Surgical Technique for High-Flow Internal Maxillary Artery to Middle Cerebral Artery Bypass Using a Superficial Temporal Artery Interposition Graft

2017 ◽  
Vol 13 (2) ◽  
pp. 246-257 ◽  
Author(s):  
Xuequan Feng ◽  
Ali Tayebi Meybodi ◽  
Jordina Rincon-Torroella ◽  
Ivan H. El-Sayed ◽  
Michael T. Lawton ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
High Flow ◽  
Maxillary Artery ◽  
Internal Maxillary Artery ◽  
Middle Fossa ◽  
Middle Fossa Approach ◽  
Interposition Graft

Abstract BACKGROUND: Extracranial-to-intracranial high-flow bypass often requires cranial, cervical, and graft site incisions. The internal maxillary artery (IMA) has been proposed as a donor to decrease invasiveness, but its length is insufficient for direct intracranial bypass. We report interposition of a superficial temporal artery (STA) graft for high-flow IMA to middle cerebral artery (MCA) bypass using a middle fossa approach. OBJECTIVE: To assess the feasibility of an IMA–STA graft-MCA bypass using a new middle fossa approach. METHODS: Twelve specimens were studied. A 7.5-cm STA graft was obtained starting 1.5 cm below the zygomatic arch. The calibers of STA were measured. After a pterional craniotomy, the IMA was isolated inside the infratemporal fossa through a craniectomy within the lateral triangle (lateral to the posterolateral triangle) in the middle fossa and transposed for proximal end-to-end anastomosis to the STA. The Sylvian fissure was split exposing the insular segment of the MCA, and an STA-M2 end-to-side anastomosis was completed. Finally, the length of graft vessel was measured. RESULTS: Average diameters of the proximal and distal STA ends were 2.3 ± 0.2 and 2.0 ± 0.1 mm, respectively. At the anastomosis site, the diameter of the IMA was 2.4 ± 0.6 mm, and the MCA diameter was 2.3 ± 0.3 mm. The length of STA graft required was 56.0 ± 5.9 mm. CONCLUSION: The STA can be used as an interposition graft for high-flow IMA–MCA bypass if the STA is obtained 1.5 cm below the zygomatic arch and the IMA is harvested through the proposed approach. This procedure may provide an efficient and less invasive alternative for high-flow EC–IC bypass.

scholarly journals Bonnet Bypass for Left Superficial Temporal Artery Bifurcation to Right Middle Cerebral Artery: 2-Dimensional Operative Video

2019 ◽  
Vol 17 (5) ◽  
pp. E201-E202 ◽  
Author(s):  
Benjamin K Hendricks ◽  
Robert F Spetzler
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Saphenous Vein ◽  
Superficial Temporal Artery ◽  
Video Recording ◽  
Temporal Artery ◽  
Interposition Graft ◽  
Institutional Review ◽  
Bypass Patency ◽  
Pass Through

Abstract A bonnet bypass is a long interposition graft bypass used for extracranial to intracranial revascularization, which is useful in patients who do not have a suitable ipsilateral donor or in whom the ipsilateral donor must be sacrificed. This interposition graft is commonly the radial artery or saphenous vein. The only practical difference in this technique for revascularization is that an interposition graft must pass through the subgaleal space to the contralateral scalp to allow for reimplantation at the desired contralateral point of anastomosis. This patient underwent a bonnet bypass for revascularization of the middle cerebral artery (MCA) perfusion territory utilizing the contralateral superficial temporal artery (STA). A saphenous vein was used as the interposition graft, which was anastomosed to an M2 segment bifurcation. The graft was then temporarily occluded and passed within a calvarial trough to the contralateral frontoparietal region. The graft was then anastomosed to the contralateral STA at a bifurcation to accommodate the graft size mismatch. The patient tolerated the bypass procedure well and demonstrated bypass patency on postoperative angiographic imaging. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Double-Barrel Superficial Temporal Artery-Middle Cerebral Artery Bypass: Can It Be Considered “High-Flow?”

2017 ◽  
Vol 14 (3) ◽  
pp. 288-294 ◽  
Author(s):  
Jacob Cherian ◽  
Visish Srinivasan ◽  
Peter Kan ◽  
Edward AM Duckworth
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
High Flow ◽  
Low Flow ◽  
Flow Probe ◽  
Flow Measurements ◽  
The Impact ◽  
Probe Measurements

Abstract BACKGROUND Traditionally, superficial temporal artery-middle cerebral artery (STA-MCA) bypass uses one STA branch. Its augmentation of flow has classically been described as “low flow.” In a double-barrel STA-MCA bypass, however, both branches of the STA are utilized. Here we hypothesize that this should not be considered “low flow.” OBJECTIVE To review quantitative flow data from our cases and investigate the impact of double-barrel STA-MCA bypass on total flow augmentation, and to assess whether double-barrel STA-MCA bypass might be useful in situations that traditionally demand more complex bypass strategies. METHODS Intraoperative flow probe measurements from STA-MCA bypass cases were retrospectively tabulated and compared. Cut flow and bypass flow measurements were, respectively, taken before and after completion of anastomoses. The higher value was labeled best observed flow (BOF). RESULTS We identified 21 STA-MCA bypass cases with available intraoperative flow probe measurements, of which 17 utilized double-barrel technique. Only 1 STA branch was available in 4 cases. Significantly higher average BOF was seen when utilizing 2 STA branches (69 vs 39 cc/min, P < .001). A majority (9/17) of double-barrel bypasses provided BOF ≥ 65 cc/min (120 cc/min maximum). The single branch bypass maximum BOF was 40 cc/min. CONCLUSION Double-barrel bypass technique significantly enhances STA-MCA flow capacity and may be useful in situations in which a high-flow bypass is needed. The 2 efferent limbs allow flexibility in distributing flow across separate at-risk territories. The method compares favorably to other descriptions of high-flow bypass without the morbidity of graft harvest or an additional cervical incision.

Prolonged/delayed cerebral hyperperfusion in adult patients with moyamoya disease with RNF213 gene polymorphism c.14576G>A (rs112735431) after superficial temporal artery–middle cerebral artery anastomosis

2020 ◽  
pp. 1-8
Author(s):  
Ryosuke Tashiro ◽  
Miki Fujimura ◽  
Masahito Katsuki ◽  
Taketo Nishizawa ◽  
Yasutake Tomata ◽  
...  
Keyword(s):  
Genetic Analysis ◽  
Gene Polymorphism ◽  
Intracerebral Hemorrhage ◽  
Middle Cerebral Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Adult Patients ◽  
Cerebral Hyperperfusion

OBJECTIVESuperficial temporal artery–middle cerebral artery (STA-MCA) anastomosis is the standard surgical management for moyamoya disease (MMD), whereas cerebral hyperperfusion (CHP) is one of the potential complications of this procedure that can result in delayed intracerebral hemorrhage and/or neurological deterioration. Recent advances in perioperative management in the early postoperative period have significantly reduced the risk of CHP syndrome, but delayed intracerebral hemorrhage and prolonged/delayed CHP are still major clinical issues. The clinical implication of RNF213 gene polymorphism c.14576G>A (rs112735431), a susceptibility variant for MMD, includes early disease onset and a more severe form of MMD, but its significance in perioperative pathology is unknown. Thus, the authors investigated the role of RNF213 polymorphism in perioperative hemodynamics after STA-MCA anastomosis for MMD.METHODSAmong 96 consecutive adult patients with MMD comprising 105 hemispheres who underwent serial quantitative cerebral blood flow (CBF) analysis by N-isopropyl-p-[123I]iodoamphetamine SPECT after STA-MCA anastomosis, 66 patients consented to genetic analysis of RNF213. Patients were routinely maintained under strict blood pressure control during and after surgery. The local CBF values were quantified at the vascular territory supplied by the bypass on postoperative days (PODs) 1 and 7. The authors defined the radiological CHP phenomenon as a local CBF increase of more than 150% compared with the preoperative values, and then they investigated the correlation between RNF213 polymorphism and the development of CHP.RESULTSCHP at POD 1 was observed in 23 hemispheres (23/73 hemispheres [31.5%]), and its incidence was not statistically different between groups (15/41 [36.6%] in RNF213-mutant group vs 8/32 [25.0%] in RNF213–wild type (WT) group; p = 0.321). CHP on POD 7, which is a relatively late period of the CHP phenomenon in MMD, was evident in 9 patients (9/73 hemispheres [12.3%]) after STA-MCA anastomosis. This prolonged/delayed CHP was exclusively observed in the RNF213-mutant group (9/41 [22.0%] in the RNF213-mutant group vs 0/32 [0.0%] in the RNF213-WT group; p = 0.004). Multivariate analysis revealed that RNF213 polymorphism was significantly associated with CBF increase on POD 7 (OR 5.47, 95% CI 1.06–28.35; p = 0.043).CONCLUSIONSProlonged/delayed CHP after revascularization surgery was exclusively found in the RNF213-mutant group. Although the exact mechanism underlying the contribution of RNF213 polymorphism to the prolonged/delayed CBF increase in patients with MMD is unclear, the current study suggests that genetic analysis of RNF213 is useful for predicting the perioperative pathology of patients with MMD.

A 1-Donor 2-Recipient Superficial Temporal Artery-Middle Cerebral Artery Bypass for Moyamoya Syndrome: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Nickalus R Khan ◽  
Jacques J Morcos
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Artery Bypass ◽  
Superficial Temporal Artery ◽  
Temporal Artery ◽  
Surgical Anatomy ◽  
Large Area ◽  
Ischemic Disease ◽  
Near Occlusion ◽  
Direct Bypass

Abstract We present the case of a 34-yr-old male who suffered repeated ischemic events resulting in right-sided weakness. He was found to have left M1 segment near occlusion on angiography with a large area of uncompensated hypoperfusion. The patient underwent a direct superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Direct bypass in the acute setting of ischemia has been previously described.1-5 Moyamoya ischemic disease can be treated with either direct or indirect surgical revascularization. There have been several techniques developed for direct bypasses in moyamoya ischemic disease. These include the standard 1-donor 1-recipient (1D1R) end-to-side (ES) bypass, the “double-barrel” 2-donor 2-recipient (2D2R) ES bypass, and the more recently developed 1-donor 2-recipient (1D2R)6,7 utilizing both an ES and a side-to-side (SS) bypass with a 1-donor vessel. The case presentation, surgical anatomy, decision-making, operative nuances, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video.

Sign in / Sign up

Export Citation Format

Share Document