Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior... Abstract BACKGROUND Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch. OBJECTIVE To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization. METHODS Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients. RESULTS Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization. CONCLUSION The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option. Revascularization, Bypass, Cerebrovascular surgery ABBREVIATIONS ABBREVIATIONS DLCFA descending branch of the lateral circumflex femoral artery MCA middle cerebral artery MRI magnetic resonance imaging OA occipital artery PICA posterior inferior cerebellar artery RAGs radial artery grafts STA superficial temporal artery SVGs saphenous vein grafts VA vertebral artery Yasargil first introduced cerebral revascularization nearly 4 decades ago, and its use has become increasingly prevalent.1 Currently, cerebral bypass serves as an important tool in the management of complex intracranial aneurysms, moyamoya disease, and to a lesser extent symptomatic carotid occlusion.2,3 Several considerations must be accounted for during surgical planning for cerebral bypass, including vessel graft selection. The appropriate graft depends on factors such as flow requirement, graft accessibility, harvest risk, and long-term patency rates.4 Initial studies focused on radial artery grafts (RAGs), saphenous vein grafts (SVGs), and superficial temporal artery (STA) grafts, though to date numerous other vessels have been described as suitable donors.5-7 RAGs and SVGs have been by far the most popular revascularization grafts, with RAGs generally preferred for cerebral bypass due to higher patency rates than venous grafts.8 Posterior inferior cerebral artery (PICA) revascularization can nonetheless be achieved with relative ease and without a graft when a contralateral PICA is present. However, in cases when a contralateral PICA is not viable, identification of an appropriately sized graft is challenging. High-flow grafts such as the RAG or SVG can be problematic due to size mismatch incompatibility.8 Some authors favor the occipital artery (OA) in these circumstances. However, it has been our experience that the OA is tedious to dissect, which can extend operative time and risk graft spasm or injury. Additionally, other authors have cited relatively high complication rates when using the OA for revascularization.9 TABLE. Clinical Summary of 3 Patients Undergoing PICA Revascularization With DBLCFA Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Abbreviations: ASA: anterior spinal artery; mRS: modified Rankin Scale; PICA: posterior inferior cerebellar artery; VA: vertebral artery; View Large TABLE. Clinical Summary of 3 Patients Undergoing PICA Revascularization With DBLCFA Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Abbreviations: ASA: anterior spinal artery; mRS: modified Rankin Scale; PICA: posterior inferior cerebellar artery; VA: vertebral artery; View Large Utilization of a descending branch of the lateral circumflex femoral artery (DLCFA) graft for myocardial revascularization and free flap tissue reconstruction is well described.10-13 A single case report in the neurosurgical literature describes the use of the DLCFA graft for middle cerebral artery (MCA) revascularization in the absence of an acceptable RAG.6 We report employing the DLCFA for PICA revascularization. Due to its size, relatively low harvest risk and accessibility, we propose the DLCFA to be an acceptable, if not preferred, arterial graft for PICA revascularization. METHODS We performed a retrospective analysis of prospectively collected data for patients undergoing extracranial–intracranial bypass with DLCFA grafts (n = 3). We recorded clinical and radiographic data for each patient, including demographics, date of surgery, indication for surgery, presenting neurological exam, ischemic events including preoperative, perioperative, and postoperative stroke, temporary clip time, vasospasm, graft spasm, graft patency on postoperative angiogram, modified Rankin scale at time of follow-up, and duration of follow-up. Radiographic data included preoperative and postoperative computed tomography angiogram, diagnostic cerebral angiogram, and magnetic resonance imaging (MRI). Patients in this series were considered for PICA revascularization using a DLFCA high-flow graft only if a suitable contralateral PICA was not available for direct PICA-PICA bypass. The exact location for graft take-off and landing was made on a case-by-case basis based on the patient's vascular pathology. The surgical technique for graft harvest and an example PICA revascularization is presented below as a Case Presentation. RESULTS Clinical Data Summary and Neurological Outcomes Table summarizes the patient demographics, procedure, and outcomes. Patient 1 was found to have a ruptured PICA aneurysm in the lateral medullary segment. The patient had an extradural origin of the ipsilateral PICA and underwent an extradural PICA to tonsillar PICA bypass using the DLCFA followed by occlusion proximal to the aneurysm. This procedure was complicated by a hematoma at the DLCFA harvest site that required evacuation. Her hospital course was also notable for symptomatic vasospasm, including the DLCFA graft, requiring multiple intra-arterial treatments. The patient was able to avoid any ischemic complications of vasospasm and remained neurologically intact at discharge and on 7-mo follow-up. MRI at delayed follow-up demonstrated no major PICA strokes. Patient 2 presented with a ruptured fusiform aneurysm of the proximal PICA and was treated with a V4-PICA bypass using the DLCFA. The patient's hospital course was also complicated by symptomatic vasospasm. However, the graft remained patent without spasm and she avoided any ischemic complications from vasospasm. At 3-mo follow-up the patient was asymptomatic and neurologically intact. Patient 3 presented with a ruptured fusiform vertebral artery (VA) aneurysm with the PICA originating from the aneurysmal segment. The patient was treated with a V3-PICA bypass using a DLCFA. The patient then underwent aneurysm coiling with preservation of the VA. Postoperatively, the patient suffered severe diffuse vasospasm (including the bypass graft), requiring multiple intra-arterial treatments, although the graft remained patent on 2-wk postoperative vascular imaging. Unfortunately, the aneurysmal VA expanded after initial endovascular treatment and required complete vessel sacrifice 1-wk postintervention. This endovascular procedure was complicated by anterior spinal artery thrombosis resulting in complete quadriplegia. Case Presentation History A 57-yr-old old female presented 5 d after experiencing the worst headache of her life. The patient had a diagnostic angiogram that was significant for a fusiform aneurysm of the proximal left PICA. The patient had mild vasospasm and treatment was deferred until she was out of the vasospasm period. On postbleed day 14, the patient was taken to the operating room for revascularization of the distal PICA and proximal occlusion (Figures 1 and 2, and Video, Supplemental Digital Content). FIGURE 1. View largeDownload slide Preoperative 3-dimensaional CT-angiogram demonstrating a fusiform aneurysm of the proximal left PICA. FIGURE 1. View largeDownload slide Preoperative 3-dimensaional CT-angiogram demonstrating a fusiform aneurysm of the proximal left PICA. FIGURE 2. View largeDownload slide Postoperative imaging after a V4-PICA bypass using a DLCFA graft. A–B, Serial anterior–posterior images of a right vertebral postoperative angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. The distal right vertebral was stenotic preoperatively, with distal flow/washout largely unchanged from preoperative angiogram. C, Anterior–posterior images of a left vertebral postoperative angiogram demonstrating patency of the left vertebral artery and occlusion of the fusiform proximal left PICA aneurysm. D, Postoperative 3-dimensional CT angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. Arterial blips are imaging artifact from vessel clips. E, Postoperative MRI demonstrating no postoperative ischemia. FIGURE 2. View largeDownload slide Postoperative imaging after a V4-PICA bypass using a DLCFA graft. A–B, Serial anterior–posterior images of a right vertebral postoperative angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. The distal right vertebral was stenotic preoperatively, with distal flow/washout largely unchanged from preoperative angiogram. C, Anterior–posterior images of a left vertebral postoperative angiogram demonstrating patency of the left vertebral artery and occlusion of the fusiform proximal left PICA aneurysm. D, Postoperative 3-dimensional CT angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. Arterial blips are imaging artifact from vessel clips. E, Postoperative MRI demonstrating no postoperative ischemia. Procedures Craniotomy and Bypass Procedure The patient was placed in the park bench position with the right side up, right shoulder forward, head turned to the left, and the chin tucked. A midline incision from the inion to the spinous process of C2 was used. A standard suboccipital craniotomy was performed and the tonsillar loop of the left PICA was dissected out. The contralateral PICA was explored and was unfavorably positioned for a traditional PICA–PICA bypass. The V4 segment was then prepared as a donor and the patient was placed in burst suppression. Systolic blood pressure was maintained 10 to 20 points above baseline during temporary occlusion. The DLCFA was then anastomosed in an end-to-side fashion to the right V4 segment using 9.0 nylon interrupted sutures. There was good flow into the graft after the anastomosis, and it was heparinized and occluded with a temporary aneurysm clip. The distal end of the DLCFA was then anastomosed to the tonsillar loop of the left PICA using interrupted 10.0 nylon. The left V4 segment was then explored, and the origin of the aneurysmal segment of the PICA was identified and occluded with a permanent aneurysm clip. The DLCFA was then allowed to perfuse with good pulsatility. The aneurysmal segment was further explored and the rupture site was clipped with care not to occlude any perforating arteries or the PICA itself so that the more proximal perforators would not be trapped and could be irrigated in a retrograde fashion by the bypass. The temporary clip ischemia time for this case was 45 min, with an average across all three anastomoses of 36.6 min (range 30-45 min). Vessel Harvest Technique The harvest of the DLCFA was performed in parallel with the craniotomy by a separate plastic surgery team. The vessel harvest was performed in a similar fashion in all cases. Once the patient was positioned and the craniotomy had begun, the vessel harvest team made an incision over the lateral aspect of the midfemur (Figure 3A). The interval between the rectus femoris and the vastus lateralis was then identified (Figure 3B). Careful dissection was used to identify the DLCFA in the extra muscular position. An 8 to 10 cm sample was prepared with protection of the side branches and attention to atraumatic dissection of the vessel in all cases (Figure 3C). The graft was harvested as an arterial pedicle, in some cases with associated veins in an attempt to further minimize vessel manipulation. After harvest, the vessel was transferred to the craniotomy surgical site where further microvascular dissection and eventual anastomosis was performed. FIGURE 3. View largeDownload slide Harvest of DLFCA graft. A, DLCFA harvest begins with an incision over the lateral aspect of the midfemur. B, Dissection is continued between the rectus femoris and the vastus lateralis. C, An 8 to 10 cm graft, consisting of the arterial pedicle with 2 associated veins is harvested for transfer to the craniotomy site for microvascular anastomosis. FIGURE 3. View largeDownload slide Harvest of DLFCA graft. A, DLCFA harvest begins with an incision over the lateral aspect of the midfemur. B, Dissection is continued between the rectus femoris and the vastus lateralis. C, An 8 to 10 cm graft, consisting of the arterial pedicle with 2 associated veins is harvested for transfer to the craniotomy site for microvascular anastomosis. DISCUSSION A critical challenge of cerebral revascularization surgery is choosing an appropriate reconstructive strategy for any given lesion and its downstream at risk territory. The PICA circulation is considered a low-flow system with multiple reconstructive options based on lesion location.14 Three patients in this series had proximal PICA or VA/PICA lesions, which in patients with a suitable contralateral PICA are typically treated with a direct side-to-side anastomosis.14 When PICA–PICA bypass is not possible, other revascularization options include aneurysm resection and arterial reanastomosis or reimplantation, and bypass.14 In the senior author's experience, direct reanastomosis or reimplantation in the neurovascularly dense posterior fossa is nonetheless challenging, especially as it can require mobilization of the PICA in segments containing brainstem perforators. Surgical bypass is thus typically pursued in this situation at our institution. The OA is the main in situ low-flow donor for PICA bypass due to it anatomic proximity and requirement for only 1 anastomosis site. The OA is not ideally suited for this use, however, as it is anatomically complex, difficult to dissect, and a relative size mismatch to the PICA (anatomic studies show the PICA has a diameter of 1.84 ± 0.45 mm at the origin, which decreases to 1.68 ± 0.38 mm at the tonsillar loop, yet OA diameters range from 2.3 to 2.7 mm).3,8,15-17 While interposition grafts add a second anastomosis site, they have a more consistent anatomy that facilitates harvest and can be tailored to the specific revascularization need. SVGs have been used for revascularization of the posterior fossa18 but are typically reserved for recipient vessels larger than the PICA. The RAG is the main donor vessel used for interposition graft PICA revascularization,14,19-21 although similar to the OA its diameter ranges from 2.5 to 3.7 mm. This presents a potential size mismatch, particularly at the tonsillar PICA loops where anastomoses are commonly performed.5,22 Furthermore, RAGs are prone to expand after anastomosis, possibly from denervation of the graft after harvest, compounding any diameter mismatch with the PICA.8 While such graft expansion may be favorable for bypass in high flow settings, it is not needed for PICA revascularization as long-term declines in graft flow in this system are likely to be compensated for by collateralization. Donor–recipient size mismatches may also lead to flow mismatches or local increases in perfusion above baseline, the latter of which has been linked to an increased risk of hyperperfusion complications.23 The DLCFA graft, which has been previously described in the cardiothoracic and plastic surgery literature as a reliable and effective alternative for myocardial revascularization and various free flaps,10-13 is also particularly well suited for PICA revascularization. Avoiding the size mismatch issues of the RAG, the DLCFA is 3 mm at its origin and remains stable at 2 mm for up to 12 to 15 cm along its course in the thigh, allowing harvest of a graft more closely size matched to the PICA.12,13,24 Additionally, the DLFCA harvest site is farther from the cranial surgical field than the RAG, allowing for an unobtrusive parallel harvest by a separate surgical team. It also has surrounding musculature with an abundant collateral supply that limits harvest site ischemia and requires a harvest incision that is relatively more cosmetic than that of the RAG as it is on a body surface that is typically covered. Compared to the RAG where harvest site complications can affect upper extremity function,25 the DLCFA is generally considered a safe graft for harvest. There was 1 minor complication related to DLCFA graft harvest in this series, a surgical site hematoma that required secondary evacuation, but no major complications or neurological injuries. This is consistent with published data on DLCFA harvest from the cardiovascular literature, where the only reported harvest site complication in a series of 147 patients with a nearly 2-yr average follow-up was transient thigh dysesthesias in 4% of patients.11 However, as most neurosurgeons lack operative experience with the anterior thigh vasculature, and plastic surgeons are familial with DLCFA harvest as part of commonly used anteriolateral thigh flaps, a multispecialty approach to DLCFA bypass procedures is prudent and recommend by the authors. The DLCFA also has potential patency advantages as compared to the RAG, as it is resistant to atherosclerotic changes that can decrease graft patency and promote spasm.26-28 In this small series, however, 2 of 3 patients (66%) developed graft spasm. While this is higher than the reported spasm risk associated with RAGs for cerebral bypass,29,30 these findings differ from larger scale cardiac surgery data suggesting that DLCFA grafts have relatively high patency rates and a low incidence of spasm.11,13 The true spasm risk with DLCFA grafts for PICA revascularization is thus likely lower than observed herein. Spurred by this clinical experience, we are nonetheless actively developing novel antispasm regimens to address this need. Given the small n and relatively short follow-up in this series, a more exact delineation of the spasm incidence and long-term patency rates of DLCFA grafts for PICA bypass will need to be assessed in future studies. Despite the potential advantages of the DLCFA for appropriately selected cerebral bypass cases, there is only 1 previous case of DLCFA graft bypass in the neurosurgical literature.6 Baskaya et al6 reported the successful management of a large suprasellar fusiform aneurysm with harvest of the DLCFA for anastomosis of the M2 segment of the MCA to the external carotid artery. The DLCFA was selected in this case, as opposed to a RAG, because of an arterial thrombosis in the RAG from multiple arterial line attempts and a failure of Allen's test on the contralateral side. Furthermore, the STA was compromised from a previous craniotomy and the SVG was considered to be a vessel flow mismatch. The DLCFA was harvested in the same manner as described in our case. While this was an elegant solution to the authors’ difficult case, the authors feel that the DLCFA was a rescue graft in this setting. First, the larger diameter of the RAG is a better size match for M2 anastomosis. Second, as high-flow grafts are typically designed as flow replacement for the entire ICA, the smaller diameter of the DLCFA makes it a less favorable choice than the RAG as a high-flow option for the anterior circulation. While the DLCFA was only used for PICA revascularization in this series, its success in this setting suggests it could be considered as an interposition graft option for other low-flow revascularization cerebral bypass needs. CONCLUSION Cerebral revascularization surgeries requiring harvest of a graft must account for several factors. Matching the size of the donor to the recipient vessel is vital to success of the graft. PICA revascularization in which the contralateral PICA is absent or nonsuitable for bypass requires an alternative vessel. Prior studies have identified RAGs for use in this setting; however, we suggest that the DLCFA is a more ideal vessel choice as it is a better match for size and vessel flow, is readily accessible, and has demonstrated acceptable patency. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Yasargil MG, Krayenbuhl HA, Jacobson JH, 2nd. Microneurosurgical arterial reconstruction. J Korean Neurosurg Soc . 1970; 67( 1): 121- 129. 2. Lee CY, Kim CH, Lee CY, Sohn SI, Hong JH. Urgent bypass surgery following failed endovascular treatment in acute symptomatic stroke patient with MCA occlusion. Neurologist . 2017; 22( 1): 14- 17. Google Scholar CrossRef Search ADS PubMed  3. Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation. J Neurosurg . 2005; 102( 1): 132- 147. 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Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery . 2001; 49( 3): 646- 658; discussion 658-649. Google Scholar PubMed  Supplemental digital content is available for this article at www.operativeneurosurgery-online.com. Supplemental Digital Content Video Supplemental Digital Content Video Close COMMENTS The authors present their skillful management of 3 VA aneurysms requiring revascularization procedures as part of their treatment, using the lateral femorocutaneous artery (DLCFA) as an interposition graft between the VA and PICA. As the authors recognized, other techniques for revascularization of that segment exist, but were not considered an option in the cases presented due to mismatch or previous negative experience. Graft selection, particularly when interposition grafts are needed, are key to the success and durability of a by-pass, and vessel wall structure (ie, arterial vs venous graft) and caliber matching are perhaps the 2 most important attributes aside from indication and technique1. In alignment with those tenets, the DLCFA appears a reasonable choice as an interposition graft, as documented in these masterfully executed cases. Even though this report introduces yet another valuable resource for by-pass grafting, consideration should be given in the selection process to the added time required for graft harvesting in a remote site where neurosurgeons are usually unfamiliar with the anatomy, risk of injury of the femoral nerve as the LCFA passes between its divisions, as well as increased surgical time and risk of bypass failure associated with 2 anastomosis sites versus a more direct approach using a local donor and a single anastomosis. In cases similar to the ones reported and a bypass has been deemed necessary, we have had success with a modified version of the occipital-vertebral artery (OA-VA) bypass as described by Spetzler et al2,3, or PICA-PICA anastomosis when those have been suitable. We have also been able to use a radial or ulnar graft in other cases. The current report introduces an alternative conduit when none of the above techniques are possible. This report underscores the value of cerebral revascularization techniques and highlight their role in the armamentarium of therapies available for the treatment of these unique, challenging cerebrovascular lesions. The authors should be congratulated for their skill and resourceful approach to the treatment of these complex lesions in an unfavorable context. Norberto Andaluz Cincinnati, Ohio 1. Kocaeli H, Andaluz N, Choutka O, Zuccarello M. Use of radial artery grafts in extracranial-intracranial revascularization procedures. Neurosurg Focus  2008; 24 ( 2): E5. Google Scholar CrossRef Search ADS PubMed  2. Spetzler RF, Hadley MN, Martin NA, Hopkins LN, Carter LP, Budny J. Vertebrobasilar insufficiency. Part 1: Microsurgical treatment of extracranial vertebrobasilar disease. J Neurosurg  1987; 66( 5): 648- 61. Google Scholar CrossRef Search ADS PubMed  3. Hadley MN, Spetzler RF, Masferrer R, Martin NA, Carter LP. Occipital artery to extradural vertebral artery bypass procedure. Case report. J Neurosurg  1985; 63( 4): 622- 5. Google Scholar CrossRef Search ADS PubMed  In this manuscript, the authors report 3 cases of revascularization using a descending branch of the lateral circumflex femoral artery (DLCFA) graft for a ruptured PICA aneurysm, in which the contralateral PICA was not available. This short paper provides a concise description of the procedure and is supported by an excellent video, in which we see the surgeon's delicate and skillful technique. When treating fusiform PICA aneurysms, it is a welcome addition to a vascular neurosurgeon's armamentarium to know that using a DLCFA is feasible in order to ensure a proper vessel caliber match when the contralateral PICA is not available. The fact that harvesting the DLCFA may be performed by a separate specialized team while the neurosurgical team proceeds with exposure, saves time and simplifies the procedure for the neurosurgeon. Although the goal of the authors was to demonstrate the feasibility of using DLCFA, which was skillfully achieved, one can not conclude as to its efficacy in this small series. Nor can one generalize as to its indication in all fusiform PICA aneurysms. Spontaneous anastomosis via collateral circulation plays a significant role in supplying the cerebellum in cases of PICA occlusion. Endovascular treatment of ruptured fusiform PICA aneurysms by occlusion of both the aneurysm and the parent vessel distal to its origin, resulted most of the time, in absence of, or minor stroke1,2. In the present series, although it is reported that in 1 case there was no “major” stroke, no information is given regarding the occurrence of ischemic complications as assessed by imagery in all 3 cases. Although a bypass is certainly essential in some cases, studying the collateral circulation may help to evaluate its indication. It is also important to consider the possibility that surgery itself may contribute towards clinical, symptomatic vasospasm3,4, which occurred in all cases in this series. Michel W. Bojanowski Montreal, Canada 1. Maimon S, Saraf-Lavi E, Rappaport ZH, Bachar G. Endovascular Treatment of Isolated Dissecting Aneurysm of the Posterior Inferior Cerebellar Artery. Am J Neuroradiol  2006; 27: 527- 32. Google Scholar PubMed  2. Ionnidis I, Nasis N, Andreou A. Dissecting Posterior Inferior Cerebellar Artery Aneurysms. Interventional Neuroradiology  2012; 18: 442- 448. Google Scholar CrossRef Search ADS PubMed  3. Rabinstein AA, Pichelmann MA, Friedman JA et al. Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion. J Neurosurg  2003; 98: 319- 325. Google Scholar CrossRef Search ADS PubMed  4. Yalamanchili K, Rosenwasser RH, Thomas JE, Liebman K, McMorrow C, Gannon P. Frequency of Cerebral Vasospasm in Patients Treated with Endovascular Occlusion of Intracranial Aneurysms. Am J Neuroradiol  1998; 19: 553- 558. Google Scholar PubMed  Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization

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Oxford University Press
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Copyright © 2018 by the Congress of Neurological Surgeons
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2332-4252
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2332-4260
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10.1093/ons/opx241
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Abstract

Abstract BACKGROUND Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch. OBJECTIVE To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization. METHODS Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients. RESULTS Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization. CONCLUSION The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option. Revascularization, Bypass, Cerebrovascular surgery ABBREVIATIONS ABBREVIATIONS DLCFA descending branch of the lateral circumflex femoral artery MCA middle cerebral artery MRI magnetic resonance imaging OA occipital artery PICA posterior inferior cerebellar artery RAGs radial artery grafts STA superficial temporal artery SVGs saphenous vein grafts VA vertebral artery Yasargil first introduced cerebral revascularization nearly 4 decades ago, and its use has become increasingly prevalent.1 Currently, cerebral bypass serves as an important tool in the management of complex intracranial aneurysms, moyamoya disease, and to a lesser extent symptomatic carotid occlusion.2,3 Several considerations must be accounted for during surgical planning for cerebral bypass, including vessel graft selection. The appropriate graft depends on factors such as flow requirement, graft accessibility, harvest risk, and long-term patency rates.4 Initial studies focused on radial artery grafts (RAGs), saphenous vein grafts (SVGs), and superficial temporal artery (STA) grafts, though to date numerous other vessels have been described as suitable donors.5-7 RAGs and SVGs have been by far the most popular revascularization grafts, with RAGs generally preferred for cerebral bypass due to higher patency rates than venous grafts.8 Posterior inferior cerebral artery (PICA) revascularization can nonetheless be achieved with relative ease and without a graft when a contralateral PICA is present. However, in cases when a contralateral PICA is not viable, identification of an appropriately sized graft is challenging. High-flow grafts such as the RAG or SVG can be problematic due to size mismatch incompatibility.8 Some authors favor the occipital artery (OA) in these circumstances. However, it has been our experience that the OA is tedious to dissect, which can extend operative time and risk graft spasm or injury. Additionally, other authors have cited relatively high complication rates when using the OA for revascularization.9 TABLE. Clinical Summary of 3 Patients Undergoing PICA Revascularization With DBLCFA Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Abbreviations: ASA: anterior spinal artery; mRS: modified Rankin Scale; PICA: posterior inferior cerebellar artery; VA: vertebral artery; View Large TABLE. Clinical Summary of 3 Patients Undergoing PICA Revascularization With DBLCFA Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Case  Age/Sex  Indication  Procedure  Initial exam  Stroke at presentation  Perioperative stroke  Postoperative stroke  Recipient vessel  Temporary clip time (min)  Follow-up  mRS at follow-up  Graft spasm  1  51F  Ruptured PICA aneurysm  Extradural PICA-intradural PICA bypass  Intact  No  No  No  Tonsilar loop of PICA  35  1 mo  1  Yes  2  57F  Ruptured PICA aneurysm  V4-PICA bypass  Lethargic, no focal neurological deficit  No  No  No  Tonsilar loop of PICA  45  2 mo  0  No  3  44M  Ruptured VA aneurysm  V3-PICA bypass  Lethargic, no focal neurological deficit  No  No  ASA stroke  Tonsilar loop of PICA  30  1 mo  5  Yes  Abbreviations: ASA: anterior spinal artery; mRS: modified Rankin Scale; PICA: posterior inferior cerebellar artery; VA: vertebral artery; View Large Utilization of a descending branch of the lateral circumflex femoral artery (DLCFA) graft for myocardial revascularization and free flap tissue reconstruction is well described.10-13 A single case report in the neurosurgical literature describes the use of the DLCFA graft for middle cerebral artery (MCA) revascularization in the absence of an acceptable RAG.6 We report employing the DLCFA for PICA revascularization. Due to its size, relatively low harvest risk and accessibility, we propose the DLCFA to be an acceptable, if not preferred, arterial graft for PICA revascularization. METHODS We performed a retrospective analysis of prospectively collected data for patients undergoing extracranial–intracranial bypass with DLCFA grafts (n = 3). We recorded clinical and radiographic data for each patient, including demographics, date of surgery, indication for surgery, presenting neurological exam, ischemic events including preoperative, perioperative, and postoperative stroke, temporary clip time, vasospasm, graft spasm, graft patency on postoperative angiogram, modified Rankin scale at time of follow-up, and duration of follow-up. Radiographic data included preoperative and postoperative computed tomography angiogram, diagnostic cerebral angiogram, and magnetic resonance imaging (MRI). Patients in this series were considered for PICA revascularization using a DLFCA high-flow graft only if a suitable contralateral PICA was not available for direct PICA-PICA bypass. The exact location for graft take-off and landing was made on a case-by-case basis based on the patient's vascular pathology. The surgical technique for graft harvest and an example PICA revascularization is presented below as a Case Presentation. RESULTS Clinical Data Summary and Neurological Outcomes Table summarizes the patient demographics, procedure, and outcomes. Patient 1 was found to have a ruptured PICA aneurysm in the lateral medullary segment. The patient had an extradural origin of the ipsilateral PICA and underwent an extradural PICA to tonsillar PICA bypass using the DLCFA followed by occlusion proximal to the aneurysm. This procedure was complicated by a hematoma at the DLCFA harvest site that required evacuation. Her hospital course was also notable for symptomatic vasospasm, including the DLCFA graft, requiring multiple intra-arterial treatments. The patient was able to avoid any ischemic complications of vasospasm and remained neurologically intact at discharge and on 7-mo follow-up. MRI at delayed follow-up demonstrated no major PICA strokes. Patient 2 presented with a ruptured fusiform aneurysm of the proximal PICA and was treated with a V4-PICA bypass using the DLCFA. The patient's hospital course was also complicated by symptomatic vasospasm. However, the graft remained patent without spasm and she avoided any ischemic complications from vasospasm. At 3-mo follow-up the patient was asymptomatic and neurologically intact. Patient 3 presented with a ruptured fusiform vertebral artery (VA) aneurysm with the PICA originating from the aneurysmal segment. The patient was treated with a V3-PICA bypass using a DLCFA. The patient then underwent aneurysm coiling with preservation of the VA. Postoperatively, the patient suffered severe diffuse vasospasm (including the bypass graft), requiring multiple intra-arterial treatments, although the graft remained patent on 2-wk postoperative vascular imaging. Unfortunately, the aneurysmal VA expanded after initial endovascular treatment and required complete vessel sacrifice 1-wk postintervention. This endovascular procedure was complicated by anterior spinal artery thrombosis resulting in complete quadriplegia. Case Presentation History A 57-yr-old old female presented 5 d after experiencing the worst headache of her life. The patient had a diagnostic angiogram that was significant for a fusiform aneurysm of the proximal left PICA. The patient had mild vasospasm and treatment was deferred until she was out of the vasospasm period. On postbleed day 14, the patient was taken to the operating room for revascularization of the distal PICA and proximal occlusion (Figures 1 and 2, and Video, Supplemental Digital Content). FIGURE 1. View largeDownload slide Preoperative 3-dimensaional CT-angiogram demonstrating a fusiform aneurysm of the proximal left PICA. FIGURE 1. View largeDownload slide Preoperative 3-dimensaional CT-angiogram demonstrating a fusiform aneurysm of the proximal left PICA. FIGURE 2. View largeDownload slide Postoperative imaging after a V4-PICA bypass using a DLCFA graft. A–B, Serial anterior–posterior images of a right vertebral postoperative angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. The distal right vertebral was stenotic preoperatively, with distal flow/washout largely unchanged from preoperative angiogram. C, Anterior–posterior images of a left vertebral postoperative angiogram demonstrating patency of the left vertebral artery and occlusion of the fusiform proximal left PICA aneurysm. D, Postoperative 3-dimensional CT angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. Arterial blips are imaging artifact from vessel clips. E, Postoperative MRI demonstrating no postoperative ischemia. FIGURE 2. View largeDownload slide Postoperative imaging after a V4-PICA bypass using a DLCFA graft. A–B, Serial anterior–posterior images of a right vertebral postoperative angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. The distal right vertebral was stenotic preoperatively, with distal flow/washout largely unchanged from preoperative angiogram. C, Anterior–posterior images of a left vertebral postoperative angiogram demonstrating patency of the left vertebral artery and occlusion of the fusiform proximal left PICA aneurysm. D, Postoperative 3-dimensional CT angiogram demonstrating patency of the right V4 to left PICA bypass, with occlusion of the fusiform proximal left PICA aneurysm. Arterial blips are imaging artifact from vessel clips. E, Postoperative MRI demonstrating no postoperative ischemia. Procedures Craniotomy and Bypass Procedure The patient was placed in the park bench position with the right side up, right shoulder forward, head turned to the left, and the chin tucked. A midline incision from the inion to the spinous process of C2 was used. A standard suboccipital craniotomy was performed and the tonsillar loop of the left PICA was dissected out. The contralateral PICA was explored and was unfavorably positioned for a traditional PICA–PICA bypass. The V4 segment was then prepared as a donor and the patient was placed in burst suppression. Systolic blood pressure was maintained 10 to 20 points above baseline during temporary occlusion. The DLCFA was then anastomosed in an end-to-side fashion to the right V4 segment using 9.0 nylon interrupted sutures. There was good flow into the graft after the anastomosis, and it was heparinized and occluded with a temporary aneurysm clip. The distal end of the DLCFA was then anastomosed to the tonsillar loop of the left PICA using interrupted 10.0 nylon. The left V4 segment was then explored, and the origin of the aneurysmal segment of the PICA was identified and occluded with a permanent aneurysm clip. The DLCFA was then allowed to perfuse with good pulsatility. The aneurysmal segment was further explored and the rupture site was clipped with care not to occlude any perforating arteries or the PICA itself so that the more proximal perforators would not be trapped and could be irrigated in a retrograde fashion by the bypass. The temporary clip ischemia time for this case was 45 min, with an average across all three anastomoses of 36.6 min (range 30-45 min). Vessel Harvest Technique The harvest of the DLCFA was performed in parallel with the craniotomy by a separate plastic surgery team. The vessel harvest was performed in a similar fashion in all cases. Once the patient was positioned and the craniotomy had begun, the vessel harvest team made an incision over the lateral aspect of the midfemur (Figure 3A). The interval between the rectus femoris and the vastus lateralis was then identified (Figure 3B). Careful dissection was used to identify the DLCFA in the extra muscular position. An 8 to 10 cm sample was prepared with protection of the side branches and attention to atraumatic dissection of the vessel in all cases (Figure 3C). The graft was harvested as an arterial pedicle, in some cases with associated veins in an attempt to further minimize vessel manipulation. After harvest, the vessel was transferred to the craniotomy surgical site where further microvascular dissection and eventual anastomosis was performed. FIGURE 3. View largeDownload slide Harvest of DLFCA graft. A, DLCFA harvest begins with an incision over the lateral aspect of the midfemur. B, Dissection is continued between the rectus femoris and the vastus lateralis. C, An 8 to 10 cm graft, consisting of the arterial pedicle with 2 associated veins is harvested for transfer to the craniotomy site for microvascular anastomosis. FIGURE 3. View largeDownload slide Harvest of DLFCA graft. A, DLCFA harvest begins with an incision over the lateral aspect of the midfemur. B, Dissection is continued between the rectus femoris and the vastus lateralis. C, An 8 to 10 cm graft, consisting of the arterial pedicle with 2 associated veins is harvested for transfer to the craniotomy site for microvascular anastomosis. DISCUSSION A critical challenge of cerebral revascularization surgery is choosing an appropriate reconstructive strategy for any given lesion and its downstream at risk territory. The PICA circulation is considered a low-flow system with multiple reconstructive options based on lesion location.14 Three patients in this series had proximal PICA or VA/PICA lesions, which in patients with a suitable contralateral PICA are typically treated with a direct side-to-side anastomosis.14 When PICA–PICA bypass is not possible, other revascularization options include aneurysm resection and arterial reanastomosis or reimplantation, and bypass.14 In the senior author's experience, direct reanastomosis or reimplantation in the neurovascularly dense posterior fossa is nonetheless challenging, especially as it can require mobilization of the PICA in segments containing brainstem perforators. Surgical bypass is thus typically pursued in this situation at our institution. The OA is the main in situ low-flow donor for PICA bypass due to it anatomic proximity and requirement for only 1 anastomosis site. The OA is not ideally suited for this use, however, as it is anatomically complex, difficult to dissect, and a relative size mismatch to the PICA (anatomic studies show the PICA has a diameter of 1.84 ± 0.45 mm at the origin, which decreases to 1.68 ± 0.38 mm at the tonsillar loop, yet OA diameters range from 2.3 to 2.7 mm).3,8,15-17 While interposition grafts add a second anastomosis site, they have a more consistent anatomy that facilitates harvest and can be tailored to the specific revascularization need. SVGs have been used for revascularization of the posterior fossa18 but are typically reserved for recipient vessels larger than the PICA. The RAG is the main donor vessel used for interposition graft PICA revascularization,14,19-21 although similar to the OA its diameter ranges from 2.5 to 3.7 mm. This presents a potential size mismatch, particularly at the tonsillar PICA loops where anastomoses are commonly performed.5,22 Furthermore, RAGs are prone to expand after anastomosis, possibly from denervation of the graft after harvest, compounding any diameter mismatch with the PICA.8 While such graft expansion may be favorable for bypass in high flow settings, it is not needed for PICA revascularization as long-term declines in graft flow in this system are likely to be compensated for by collateralization. Donor–recipient size mismatches may also lead to flow mismatches or local increases in perfusion above baseline, the latter of which has been linked to an increased risk of hyperperfusion complications.23 The DLCFA graft, which has been previously described in the cardiothoracic and plastic surgery literature as a reliable and effective alternative for myocardial revascularization and various free flaps,10-13 is also particularly well suited for PICA revascularization. Avoiding the size mismatch issues of the RAG, the DLCFA is 3 mm at its origin and remains stable at 2 mm for up to 12 to 15 cm along its course in the thigh, allowing harvest of a graft more closely size matched to the PICA.12,13,24 Additionally, the DLFCA harvest site is farther from the cranial surgical field than the RAG, allowing for an unobtrusive parallel harvest by a separate surgical team. It also has surrounding musculature with an abundant collateral supply that limits harvest site ischemia and requires a harvest incision that is relatively more cosmetic than that of the RAG as it is on a body surface that is typically covered. Compared to the RAG where harvest site complications can affect upper extremity function,25 the DLCFA is generally considered a safe graft for harvest. There was 1 minor complication related to DLCFA graft harvest in this series, a surgical site hematoma that required secondary evacuation, but no major complications or neurological injuries. This is consistent with published data on DLCFA harvest from the cardiovascular literature, where the only reported harvest site complication in a series of 147 patients with a nearly 2-yr average follow-up was transient thigh dysesthesias in 4% of patients.11 However, as most neurosurgeons lack operative experience with the anterior thigh vasculature, and plastic surgeons are familial with DLCFA harvest as part of commonly used anteriolateral thigh flaps, a multispecialty approach to DLCFA bypass procedures is prudent and recommend by the authors. The DLCFA also has potential patency advantages as compared to the RAG, as it is resistant to atherosclerotic changes that can decrease graft patency and promote spasm.26-28 In this small series, however, 2 of 3 patients (66%) developed graft spasm. While this is higher than the reported spasm risk associated with RAGs for cerebral bypass,29,30 these findings differ from larger scale cardiac surgery data suggesting that DLCFA grafts have relatively high patency rates and a low incidence of spasm.11,13 The true spasm risk with DLCFA grafts for PICA revascularization is thus likely lower than observed herein. Spurred by this clinical experience, we are nonetheless actively developing novel antispasm regimens to address this need. Given the small n and relatively short follow-up in this series, a more exact delineation of the spasm incidence and long-term patency rates of DLCFA grafts for PICA bypass will need to be assessed in future studies. Despite the potential advantages of the DLCFA for appropriately selected cerebral bypass cases, there is only 1 previous case of DLCFA graft bypass in the neurosurgical literature.6 Baskaya et al6 reported the successful management of a large suprasellar fusiform aneurysm with harvest of the DLCFA for anastomosis of the M2 segment of the MCA to the external carotid artery. The DLCFA was selected in this case, as opposed to a RAG, because of an arterial thrombosis in the RAG from multiple arterial line attempts and a failure of Allen's test on the contralateral side. Furthermore, the STA was compromised from a previous craniotomy and the SVG was considered to be a vessel flow mismatch. The DLCFA was harvested in the same manner as described in our case. While this was an elegant solution to the authors’ difficult case, the authors feel that the DLCFA was a rescue graft in this setting. First, the larger diameter of the RAG is a better size match for M2 anastomosis. Second, as high-flow grafts are typically designed as flow replacement for the entire ICA, the smaller diameter of the DLCFA makes it a less favorable choice than the RAG as a high-flow option for the anterior circulation. While the DLCFA was only used for PICA revascularization in this series, its success in this setting suggests it could be considered as an interposition graft option for other low-flow revascularization cerebral bypass needs. CONCLUSION Cerebral revascularization surgeries requiring harvest of a graft must account for several factors. Matching the size of the donor to the recipient vessel is vital to success of the graft. PICA revascularization in which the contralateral PICA is absent or nonsuitable for bypass requires an alternative vessel. Prior studies have identified RAGs for use in this setting; however, we suggest that the DLCFA is a more ideal vessel choice as it is a better match for size and vessel flow, is readily accessible, and has demonstrated acceptable patency. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Yasargil MG, Krayenbuhl HA, Jacobson JH, 2nd. Microneurosurgical arterial reconstruction. J Korean Neurosurg Soc . 1970; 67( 1): 121- 129. 2. Lee CY, Kim CH, Lee CY, Sohn SI, Hong JH. Urgent bypass surgery following failed endovascular treatment in acute symptomatic stroke patient with MCA occlusion. Neurologist . 2017; 22( 1): 14- 17. Google Scholar CrossRef Search ADS PubMed  3. Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation. J Neurosurg . 2005; 102( 1): 132- 147. 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Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part I: anterior circulation. J Neurosurg . 2005; 102( 1): 116- 131. Google Scholar CrossRef Search ADS PubMed  16. Katsuno M, Tanikawa R, Uemori G, Kawasaki K, Izumi N, Hashimoto M. Occipital artery-to-posterior inferior cerebellar artery anastomosis with multiple-layer dissection of suboccipital muscles under a reverse C-shaped skin incision. Br J Neurosurg . 2015; 29( 3): 401- 405. Google Scholar CrossRef Search ADS PubMed  17. Schmidt D, Adelmann G. The course of the occipital artery–an anatomical investigation for biopsy in suspected vasculitis. Eur J Med Res . 2001; 6( 6): 235- 241. Google Scholar PubMed  18. Quiñones-Hinojosa A, Du R, Lawton MT. Revascularization with saphenous vein bypasses for complex intracranial aneurysms. Skull Base . 2005; 15( 2): 119- 132. Google Scholar CrossRef Search ADS PubMed  19. Czabanka M, Ali M, Schmiedek P, Vajkoczy P, Lawton MT. Vertebral artery-posterior inferior cerebellar artery bypass using a radial artery graft for hemorrhagic dissecting vertebral artery aneurysms: surgical technique and report of 2 cases. J Neurosurg . 2011; 114( 4): 1074- 1079. Google Scholar CrossRef Search ADS PubMed  20. Ausman JI, Nicoloff DM, Chou SN. Posterior fossa revascularization: anastomosis of vertebral artery to PICA with interposed radial artery graft. Surg Neurol . 1978; 9( 5): 281- 286. Google Scholar PubMed  21. Kocaeli H, Andaluz N, Choutka O, Zuccarello M. Use of radial artery grafts in extracranial-intracranial revascularization procedures. Neurosurg Focus . 2008; 24( 2): E5. Google Scholar CrossRef Search ADS PubMed  22. Ulku CH, Ustun ME, Buyukmumcu M, Cicekcibasi AE, Ziylan T. Radial artery graft for bypass of the maxillary to proximal posterior cerebral artery: an anatomical and technical study. Acta Otolaryngol . 2004; 124( 7): 858- 862. Google Scholar CrossRef Search ADS PubMed  23. Wang D, Zhu F, Fung KM et al.   Predicting cerebral hyperperfusion syndrome following superficial temporal artery to middle cerebral artery bypass based on intraoperative perfusion-weighted magnetic resonance imaging. Sci Rep . 2015; 5: 14140. Google Scholar CrossRef Search ADS PubMed  24. Schamún CM, Durán JC, Rodríguez JM et al.   Coronary revascularization with the descending branch of the lateral femoral circumflex artery as a composite arterial graft. J Thorac Cardiovasc Surg . 1998; 116( 5): 870- 871. Google Scholar CrossRef Search ADS PubMed  25. Budillon AM, Nicolini F, Agostinelli A et al.   Complications after radial artery harvesting for coronary artery bypass grafting: our experience. Surgery . 2003; 133( 3): 283- 287. Google Scholar CrossRef Search ADS PubMed  26. Zhang Y, Janssen L, Chu FV. Atherosclerosis of radial arterial graft may increase the potential of vessel spasm in coronary bypass surgery. J Thorac Cardiovasc Surg . 2005; 130( 5): 1477- 1478. Google Scholar CrossRef Search ADS PubMed  27. Lee JH, Choi HJ, Jung KH, Oh MH, Kim JH, Lee YM. Pathologic patency analysis of the descending branch of the lateral femoral circumflex artery in head and neck reconstruction. J Craniofac Surg . 2016; 27( 4): e385- 389. Google Scholar CrossRef Search ADS PubMed  28. Halvorson EG, Taylor HO, Orgill DP. Patency of the descending branch of the lateral circumflex femoral artery in patients with vascular disease. Plast Reconstr Surg . 2008; 121( 1): 121- 129. Google Scholar CrossRef Search ADS PubMed  29. Roh SW, Ahn JS, Sung HY, Jung YJ, Kwun BD, Kim CJ. Extracranial-intracranial bypass surgery using a radial artery interposition graft for cerebrovascular diseases. J Korean Neurosurg Soc . 2011; 50( 3): 185- 190. Google Scholar CrossRef Search ADS PubMed  30. Sekhar LN, Duff JM, Kalavakonda C, Olding M. Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery . 2001; 49( 3): 646- 658; discussion 658-649. Google Scholar PubMed  Supplemental digital content is available for this article at www.operativeneurosurgery-online.com. Supplemental Digital Content Video Supplemental Digital Content Video Close COMMENTS The authors present their skillful management of 3 VA aneurysms requiring revascularization procedures as part of their treatment, using the lateral femorocutaneous artery (DLCFA) as an interposition graft between the VA and PICA. As the authors recognized, other techniques for revascularization of that segment exist, but were not considered an option in the cases presented due to mismatch or previous negative experience. Graft selection, particularly when interposition grafts are needed, are key to the success and durability of a by-pass, and vessel wall structure (ie, arterial vs venous graft) and caliber matching are perhaps the 2 most important attributes aside from indication and technique1. In alignment with those tenets, the DLCFA appears a reasonable choice as an interposition graft, as documented in these masterfully executed cases. Even though this report introduces yet another valuable resource for by-pass grafting, consideration should be given in the selection process to the added time required for graft harvesting in a remote site where neurosurgeons are usually unfamiliar with the anatomy, risk of injury of the femoral nerve as the LCFA passes between its divisions, as well as increased surgical time and risk of bypass failure associated with 2 anastomosis sites versus a more direct approach using a local donor and a single anastomosis. In cases similar to the ones reported and a bypass has been deemed necessary, we have had success with a modified version of the occipital-vertebral artery (OA-VA) bypass as described by Spetzler et al2,3, or PICA-PICA anastomosis when those have been suitable. We have also been able to use a radial or ulnar graft in other cases. The current report introduces an alternative conduit when none of the above techniques are possible. This report underscores the value of cerebral revascularization techniques and highlight their role in the armamentarium of therapies available for the treatment of these unique, challenging cerebrovascular lesions. The authors should be congratulated for their skill and resourceful approach to the treatment of these complex lesions in an unfavorable context. Norberto Andaluz Cincinnati, Ohio 1. Kocaeli H, Andaluz N, Choutka O, Zuccarello M. Use of radial artery grafts in extracranial-intracranial revascularization procedures. Neurosurg Focus  2008; 24 ( 2): E5. Google Scholar CrossRef Search ADS PubMed  2. Spetzler RF, Hadley MN, Martin NA, Hopkins LN, Carter LP, Budny J. Vertebrobasilar insufficiency. Part 1: Microsurgical treatment of extracranial vertebrobasilar disease. J Neurosurg  1987; 66( 5): 648- 61. Google Scholar CrossRef Search ADS PubMed  3. Hadley MN, Spetzler RF, Masferrer R, Martin NA, Carter LP. Occipital artery to extradural vertebral artery bypass procedure. Case report. J Neurosurg  1985; 63( 4): 622- 5. Google Scholar CrossRef Search ADS PubMed  In this manuscript, the authors report 3 cases of revascularization using a descending branch of the lateral circumflex femoral artery (DLCFA) graft for a ruptured PICA aneurysm, in which the contralateral PICA was not available. This short paper provides a concise description of the procedure and is supported by an excellent video, in which we see the surgeon's delicate and skillful technique. When treating fusiform PICA aneurysms, it is a welcome addition to a vascular neurosurgeon's armamentarium to know that using a DLCFA is feasible in order to ensure a proper vessel caliber match when the contralateral PICA is not available. The fact that harvesting the DLCFA may be performed by a separate specialized team while the neurosurgical team proceeds with exposure, saves time and simplifies the procedure for the neurosurgeon. Although the goal of the authors was to demonstrate the feasibility of using DLCFA, which was skillfully achieved, one can not conclude as to its efficacy in this small series. Nor can one generalize as to its indication in all fusiform PICA aneurysms. Spontaneous anastomosis via collateral circulation plays a significant role in supplying the cerebellum in cases of PICA occlusion. Endovascular treatment of ruptured fusiform PICA aneurysms by occlusion of both the aneurysm and the parent vessel distal to its origin, resulted most of the time, in absence of, or minor stroke1,2. In the present series, although it is reported that in 1 case there was no “major” stroke, no information is given regarding the occurrence of ischemic complications as assessed by imagery in all 3 cases. Although a bypass is certainly essential in some cases, studying the collateral circulation may help to evaluate its indication. It is also important to consider the possibility that surgery itself may contribute towards clinical, symptomatic vasospasm3,4, which occurred in all cases in this series. Michel W. Bojanowski Montreal, Canada 1. Maimon S, Saraf-Lavi E, Rappaport ZH, Bachar G. Endovascular Treatment of Isolated Dissecting Aneurysm of the Posterior Inferior Cerebellar Artery. Am J Neuroradiol  2006; 27: 527- 32. Google Scholar PubMed  2. Ionnidis I, Nasis N, Andreou A. Dissecting Posterior Inferior Cerebellar Artery Aneurysms. Interventional Neuroradiology  2012; 18: 442- 448. Google Scholar CrossRef Search ADS PubMed  3. Rabinstein AA, Pichelmann MA, Friedman JA et al. Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion. J Neurosurg  2003; 98: 319- 325. Google Scholar CrossRef Search ADS PubMed  4. Yalamanchili K, Rosenwasser RH, Thomas JE, Liebman K, McMorrow C, Gannon P. Frequency of Cerebral Vasospasm in Patients Treated with Endovascular Occlusion of Intracranial Aneurysms. Am J Neuroradiol  1998; 19: 553- 558. Google Scholar PubMed  Copyright © 2018 by the Congress of Neurological Surgeons

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Operative NeurosurgeryOxford University Press

Published: Mar 21, 2018

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