Tailored Communicating Bypass for the Management of Complex Anterior Communicating Artery Aneurysms: “Flow-Counteraction” In Situ Bypass and Interposition Bypass Using Contralateral A2 Orifice as Donor Site

2020 ◽  
Vol 19 (2) ◽  
pp. 117-125
Author(s):  
Xuan Wang ◽  
Xiaoguang Tong ◽  
Jie Liu ◽  
Minggang Shi ◽  
Yanguo Shang ◽  
...  
Keyword(s):  
Bypass Surgery ◽  
Donor Site ◽  
Anterior Communicating Artery ◽  
Bypass Patency ◽  
Complete Obliteration ◽  
Practical Algorithm ◽  
In Situ Bypass ◽  
The Sacrifice ◽  
Reconstruction Option

Abstract BACKGROUND The use of bypass surgery for anterior communicating artery (ACOM) aneurysms is technically challenging. Communicating bypass (COMB), such as pericallosal artery side-to-side anastomosis, is the most frequently used and anatomically directed reconstruction option. However, in many complex cases, this technique may not afford a sufficient blood supply or necessitate sacrificing the ACOM and the eloquent perforators arising from it. OBJECTIVE To evaluate tailored COMB and propose a practical algorithm for the management of complex ACOM aneurysms. METHODS For 1 patient with an aneurysm incorporating the entire ACOM, conventional in Situ A3-A3 bypass was performed as the sole treatment in order to create competing flow for aneurysm obliteration, sparing the sacrifice of eloquent perforators. In situations in which A2s were asymmetric in the other case, the contralateral A2 orifice was selected as the donor site to provide adequate blood flow by employing a short segment of the interposition graft. RESULTS The aneurysm was not visualized in patients with in Situ A3-A3 bypass because of the “flow-counteraction” strategy. The second patient, who underwent implementation of the contralateral A2 orifice for ipsilateral A3 interposition bypass, demonstrated sufficient bypass patency and complete obliteration of the aneurysm. CONCLUSION The feasibility of conventional COMB combined with complete trapping may only be constrained to selected ideal cases for the treatment of complex ACOM aneurysms. Innovative modifications should be designed in order to create individualized strategies for each patient because of the complexity of hemodynamics and the vascular architecture. Flow-counteraction in Situ bypass and interposition bypass using the contralateral A2 orifice as the donor site are 2 novel modalities for optimizing the advantages and broadening the applications of COMB for the treatment of complex ACOM aneurysms.

BYPASS SURGERY FOR COMPLEX BRAIN ANEURYSMS

Neurosurgery ◽  
2009 ◽  
Vol 65 (4) ◽  
pp. 670-683 ◽  
Author(s):  
Nader Sanai ◽  
Zsolt Zador ◽  
Michael T. Lawton
Keyword(s):  
Middle Cerebral Artery ◽  
Scale Score ◽  
Cerebral Artery ◽  
Glasgow Outcome Scale ◽  
Bypass Surgery ◽  
Unruptured Aneurysms ◽  
Bypass Patency ◽  
Cerebellar Artery ◽  
Brain Aneurysms

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.

A3-A3 Bypass Surgery for Aneurysm: Technical Nuances

2018 ◽  
Vol 17 (3) ◽  
pp. 277-285 ◽  
Author(s):  
Florina-Nicoleta Grigore ◽  
Sepideh Amin-Hanjani
Keyword(s):  
Bypass Surgery ◽  
Relevant Literature ◽  
Cerebral Aneurysms ◽  
Patient Positioning ◽  
Technical Difficulty ◽  
Senior Author ◽  
Anterior Communicating Artery ◽  
Relative Depth ◽  
Bypass Procedure

Abstract BACKGROUND Cerebral bypass remains important for the treatment of complex cerebral aneurysms including dissecting, giant, and fusiform aneurysms not amenable to endovascular treatment or simple clip ligation. For such aneurysms involving the anterior communicating artery complex or its branches, distal anterior cerebral artery (ACA) A3-A3 side-to-side bypass represents a valuable treatment option. Distal ACA in situ anastomosis is recognized to be technically demanding mainly due to the relative depth and narrowness of the interhemispheric surgical corridor and type of anastomosis. OBJECTIVE To demonstrate technical nuances of A3-A3 side-to-side in situ bypass surgery through case illustrations and operative videos. METHODS Elements of the procedure relating to positioning, approach, and anastomosis which have evolved in the operative technique of the senior author were collated based on review of clinical case material, imaging and video recordings of ACA aneurysms treated with side-to-side in situ A3-A3 bypass procedure. Technical elements were contrasted with relevant literature. RESULTS Nuances relative to patient positioning, selection of craniotomy variants, adjunctive intraoperative tools and microsurgical nuances of the side-to-side bypass procedure are reviewed. Three illustrative operative video cases, along with illustrations, are provided to complement the description of the nuances. CONCLUSION In the light of the inherent technical difficulty, as well as the rather limited case volumes, the technical tips provided may contribute to bringing additional refinement and simplicity to the A3-A3 bypass procedure.

scholarly journals Surgical Clipping for Complex Middle Cerebral Artery Aneurysm: Decision-Making Tree With Tailored Bypass Strategy

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Jumpei Oda ◽  
Ichiro Nakahara ◽  
Shoji Matsumoto ◽  
Yoshio Suyama ◽  
Akiko Hasebe ◽  
...  
Keyword(s):  
Decision Making ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Artery Aneurysm ◽  
Operative Strategy ◽  
Mca Aneurysm ◽  
In Situ Bypass

Abstract INTRODUCTION Bypass surgery is important as an effective strategy for complex middle cerebral artery (MCA) aneurysms. Various bypass techniques were reported, but some of them were challenging and difficult to understand. The aim of this report was to propose our simple and flexible method for selecting ideal bypass option and its outcome. METHODS The strategy of bypass surgery is modified by a consideration of the anatomical situation as follows: Is it possible to make a flow our route? Is the amount of bypass flow sufficient? How is the location of lateral lenticulostriate artery (LSA)? Is the preservation of M2 branches possible? Modality of bypass surgery consists of (1) standard superficial temporal artery (STA)-middle cerebral artery (MCA) bypass (single/double, M3/4), (2) STA-proximal MCA (single/double, M1/2), (3) high flow bypass, (4) in-situ bypass (MCA-MCA parallels), and (4) interposition bypass. Operative strategy is selected based on our decision making tree. RESULTS Between 2015 and 2018, we experienced 280 cases (70 ruptured, 210 unruptured) of direct surgery for cerebral aneurysms. Of these cases, the MCA aneurysm accounted for 40% (112 cases). Among these, revascularization was required in 10 cases of complex anatomy. Strategy of bypass surgery included the following: STA-proximal MCA (M1) single bypass: 1 case, STA-proximal MCA (M2) single bypass: 3 cases, STA-proximal MCA (M2) double bypass: 3 cases, STA-distal MCA (M3-4): 1 case, and MCA-MCA in situ bypass: 2 cases (include combination bypass). Patency of bypass was 96% and neurological worsening that caused by surgery was 20% with no operative mortality. CONCLUSION Our decision-making tree with tailored bypass strategy is reasonable and will help select an optimal strategy for the complex MCA aneurysm surgery.

A New Endoscopic Valvulotome for In Situ Bypass Surgery

1992 ◽  
pp. 342-355
Author(s):  
Arshad Quadri ◽  
Parviz Sadhigi ◽  
Richard M. Basile
Keyword(s):  
Bypass Surgery ◽  
In Situ Bypass

In Situ Bypass in the Management of Complex Intracranial Aneurysms: Technique Application in 13 Patients

2005 ◽  
Vol 57 (suppl_1) ◽  
pp. 140-145 ◽  
Author(s):  
Alfredo Quiñones-Hinojosa ◽  
Michael T. Lawton
Keyword(s):  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Artery Bypass ◽  
Temporal Artery ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Donor Artery ◽  
In Situ Bypass ◽  
Pica Aneurysms

Abstract OBJECTIVE: Cerebral revascularization is an important part of the treatment of complex intracranial aneurysms that require deliberate occlusion of a parent artery. In situ bypass brings together intracranial donor and recipient arteries that lie parallel and in close proximity to one another rather than using an extracranial donor artery. An experience with in situ bypasses was retrospectively reviewed. METHODS: Thirteen aneurysms were treated with in situ bypasses between 1997 and 2004. During this time, 1071 aneurysms were treated microsurgically and 46 bypasses were performed as part of the aneurysm treatment. RESULTS: Treated aneurysms were located at the middle cerebral artery (MCA) in five patients, posteroinferior cerebellar artery (PICA) in three patients, vertebral artery in three patients, and anterior communicating artery in two patients. Seven aneurysms were fusiform or dolichoectatic, and six aneurysms were saccular. Microsurgical revascularization techniques included side-to-side anastomosis of intracranial arteries in eight patients and aneurysm excision with end-to-end reanastomosis of the parent artery in five patients. In situ bypasses included A3–A3 anterior cerebral artery bypass in two patients, anterior temporal artery-MCA bypass in one patient, MCA–MCA bypass in one patient, and PICA–PICA bypass in four patients. Aneurysm excision with arterial reanastomosis included three MCA aneurysms and two PICA aneurysms. On angiography, all aneurysms were completely obliterated and 12 bypasses were patent. CONCLUSION: In situ bypass is a safe and effective alternative to extracranial-intracranial bypasses and high-flow bypasses using saphenous vein or radial artery grafts. Although in situ bypasses are more demanding technically, they do not require harvesting a donor artery, can be accomplished with one anastomosis, and are less vulnerable to injury or occlusion.

Saphenous vein In situ bypass

1990 ◽  
Vol 160 (3) ◽  
pp. 294-299 ◽  
Author(s):  
David R. Knighton ◽  
Steve Santilli ◽  
David Hunter
Keyword(s):  
Saphenous Vein ◽  
In Situ Bypass

Abstract 126: Comparison of Flow Diversion and Coiling in Large Unruptured Intracranial Saccular Aneurysms

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Nohra Chalouhi ◽  
Stavropoula Tjoumakaris ◽  
Robert M Starke ◽  
L Fernando Gonzalez ◽  
Ciro Randazzo ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Multivariable Analysis ◽  
Flow Diversion ◽  
Similar Proportion ◽  
Anterior Communicating Artery ◽  
Patient Age ◽  
Aneurysm Size ◽  
Patient Âgé ◽  
Complete Obliteration ◽  
Saccular Aneurysms

Background and purpose: Flow diversion has emerged as an important tool for management of intracranial aneurysms. The purpose of this study was to compare flow diversion and traditional embolization strategies in terms of safety, efficacy, and clinical outcomes in patients with unruptured, large saccular aneurysms (≥ 10 mm). Methods: Forty patients treated with the Pipeline Embolization Device (PED) were matched in a 1:3 fashion with 120 patients treated with coiling based on patient age and aneurysm size. Fusiform and anterior communicating artery aneurysms were eliminated from the analysis. Procedural complications, angiographic results, and clinical outcomes were analyzed and compared. Results: There were no differences between the 2 groups in terms of patient age, gender, aneurysm size, and aneurysm location. The rate of procedure-related complications did not differ between the PED (7.5%) and the coil group (7.5% p=1). At the latest follow-up, a significantly higher proportion of aneurysms treated with PED (86%) achieved complete obliteration compared to coiled aneurysms (41%, p<0.001). In multivariable analysis, coiling was an independent predictor of nonocclusion. Retreatment was necessary in fewer patients in the PED group (2.8%) than the coil group (37%, p<0.001). A similar proportion of patients attained a favorable outcome (mRS 0-2) in the PED group (92%) and the coil group (94%, p=0.8). Conclusion: The PED provides higher aneurysm occlusion rates than coiling, with no additional morbidity and similar clinical outcomes. These findings suggest that the PED is a preferred treatment option for large unruptured saccular aneurysms.

Femorodistal in situ bypass

1994 ◽  
pp. 298-312
Author(s):  
R. W. H. van Reedt Dortland ◽  
B. C. Eikelboom
Keyword(s):  
In Situ Bypass
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