scholarly journals Surgical Management of Failed Revascularization in Moyamoya Vasculopathy

2021 ◽  
Vol 12 ◽  
Author(s):  
Kristin Lucia ◽  
Güliz Acker ◽  
Nicolas Schlinkmann ◽  
Stefan Georgiev ◽  
Peter Vajkoczy
Keyword(s):  
Radial Artery ◽  
Neurological Symptoms ◽  
Occipital Artery ◽  
Neurosurgical Procedures ◽  
Single Center ◽  
Radial Artery Graft ◽  
Reliable Technique ◽  
Repeat Revascularization ◽  
Artery Graft ◽  
Increased Risk

Objectives: Moyamoya vasculopathy (MMV) is a rare stenoocclusive cerebrovascular disease associated with increased risk of ischemic and hemorrhagic stroke, which can be treated using surgical revascularization techniques. Despite well-established neurosurgical procedures performed in experienced centers, bypass failure associated with neurological symptoms can occur. The current study therefore aims at characterizing the cases of bypass failure and repeat revascularization at a single center.Methods: A single-center retrospective analysis of all patients treated with revascularization surgery for MMV between January 2007 and December 2019 was performed. Angiographic data, cerebral blood flow analysis [H2O PET or single-photon emission CT (SPECT)], MRI, and clinical/operative data including follow-up assessments were reviewed.Results: We identified 308 MMV patients with 405 surgically treated hemispheres. Of the 405 hemispheres treated, 15 patients (3.7%) underwent repeat revascularization (median age 38, time to repeat revascularization in 60% of patients was within 1 year of first surgery). The most common cause of repeat revascularization was a symptomatic bypass occlusion (80%). New ischemic lesions were found in 13% of patients prior to repeat revascularization. Persistence of reduced or progressive worsening of cerebrovascular reserve capacity (CVRC) compared with preoperative status was observed in 85% of repeat revascularization cases. Intermediate-flow bypass using a radial artery graft was most commonly used for repeat revascularization (60%) followed by re-superficial temporal artery to middle cerebral artery (re-STA-MCA) bypass (26%). High-flow bypass using a saphenous vein graft and using an occipital artery to MCA bypass was each used once. Following repeat revascularization, no new ischemic events were recorded.Conclusion: Overall, repeat revascularization is needed only in a small percentage of the cases in MMV. A rescue surgery should be considered in those with neurological symptoms and decreased CVRC. Intermediate-flow bypass using a radial artery graft is a reliable technique for patients requiring repeat revascularization. Based on our institutional experience, we propose an algorithm for guiding the decision process in cases of bypass failure.

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

2011 ◽  
Vol 114 (4) ◽  
pp. 1074-1079 ◽  
Author(s):  
Marcus Czabanka ◽  
Muhammad Ali ◽  
Peter Schmiedek ◽  
Peter Vajkoczy ◽  
Michael T. Lawton
Keyword(s):  
Vertebral Artery ◽  
Radial Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Radial Artery Graft ◽  
Interposition Graft ◽  
Endovascular Occlusion ◽  
Artery Graft ◽  
Cerebellar Artery ◽  
Far Lateral Approach

Endovascular occlusion of hemorrhagic dissecting aneurysms of the vertebral artery (VA) is not possible when the posterior inferior cerebellar artery (PICA) originates from the dissecting aneurysm or when the contralateral VA provides inadequate collateral blood flow to the distal basilar circulation. The authors introduce a VA-PICA bypass with radial artery interposition graft and aneurysm trapping as an alternative approach and describe 2 cases in which this bypass was used to treat hemorrhagic dissecting VA aneurysms. The VA-PICA bypass is performed via a standard far lateral approach. An end-to-side anastomosis between the radial artery graft and the PICA at the level of the caudal loop is performed first, and an end-to-side anastomosis is performed between the V3 segment and the proximal end of the radial artery graft. A 56-year-old woman harbored a hemorrhagic dissecting VA aneurysm incorporating the origin of the PICA. Endovascular treatment failed, with aneurysm refilling on follow-up angiography. A 65-year-old man had a hemorrhagic dissecting VA aneurysm and a hypoplastic contralateral VA. Both patients were treated with the VA-PICA bypass and aneurysm trapping, with adequate filling of the PICA territory in the first patient and both the PICA territory and the basilar circulation in the second patient. Vertebral artery–PICA bypass with radial artery interposition graft and subsequent trapping of the dissected VA segment is an alternative to occipital artery–PICA and PICA-PICA bypass for the treatment of hemorrhagic dissecting VA aneurysms that are not suitable for endovascular occlusion.

Endovascular Management of Symptomatic Spasm of Radial Artery Bypass Graft

Neurosurgery ◽  
2010 ◽  
Vol 67 (3) ◽  
pp. 794-798 ◽  
Author(s):  
Sabareesh K. Natarajan ◽  
Erik F. Hauck ◽  
L. Nelson Hopkins ◽  
Elad I. Levy ◽  
Adnan H. Siddiqui
Keyword(s):  
Radial Artery ◽  
Moyamoya Disease ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Occipital Artery ◽  
Artery Bypass Graft ◽  
Perfusion Deficit ◽  
Radial Artery Graft ◽  
Symptomatic Vasospasm ◽  
Artery Graft

Abstract OBJECTIVE To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease. CLINICAL PRESENTATION A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging. TECHNIQUE The patient underwent a left MCA bypass graft for flow augmentation. She returned with an occluded bypass graft, collateralization of the anterior MCA territory through a spontaneous synangiosis, and a severe perfusion deficit in the posterior MCA territory. She underwent a revision bypass graft procedure with the radial artery from the occipital artery stump to the MCA-M3 branch. She developed repeated symptomatic vasospasm of the radial artery graft postoperatively. After systemic anticoagulation, the graft was accessed through the occipital artery, and intra-arterial verapamil was injected. When this failed to resolve the graft spasm, the radial artery graft was accessed with a 0.14-inch Synchro-2 microwire (Boston Scientific, Natick Massachusetts), and sequential angioplasties were performed using over-the-wire balloons from the proximal to distal anastomosis and in the occipital artery stump. A nitroglycerin patch was applied cutaneously over the graft to relieve the vasospasm. RESULTS No complications occurred. Graft patency with robust flow was observed on the 5-month follow-up angiogram. CONCLUSION Endovascular techniques can be safely used for salvage of spastic extracranial-intracranial grafts.

scholarly journals Surgical removal using V3-radial artery graft-V4 bypass and occipital artery-posterior inferior cerebellar artery bypass for a giant thrombosed aneurysm of vertebral artery compressing brain stem: Case report

2019 ◽  
Vol 10 ◽  
pp. 220
Author(s):  
Sho Tsunoda ◽  
Tomohiro Inoue ◽  
Kazuaki Naemura ◽  
Atsuya Akabane
Keyword(s):  
Blood Flow ◽  
Vertebral Artery ◽  
Brain Stem ◽  
Radial Artery ◽  
Posterior Inferior Cerebellar Artery ◽  
Occipital Artery ◽  
Radial Artery Graft ◽  
Muscle Testing ◽  
Artery Graft ◽  
Cerebellar Artery

Background: Giant thrombosed vertebral artery aneurysms (GTVAs) are difficult disease to treat. Here, we are reporting a case of GTVA successfully treated with excluding the pathological segment and restoring the anterograde blood flow of the parent artery, highlighting the reliable surgical procedure. Case Description: A 55-year-old man with a left GTVA complained of right hemiparesis (manual muscle testing 4/5) represented by hand clumsiness and gait disturbance, in addition to severe left-sided dysesthesia, was referred to our hospital. The posterior inferior cerebellar artery (PICA) was incorporated into the GTVA segment, and the contralateral vertebral artery showed atherosclerotic change. Thus, we decided to treat the aneurysm with aneurysm trapping and thrombectomy, in conjunction with V3-radial artery graft (RAG)-V4 bypass and occipital artery (OA)-PICA bypass through a suboccipital transcondylar approach. The distal end of the dilated segment was meandering and deflecting outwardly to the vicinity of the internal auditory canal and was stretched in an axial direction. Thus, the V4 stump can be transposed to the triangle space made by the medulla, lower cranial nerves, and sigmoid sinus, and we could perform a safe and reliable anastomosis through the corridor. After the surgery, the compression of the brain stem was released, and right hemiparesis was improved completely after rehabilitation. The patient was discharged with a modified Rankin Scale score of 1. Conclusion: Trapping of the aneurysm and thrombectomy are the most radical treatment for GTVA, and if possible, reconstruction of anterograde blood flow with V3-RAG-V4 bypass and OA-PICA bypass is desirable.

scholarly journals High-flow bypass with radial artery graft for cavernous carotid aneurysms: A case series

2020 ◽  
Vol 15 (4) ◽  
pp. 863
Author(s):  
BoonSeng Liew ◽  
Riki Tanaka ◽  
Kento Sasaki ◽  
Kyosuke Miyatani ◽  
Tsukasa Kawase ◽  
...  
Keyword(s):  
Radial Artery ◽  
Case Series ◽  
High Flow ◽  
Radial Artery Graft ◽  
Artery Graft ◽  
Carotid Aneurysms ◽  
Cavernous Carotid Aneurysms

scholarly journals High-flow bypass with radial artery graft for cavernous carotid aneurysm

2020 ◽  
Vol 15 (3) ◽  
pp. 678
Author(s):  
RaghavendraKumar Sharma ◽  
Ambuj Kumar ◽  
Riki Tanaka ◽  
Yashuhiro Yamada ◽  
Katsumi Takizawa ◽  
...  
Keyword(s):  
Radial Artery ◽  
High Flow ◽  
Radial Artery Graft ◽  
Artery Graft ◽  
Cavernous Carotid Aneurysm

scholarly journals High flow bypass for right giant cavernous internal carotid artery aneurysm with fibromuscular dysplasia of cervical internal carotid artery: microsurgical 2-D video

2020 ◽  
Vol 11 ◽  
pp. 177
Author(s):  
Miguel Angel Lopez-Gonzalez ◽  
Xiaochun Zhao ◽  
Dinesh Ramanathan ◽  
Timothy Marc Eastin ◽  
Song Minwoo
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Radial Artery ◽  
Fibromuscular Dysplasia ◽  
Internal Carotid ◽  
High Flow ◽  
Oculomotor Nerve Palsy ◽  
Radial Artery Graft ◽  
Artery Graft ◽  
Cervical Internal Carotid Artery

Background: It is well known that intracranial aneurysms can be associated to fibromuscular dysplasia (FMD). Nevertheless, it is not clear the best treatment strategy when there is an association of giant symptomatic cavernous carotid aneurysm with extensive cervical internal carotid artery (ICA) FMD. Case Description: We present the case of 63 year-old right-handed female with hypothyroidism, 1 month history of right-sided pulsatile headache and visual disturbances with feeling of fullness sensation and blurry vision. Her neurological exam showed partial right oculomotor nerve palsy with mild ptosis, asymmetric pupils (right 5 mm and left 3mm, both reactive), and mild exotropia, normal visual acuity. Computed tomography angiogram and conventional angiogram showed 2.5 × 2.6 × 2.6 cm non-ruptured aneurysm arising from cavernous segment of the right ICA. She had right hypoplastic posterior communicant artery, and collateral flow through anterior communicant artery during balloon test occlusion and the presence of right cervical ICA FMD. The patient was started on aspirin. After lengthy discussion of treatment options in our neurovascular department, between observations, endovascular treatment with flow diverter device, or high flow bypass, recommendation was to perform high flow bypass and patient consented for the procedure. We performed right-sided pterional trans-sylvian microsurgical approach and right neck dissection at common carotid bifurcation under electrophysiology monitoring (somatosensory evoked potentials and electroencephalography); while vascular surgery department assisted with the radial artery graft harvesting. The radial artery graft was passed through preauricular tunnel, cranially was anastomosed at superior trunk of middle cerebral artery, and caudally at external carotid artery (Video). Intraoperative angiogram showed adequate bypass patency and lack of flow within aneurysm. The patient was extubated postoperatively and discharged home with aspirin in postoperative day 5. Improvement on oculomotor deficit was complete 3 weeks after surgery. Conclusion: Nowadays, endovascular therapy can manage small to large cavernous ICA aneurysms even if associated to FMD, although giant symptomatic cavernous carotid aneurysms impose a different challenge. Here, we present the management for the association of symptomatic giant cavernous ICA aneurysm and cervical ICA FMD with high flow bypass. We consider important to keep the skills in the cerebrovascular neurosurgeon armamentarium for the safe management of these lesions.

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