS

We introduce our technique of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass with figures and video to illustrate the procedure.

CONCLUSION

Surgical nuances of STA to MCA anastomosis will help cerebrovascular neurosurgeons to master low-flow bypass for MMD.