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Toyota S, Iwaisako K, Wakayama A, Yoshimine T. Fixation and protective method for the interposition graft in bonnet bypass--technical note. Neurol Med Chir (Tokyo) 2010; 50:263-6. [PMID: 20339284 DOI: 10.2176/nmc.50.263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bonnet bypass is recommended for the rare patients in whom no alternative revascularization procedure is available. Fixation and protection of the interposition graft are important for stable anastomosis, and to avoid mechanical injury after operation. Here, we describe a new technique for fixation and protection of the interposition graft in bonnet bypass. The interposition graft is passed through a bone groove created in the skull, and covered with microplates, temporal fascia, and muscle. The method prevents the interposition graft from slipping out during the anastomosis, and can also protect the graft from mechanical injury after the operation.
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Affiliation(s)
- Shingo Toyota
- Department of Neurosurgery, Osaka Neurological Institute, Toyonaka, Osaka, Japan
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Abstract
Abstract
OBJECTIVE
Bypass surgery for brain aneurysms is evolving from extracranial-intracranial (EC-IC) to intracranial-intracranial (IC-IC) bypasses that reanastomose parent arteries, revascularize efferent branches with in situ donor arteries or reimplantation, and reconstruct bifurcated anatomy with grafts that are entirely intracranial. We compared results with these newer IC-IC bypasses to conventional EC-IC bypasses.
METHODS
During a 10-year period, 82 patients underwent bypass surgery as part of their aneurysm management. A quarter of the patients presented with ruptured aneurysms and two-thirds presented with compressive symptoms from unruptured aneurysms. Most aneurysms (82%) had non-saccular morphology and 56% were giant sized. Common locations included the cavernous internal carotid artery (23%), middle cerebral artery (20%), and posteroinferior cerebellar artery (12%).
RESULTS
Forty-seven patients (57%) received EC-IC bypasses and 35 patients (43%) received IC-IC bypasses, including 9 in situ bypasses, 6 reimplantations, 11 reanastomoses, and 9 intracranial grafts. Aneurysm obliteration rates were comparable in EC-IC and IC-IC bypass groups (97.9% and 97.1%, respectively), as were bypass patency rates (94% and 89%, respectively). Three patients died (surgical mortality, 3.7%), and 4 patients were permanently worse as a result of bypass occlusions (neurological morbidity, 4.9%). At late follow-up (mean duration, 41 months), good outcomes (Glasgow Outcome Scale score 5 or 4) were measured in 68 patients (90%) overall, and were similar in EC-IC and IC-IC bypass groups (91% and 89%, respectively). Changes in Glasgow Outcome Scale score were slightly more favorable with IC-IC bypass (6% worse or dead after IC-IC bypass versus 14% with EC-IC bypass).
CONCLUSION
IC-IC bypasses compare favorably to EC-IC bypasses in terms of aneurysm obliteration rates, bypass patency rates, and neurological outcomes. IC-IC bypasses can be more technically challenging to perform, but they do not require harvest of extracranial donor arteries, spare patients a neck incision, shorten interposition grafts, are protected inside the cranium, use caliber-matched donor and recipient arteries, and are not associated with ischemic complications during temporary arterial occlusions. IC-IC bypass can replace conventional EC-IC bypass with more anatomic reconstructions for selected aneurysms involving the middle cerebral artery, posteroinferior cerebellar artery, anterior cerebral artery, and basilar apex.
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Affiliation(s)
- Nader Sanai
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Zsolt Zador
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
| | - Michael T. Lawton
- Department of Neurological Surgery, University of California at San Francisco, San Francisco, California
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Dacey RG, Zipfel GJ, Ashley WW, Chicoine MR, Reinert M. Automated, compliant, high-flow common carotid to middle cerebral artery bypass. J Neurosurg 2008; 109:559-64. [DOI: 10.3171/jns/2008/109/9/0559] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the use of the Cardica C-Port xA Distal Anastomosis System to perform an automated, high-flow extracranial–intracranial bypass. The C-Port system has been developed and tested in coronary artery bypass surgery for rapid distal coronary artery anastomoses. Air-powered, it performs an automated end-to-side anastomosis within seconds by nearly simultaneously making an arteriotomy and inserting 13 microclips into the graft and recipient vessel. Intracranial use of the device was first simulated in a cadaver prepared for microsurgical anatomical dissection.
The authors used this system in a 43-year-old man who sustained a subarachnoid hemorrhage after being assaulted and was found to have a traumatic pseudoaneurysm of the proximal intracranial internal carotid artery. The aneurysm appeared to be enlarging on serial imaging studies and it was anticipated that a bypass would probably be needed to treat the lesion. An end-to-side bypass was performed with the C-Port system using a saphenous vein conduit extending from the common carotid artery to the middle cerebral artery. The bypass was demonstrated to be patent on intraoperative and postoperative arteriography. The patient had a temporary hyperperfusion syndrome and subsequently made a good neurological recovery.
The C-Port system facilitates the performance of a high-flow extracranial–intracranial bypass with short periods of temporary arterial occlusion. Because of the size and configuration of the device, its use is not feasible in all anatomical situations that require a high-flow bypass; however it is a useful addition to the armamentarium of the neurovascular surgeon.
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Affiliation(s)
- Ralph G. Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory J. Zipfel
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - William W. Ashley
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael R. Chicoine
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael Reinert
- 2Department of Neurosurgery, Inselspital Bern, University of Bern, Switzerland
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