Abstract In this 3-dimensional video, we perform a side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery (STA) to provide flow augmentation in a symptomatic 59-yr-old male with bilateral internal carotid artery occlusion at the origin, and left M1 segment occlusion. The patient suffered multiple left hemispheric strokes despite maximal medical therapy and was found to have poor hemodynamic reserve in the left hemisphere during evaluation with regional and global blood oxygenation level-dependent functional magnetic resonance imaging with CO2-challenge as well as quantitative magnetic resonance angiography and noninvasive optimal vessel analysis pre- and post-acetazolamide challenge. Postoperatively, the patient did very well and his hemodynamic studies improved significantly. The importance of this technique relies on the fact that we are using a single donor vessel to perform 2 anastomoses, and carries the following advantages: (1) the frontal STA branch remains intact and therefore can still be used at a later time if further revascularization is needed; (2) wound complications related to devascularizing the scalp from harvesting both STA branches are reduced; (3) 2 vascular territories are augmented (frontal and temporal) while using a single donor; (4) we are maximizing donor potential and optimizing cut flow index (CFI; total bypass flow postanastomosis divided by bypass cut flow) by flow augmenting 2 separate vascular beds therefore increasing demand. To explain that fourth point further: if the STA donor is able to carry a maximum 100 mL/min when cut, and after performing the first anastomosis bypass flow is only 37 mL/min, CFI will be 37/100 = 0.37, reflecting low demand, a poor indicator of graft patency, as previously published.1,2 By adding a second anastomosis which demands an additional 60 mL/min from the same STA donor, CFI (60 + 37)/100 improves to 1. Institutional Review Board approval was obtained for the review of patient chart and video files. Informed consent was obtained directly from the patient via telephone regarding use of media for educational and publication purposes. Cerebrovascular bypass, Cut flow index (CFI), Extracranial to intracranial (EC-IC) bypass, Flow augmentation, Moyamoya, Single vessel double anastomosis (SVDA), Superficial temporal artery (STA) View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy091 View largeDownload slide Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opy091 Side-to-Side and End-to-Side Double Anastomosis Using the Parietal-Branch of the Superficial Temporal Artery—A Novel Technique for Extracranial to Intracranial Bypass Surgery: 3-Dimensional Operative Video Side-to-Side and End-to-Side Double Anastomosis Using the Parietal-Branch of the Superficial Temporal Artery—A Novel Technique for Extracranial to Intracranial Bypass Surgery: 3-Dimensional Operative Video Close Disclosures Dr Charbel is a consultant for Transonic Inc. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 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 ( 1 Suppl ): 75 - 85 ; discussion 75-85 . Google Scholar PubMed 2. Hage ZA , Amin-Hanjani S , Charbel FT . Cerebral revascularization: state of the art . Neurosurg Quart . 2013 ; 23 ( 1 ): 13 - 26 . Google Scholar CrossRef Search ADS COMMENTS This video illustrates a novel extension of the typical superficial temporal artery to middle cerebral artery bypass (STAMCA) technique. In order to perfuse 2 cortical vessels, the typical approach is to use a so-called “double barrel” approach employing both the frontal and parietal branches of the superficial temporal artery, which are each anastomosed to a separate vessel. In this technique, the authors perform a variation in which a single branch is attached to 2 vessels using side-to-side en passage followed by end-to-side at the terminal part of the graft. Given that the superficial temporal artery is much longer than is usually needed for a single bypass, this technique offers a clever way to augment flow using a single donor vessel. The next question is, why not perfuse 4 vessels using both branches? I applaud the authors for sharing this useful addition to the bypass armamentarium. Peter Nakaji Phoenix, Arizona In this surgical video, the authors demonstrate a double anastomosis STA-MCA bypass. The side-to-side anastomosis recipient is a temporal MCA branch while the end-to-side anastomosis recipient is a frontal MCA branch. In this way, the authors achieve perfusion of both MCA territories with a single donor vessel. As the authors mention, using a single donor vessel may reduce wound complications associated with scalp devascularization, but also keep the anterior STA branch intact should further revascularization be required in the future. An interesting feature of this bypass technique is the maximization of donor vessel potential. The STA cut flow was 60 cc/min. Following the first anastomosis (side-to-side), the bypass flow was 30 cc/min. However, following the second anastomosis (end-to-side) the proximal bypass flow increased to 90 cc/min and the distal bypass flow was measured as 36.5 cc/min. As the authors mention, this increase in demand by the distal vascular territories augmented flow within the bypass. The authors should be commended on their technique and demonstration of the complex physiology surrounding cerebral ischemia and revascularization procedures. Jacques J. Morcos Miami, Florida This paper and video demonstrate a novel and unique technical report of hemispheric revascularization of 2 unique vascular territories with a single donor, the superficial temporal artery (STA). While this technique has been utilized with larger transplanted donor vessels for flow replacement when treating complex aneurysms, this is a novel and first demonstration of its kind when utilized for flow augmentation. As the authors correctly point out, double barrel bypass, which can be utilized to reavascularize 2 territories, does require the harvesting of a second STA branch. This separate dissection not only adds time to the procedure but additionally may increase the risk of poor wound healing due to more aggressive devascularization. The abstract and accompanying video are done beautifully with the key steps, particularly for the side to side anastomosis, well described and illustrated. The authors demonstrate their “cut flow index” methodology, which is invaluable in assessing these grafts intraoperatively. This technique, however, is more difficult than an end to side STA-MCA bypass alone and may not be readily applicable in all situations, particularly as the donor or recipient vessel caliber decreases in size. A side to side bypass with a submillimeter vessel can be challenging and the neurosurgeon considering utilizing this technique should be sure to have performed this before and/or have spent time in the lab prior to attempting it as a part of a "double anastomosis” strategy. The University of Illinois/Chicago team has been a consistent leader in innovation using technology and technique for greater than a decade and we look forward to more contributions to our knowledge and surgical armamentarium from them in the future. Jason A. Ellis David J. Langer New York, New York The authors provide an excellent and beautifully depicted video illustrating the use of a single donor vessel to perform a cerebral revascularization procedure. The teaching points are clear and the narrator provides the necessary highlights and explanation for the viewer to appreciate the nuances. In particular, the precise method and direction of suture placement when sewing the back wall and transitioning to the front is explained superbly. It is also noteworthy the surgeons’ advanced considerations in regards to reducing ischemia and maximizing efficiency as can be seen by placing the first donor suture prior to clamping and opening the recipient vessel. This is an exceptional and highly educational video that will benefit the neurosurgical community greatly. Carlos David Burlington, Massachusetts This video does a good job of demonstrating a novel surgical technique to help patients who might require improvement of global hemispheric perfusion. Combining the objective results of cut-flow index and post-bypass perfusion imaging shows more concrete evidence of the usefulness of this technique. Rohan V. Chitale Nashville, Tennessee This is an excellent video demonstrating a beautiful and elegant technique of double superficial temporal artery-middle cerebral artery (STA-MCA) bypass by the use of a single donor vessel. In fact the authors anastomized the parietal branch of the superficial temporal artery (STA) with: 1) a cortical M4 recipient artery lying on the temporal cortex by means of a side-to-side anastomosis; 2) a cortical M4 recipient artery lying on the frontal cortex via an end-to-side anastomosis. This way 2 vascular MCA territories (frontal and temporal) are revascularized by the use of a single donor vessel. This technique has not been reported in such an elegant and educational way so far. It is useful in case only 1 donor is available (single frontal or single parietal STA branch suitable) or to reduce the possible wound healing problems linked to the use of both frontal and parietal STA branch. Besides the beauty of this technique and its technical advantages, the author showed very well how the flow demand is the main determinant of donor capacity. Giuseppe Esposito Luca Regli Zurich, Switzerland Copyright © 2018 by the Congress of Neurological Surgeons
Operative Neurosurgery – Oxford University Press
Published: Apr 12, 2018
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