Early intraoperative occlusion of a superficial temporal artery to middle cerebral artery (STA-MCA) bypass is a rare event, but must be identified and treated immediately if it occurs. This video demonstrates the management of this complication in a 45-yr-old symptomatic bilateral moyamoya patient. The patient was positioned supine with the head turned to the right. After harvesting the STA and performing a minipterional craniotomy, the M4 branch of MCA was selected as a recipient artery. The donor artery was fish mouthed and the end-to-side anastomosis was completed. Fluorescein-Yellow-560 angiogram was suspicious for a thrombus at the anastomosis site, which was confirmed by palpation and Doppler sonography. The platelet plug was dislodged with external manipulation of the anastomosis, but kept reaccumulating. Therefore, the anastomosis was opened, the platelet plug was removed, and the STA was trimmed back to fresh tissues. A second end-to-side bypass was performed, and indocyanine green angiography and Doppler ultrasonography showed patency of bypass. Patency was reconfirmed by postoperative angiography. This case demonstrates the treatment of early intraoperative bypass occlusion. The combination of intraoperative fluorescence imaging and careful inspection by the surgeon detected the occlusion. This complication is often caused by traumatic handling of arterial tissues with the microforceps and poor technique, but can occur without clear etiology, as in this case. Actions to avert bypass occlusion include: bathing STA in papaverine after it is harvested; irrigating locally with heparinized saline while suturing the anastomosis; administering heparin systemically (5000U); and giving aspirin immediately after surgery (but not preoperatively). When a bypass cannot be reopened by other means, redoing the anastomosis is the only option, paying meticulous attention to suturing technique. View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx156 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx156 Management of Early Intraoperative Superficial Temporal Artery to Middle Cerebral Artery Bypass Occlusion in a Moyamoya Patient: 3-Dimensional Operative Video Management of Early Intraoperative Superficial Temporal Artery to Middle Cerebral Artery Bypass Occlusion in a Moyamoya Patient: 3-Dimensional Operative Video Close Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. COMMENTS This 3-dimensional operative video nicely demonstrates how to identify early intraoperative STA-MCA bypass occlusion using fluorescence techniques and how to manage bypass occlusion via endarterectomy and reanastomosis. At the University of Illinois at Chicago, we have developed a strategy to identify and manage bypass occlusion by measuring flow intraoperatively and calculating the cut flow index.1 Specifically, the cut flow index is an intraoperative predictor of bypass success and also helps to identify the source of bypass failure-donor, anastomosis, or recipient. Thus, this approach guides the surgeon to the best course of action when faced with intraoperative bypass occlusion. Fady T. Charbel Sophia F. Shakur Chicago, Illinois 1. Amin-Hanjani S, Du X, Mlinarevich N, Meglio G, Zhao M, Charbel FT. The cut flow index: an intraoperative predictor of the success of extracranial-intracranial bypass for occlusive cerebrovascular disease. Neurosurgery . 2005; 56( ONS Suppl 1): 75- 85. Google Scholar PubMed This is an excellent and very instructive video presentation of the complication of graft occlusion by a platelet thrombus in a patient undergoing an STA-MCA anastomosis for Moyamoya disease. The fact that this complication can occur to a master surgeon who does these cases frequently is notable. The video demonstrates all of the essential elements of excellent technique for this procedure. The cross-sectional area of the anastomosis is optimized by fish mouthing the donor vessel, the placement of the anchor sutures in the graft prior to recipient vessel occlusion further reduces temporary occlusion time, the meticulous technique that the author uses with regard to avoidance of intimal manipulation with the forceps and the efficient running suture technique are all things that we should emulate in performing this procedure. The dramatic demonstration of the white thrombus, which develops some minutes after the graft is initially patent, is striking. It raises the question of whether an antiplatelet medication strategy would be appropriate for selected cases undergoing this procedure. It appears that a combination of indocyanine green and fluorescein dyes can be used to advantage in detecting this unusual complication. The authors are to be congratulated on providing us with a demonstration of meticulous technique and very effective management of an unusual complication in bypass surgery. Ralph G. Dacey St. Louis, Missouri Copyright © 2017 by the Congress of Neurological Surgeons
Operative Neurosurgery – Oxford University Press
Published: Apr 1, 2018
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