Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video

Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral... Abstract Posterior cerebral artery (PCA) aneurysms can be technically challenging lesions due to the intricacy of perforating branches and the relationship to cranial nerves and the brainstem. Fusiform aneurysms of the perimesencephalic segment of the PCA are a rare finding which does not favor direct clip occlusion or reconstruction. In such cases, proximal parent vessel occlusion is an option for aneurysm treatment. Extracranial-intracranial (EC-IC) bypass can be used to revascularize beyond the lesion when considering proximal occlusion. Based on previous literature for occipital artery (OA) bypass and the time-consuming dissection required for OA harvest, an interposition graft was chosen. The descending branch of the lateral circumflex femoral artery (DLCFA) is a good alternative interposition graft with a diameter that is favorable for revascularizing smaller, more distal vessels. This 3-dimensional video presents the case of a 26-year-old female with severe headaches who was found to have unruptured, fusiform aneurysmal dilatations of the PCA. Given the patient's youth and the morphology of the aneurysms, an EC-IC bypass with proximal occlusion was recommended. The DLCFA was used as an interposition graft. The left OA was found to be a suitable donor. A subtemporal approach was used to access the PCA for proximal occlusion. An occipital interhemispheric approach was performed to isolate a suitable recipient segment of the ipsilateral PCA branch for microvascular end-to-side anastomosis. Postoperative catheter angiography showed significant thrombosis of the fusiform aneurysms and a patent EC-IC bypass. Postoperative magnetic resonance imaging showed no infarcts and the patient was discharged neurologically intact. The patient was consented for inclusion in a prospective institutional review board (IRB) approved database from which this IRB approved retrospective report was performed. The consent for intraoperative video and picture use was also obtained. Images in the video between 0:49 and 1:11, © University of Southern California Neurorestoration Center. Used with permission, all rights reserved. Bypass, Cerebral revascularization, Fusiform aneurysm, Lateral circumflex femoral artery View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy057 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy057 Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 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. COMMENT The authors provide a very nicely documented and illustrated case in which they employed a less commonly considered interposition graft in the treatment of a distal posterior cerebral artery aneurysm. The use of the descending branch of the lateral circumflex femoral artery is less familiar to the neurosurgical community but as depicted in the video provides an excellent alternative to more commonly employed radial grafts. The authors point out the benefits and advantages of employing this specific graft and illustrate excellent surgical technique in the management of this complex case. Two other points merit consideration however; the anastomosis at the distal PCA may have been technically less challenging by running the back-wall from the inside and later converting to the outside on the front-wall as is employed in PICA-PICA anastomoses. Further, an endovascular occlusion of the PCA and aneurysm after completing the bypasses may have been equally efficacious and avoided the subtemporal portion of the procedure. The authors are to be commended on this excellent surgical presentation. Carlos David Burlington, Massachusetts Copyright © 2018 by the Congress of Neurological Surgeons http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Operative Neurosurgery Oxford University Press

Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video

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Publisher
Congress of Neurological Surgeons
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
2332-4252
eISSN
2332-4260
D.O.I.
10.1093/ons/opy057
Publisher site
See Article on Publisher Site

Abstract

Abstract Posterior cerebral artery (PCA) aneurysms can be technically challenging lesions due to the intricacy of perforating branches and the relationship to cranial nerves and the brainstem. Fusiform aneurysms of the perimesencephalic segment of the PCA are a rare finding which does not favor direct clip occlusion or reconstruction. In such cases, proximal parent vessel occlusion is an option for aneurysm treatment. Extracranial-intracranial (EC-IC) bypass can be used to revascularize beyond the lesion when considering proximal occlusion. Based on previous literature for occipital artery (OA) bypass and the time-consuming dissection required for OA harvest, an interposition graft was chosen. The descending branch of the lateral circumflex femoral artery (DLCFA) is a good alternative interposition graft with a diameter that is favorable for revascularizing smaller, more distal vessels. This 3-dimensional video presents the case of a 26-year-old female with severe headaches who was found to have unruptured, fusiform aneurysmal dilatations of the PCA. Given the patient's youth and the morphology of the aneurysms, an EC-IC bypass with proximal occlusion was recommended. The DLCFA was used as an interposition graft. The left OA was found to be a suitable donor. A subtemporal approach was used to access the PCA for proximal occlusion. An occipital interhemispheric approach was performed to isolate a suitable recipient segment of the ipsilateral PCA branch for microvascular end-to-side anastomosis. Postoperative catheter angiography showed significant thrombosis of the fusiform aneurysms and a patent EC-IC bypass. Postoperative magnetic resonance imaging showed no infarcts and the patient was discharged neurologically intact. The patient was consented for inclusion in a prospective institutional review board (IRB) approved database from which this IRB approved retrospective report was performed. The consent for intraoperative video and picture use was also obtained. Images in the video between 0:49 and 1:11, © University of Southern California Neurorestoration Center. Used with permission, all rights reserved. Bypass, Cerebral revascularization, Fusiform aneurysm, Lateral circumflex femoral artery View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy057 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy057 Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 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. COMMENT The authors provide a very nicely documented and illustrated case in which they employed a less commonly considered interposition graft in the treatment of a distal posterior cerebral artery aneurysm. The use of the descending branch of the lateral circumflex femoral artery is less familiar to the neurosurgical community but as depicted in the video provides an excellent alternative to more commonly employed radial grafts. The authors point out the benefits and advantages of employing this specific graft and illustrate excellent surgical technique in the management of this complex case. Two other points merit consideration however; the anastomosis at the distal PCA may have been technically less challenging by running the back-wall from the inside and later converting to the outside on the front-wall as is employed in PICA-PICA anastomoses. Further, an endovascular occlusion of the PCA and aneurysm after completing the bypasses may have been equally efficacious and avoided the subtemporal portion of the procedure. The authors are to be commended on this excellent surgical presentation. Carlos David Burlington, Massachusetts Copyright © 2018 by the Congress of Neurological Surgeons

Journal

Operative NeurosurgeryOxford University Press

Published: Apr 3, 2018

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