Radial Artery Fascial Flow-Through Free Flap for Complex Cerebral Revascularization: Technical Notes and Long-Term Neurologic and Radiographic Outcomes

2018 ◽  
Vol 16 (4) ◽  
pp. 424-434 ◽  
Author(s):  
Robert C Rennert ◽  
Kristine Ravina ◽  
Ben A Strickland ◽  
Joshua Bakhsheshian ◽  
Joseph Carey ◽  
...  
Keyword(s):  
Radial Artery ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Free Flap ◽  
Free Flaps ◽  
Graft Patency ◽  
Wound Complications ◽  
Bifurcation Aneurysm ◽  
Flow Through

AbstractBACKGROUNDSurgical innovation is critical for the management of challenging cerebrovascular pathology. Flow-through free flaps are versatile composite grafts that combine viable tissue with a revascularization source. Neurosurgical experience with these flaps is limited.OBJECTIVETo provide an in-depth technical description of the radial artery fascial (and fasciocutaneous) flow-through free flap (RAFF and RAFCF, respectively) for complex cerebral revascularizations.METHODSAn Institutional Review Board-approved, prospective database was retrospectively reviewed to identify patients that underwent extracranial-to-intracranial cerebral bypass with a RAFF or RAFCF. Patient demographics, underlying pathology, surgical treatment, complications, and outcomes were recorded.RESULTSA total of 4 patients were treated with RAFFs or RAFCFs (average age 40 ± 8.8 yr). Two patients with progressive moyamoya disease involving multiple vascular territories with predominantly anterior cerebral artery (ACA) symptoms and flow alterations underwent combined direct ACA and indirect middle cerebral artery (MCA) bypass with a RAFF. The third patient with moyamoya disease and concomitant proximal fusiform aneurysms requiring internal carotid artery sacrifice underwent dual direct ACA and MCA bypass and indirect MCA revascularization with posterior tibial artery and RAFF grafts. The fourth patient with a large MCA bifurcation aneurysm and recurrent wound complications underwent a direct MCA bypass and complex wound reconstruction using a RAFCF. Good neurologic outcomes (Glasgow Outcomes Scale score ≥4 at discharge) were achieved in all patients. There were no perioperative surgical complications, and graft patency was confirmed on long-term follow-up.CONCLUSIONThe RAFF and RAFCF are versatile grafts for complex cerebral revascularizations.

Radial Artery Fascial Flow-Through Free Flap for Combined Revascularization in Moyamoya Disease

2017 ◽  
Vol 14 (2) ◽  
pp. 139-144 ◽  
Author(s):  
Jonathan Russin ◽  
Joseph Carey
Keyword(s):  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Free Flap ◽  
Anterior Cerebral Artery ◽  
Single Case ◽  
Free Flaps ◽  
Soft Tissue Reconstruction ◽  
Single Case Report ◽  
Proximal Anterior Cerebral Artery ◽  
Flow Through

Abstract BACKGROUND Free flaps are commonly used by other surgical subspecialties for soft tissue reconstruction and revascularization. Cranial applications of these flaps have been limited to only a single case report. OBJECTIVE To present a new technique for combined revascularization in moyamoya disease using a flow-through free flap. METHODS Data were obtained from an Institutional Review Board-approved, prospectively maintained database with informed consent from the patient. RESULTS A 28-yr-old patient presented with progressive stenosis of the proximal anterior cerebral artery resulting in ischemic infarcts. Direct revascularization of the anterior cerebral artery territory and indirect revascularization of the middle cerebral artery with a large vascularized fascial pedicle was performed. CONCLUSION Flow-through free flaps offer a unique combination of revascularization and a large vascularized pedicle. This technique highlights the application of these flaps for revascularization in moyamoya disease and the value of multidisciplinary collaboration. Revascularization will likely play an increasing role in the open surgical treatment of cerebrovascular disease. We believe that flow-through free flaps will be a contribution to the future of revascularization in neurosurgery.

scholarly journals Long-Term Outcome after Successful Lower Extremity Free Flap Salvage

2018 ◽  
Vol 35 (04) ◽  
pp. 263-269 ◽  
Author(s):  
Amir Bigdeli ◽  
Emre Gazyakan ◽  
Volker Schmidt ◽  
Christoph Bauer ◽  
Günter Germann ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Component Score ◽  
Sf 36 ◽  
The Mean

Background Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage. Methods A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed. Results The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7. Conclusion Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

scholarly journals Impact of posterior cerebral artery involvement on long-term clinical and social outcome of pediatric moyamoya disease

2013 ◽  
Vol 12 (6) ◽  
pp. 626-632 ◽  
Author(s):  
Takeshi Funaki ◽  
Jun C. Takahashi ◽  
Yasushi Takagi ◽  
Kazumichi Yoshida ◽  
Yoshio Araki ◽  
...  
Keyword(s):  
Risk Factors ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Posterior Cerebral Artery ◽  
Univariate Analysis ◽  
Social Outcomes ◽  
Long Term Results ◽  
Social Outcome

Object In the study of pediatric moyamoya disease, information on long-term social outcomes and risk factors for unfavorable social outcomes remains insufficient. The authors analyzed the long-term results of surgical revascularization for pediatric patients with moyamoya disease to determine whether the involvement of a stenoocclusive lesion in the posterior cerebral artery (PCA), relatively common in pediatric moyamoya disease, represents an underlying predictor for unfavorable social outcomes. Methods Prospectively collected data on 61 consecutive patients with moyamoya disease who had undergone combined bypass surgery were analyzed. Neuroradiological features and other baseline clinical factors were incorporated into univariate and multivariate analyses to determine any association with an unfavorable social outcome, defined as difficulty attending regular school or obtaining regular employment. Results Posterior cerebral artery involvement detected by angiography on admission was noted in 22 (36.1%) of the 61 patients. Follow-up data were acquired in 56 patients (91.8%), and the mean follow-up period was 15.8 years. While transient ischemic attacks were eliminated in 52 (92.9%) of these 56 patients after surgery, and late-onset ischemic stroke was observed in only 1 patient during the follow-up period, 10 (17.9%) experienced an unfavorable social outcome. Although younger age at onset, longer duration between onset and surgery, infarction present on preoperative neuroradiological images, and PCA involvement had been identified as risk factors for an unfavorable social outcome in univariate analysis, only infarction present on preoperative images and PCA involvement remained statistically significant after multivariate adjustment. Conclusions Posterior cerebral artery involvement can be considered one of the underlying risk factors for unfavorable social outcome and should be studied further to improve social outcome in pediatric moyamoya disease.

Long-term clinical and radiographic outcomes after pial pericranial dural revascularization: a hybrid surgical technique for treatment of anterior cerebral territory ischemia in pediatric moyamoya disease

2021 ◽  
pp. 1-9
Author(s):  
Alaa Montaser ◽  
Jessica Driscoll ◽  
Hudson Smith ◽  
Madeline B. Karsten ◽  
Emily Day ◽  
...  
Keyword(s):  
Dura Mater ◽  
Moyamoya Disease ◽  
Cerebral Artery ◽  
Pediatric Patients ◽  
Radiographic Outcomes ◽  
Long Term Follow Up ◽  
Indirect Revascularization ◽  
Burr Holes

OBJECTIVE Isolated anterior cerebral artery (ACA) territory ischemia in pediatric moyamoya disease (MMD) is rare but has been increasingly recognized, particularly in children manifesting progression of disease in a delayed fashion after middle cerebral artery revascularization surgery. Surgical treatment is complicated by limited graft choices, with the small number of case series largely focused on complex, higher-risk operations (omental flap transfers, large interhemispheric rotational grafts); direct bypass (often untenable in children due to vessel size); or, alternatively, the technically simpler method of multiple burr holes (of limited efficacy outside of infants). Faced with the problem of a growing cohort of pediatric patients with MMD that could benefit from anterior cerebral revascularization, the authors sought to develop a solution that was specifically designed for children and that would be lower risk than the more complex approaches adapted from adult populations but more effective than simple burr holes. In this study, the authors aimed to describe the long-term clinical and radiographic outcomes of a novel approach of pial pericranial dural (PiPeD) revascularization, building on the principles of pial synangiosis but unique in using the pericranium and the dura mater as the primary vascular supply, and employing a larger craniotomy with arachnoid dissection to provide robust full-territory revascularization in all ages with reduced risk relative to more complex procedures. METHODS The medical records of all pediatric patients with MMD who presented at a single center between July 2009 and August 2019 were retrospectively reviewed to identify patients with MMD with anterior cerebral territory ischemia. Clinical characteristics, surgical indications, operative techniques, and long-term clinical and radiographic follow-up data were collected and analyzed. RESULTS A total of 25 operations (5.6% of total procedures) were performed in 21 patients (mean age 9.4 years [range 1–16.5 years]; 12 female and 9 male). Almost one-third of the patients had syndromic associations, with no familial cases. Complications included 1 patient (4.7%) with a superficial infection, with no postoperative strokes, hemorrhage, seizures, or deaths. Long-term follow-up was available in 18 of 21 patients (mean 24.9 months [range 4–60 months]). Radiographic engraftment was present in 90.9% (20/22 hemispheres), and no new strokes were evident on MRI on long-term follow-up, despite radiographic progression of the disease. CONCLUSIONS The use of the pericranium and the dura mater for indirect revascularization provided robust vascularized graft with great flexibility in location and high potential for engraftment, which may obviate more complex and higher-risk operations for ACA territory ischemia. Long-term follow-up demonstrated that PiPeD revascularization conferred durable, long-term radiographic and clinical protection from stroke in pediatric patients with MMD. Based on the results of the current study, the PiPeD technique can be considered an additional tool to the armamentarium of indirect revascularization procedures in select pediatric patients with MMD.

Long-Term Outcomes after Double Free Flap Reconstruction for Locally Advanced Head and Neck Cancer

2018 ◽  
Vol 35 (01) ◽  
pp. 066-073 ◽  
Author(s):  
J. Brinkman ◽  
Shoista Kambiz ◽  
Tim de Jong ◽  
Marc Mureau
Keyword(s):  
Head And Neck Cancer ◽  
Head And Neck ◽  
Neck Cancer ◽  
Free Flap ◽  
Patient Survival ◽  
Locally Advanced ◽  
Free Flaps ◽  
Advanced Head ◽  
Patient Reported

Background The use of simultaneous, multiple free flaps has become a reliable reconstructive option in patients with extensive composite defects after resection of locally advanced head and neck cancer. However, some reluctance remains among reconstructive surgeons with concerns regarding flap outcomes and limited patient survival. Therefore, we evaluated complications, long-term patient survival, and patient-reported outcomes following these extensive head and neck reconstructions. Methods All consecutive patients treated with multiple free flaps for reconstruction of extensive composite defects after resection of locally advanced head and neck cancer between 1999 and 2014 were retrospectively reviewed. Patient charts were evaluated for demographics, treatment details, complications, and patient survival. In addition, all patients alive at the start of the study were asked to complete the 10-item Eat Assessment Tool (EAT-10) and the Intelligibility Rating Scale (IRS). Results Eighty-four simultaneous, multiple free flaps were performed in 42 patients. The predominant free flap combination consisted of a fibula with either an anterolateral thigh (n = 22) or a radial forearm flap (n = 14). Complete flap survival was 95%. Nineteen patients were still alive with a mean follow-up of 55 months. Five-year patient survival was 46.3%. Mean EAT-10 score was 8.4 (range: 0–29), with only one patient reporting problematic swallowing. Ninety percent of the patients had moderate to good speech intelligibility with the IRS. Conclusion Multiple, simultaneous free flaps can be performed safely, leading to acceptable long-term patient survival and patient-reported functional outcomes. Our study demonstrates that it is worthwhile to perform these challenging microvascular reconstructions in patients with locally advanced head and neck cancer.

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