ICG Flow 800 technology targeted STA-MCA microvascular bypass for exclusion of deep-seated fusiform MCA aneurysm: 2-dimensional operative video

The authors present the case of an 18-year-old male with a deep-seated left fusiform dissecting M3 aneurysm for which endovascular treatment was not applicable. At the open surgery, they used the less commonly reported FLOW 800 fluorescent indocyanine green (ICG) videoangiography, before and after parental aneurysmal artery temporary clipping, to locate the distal outflow branch of the aneurysm and use it as the recipient artery for a superficial temporal artery–M4 bypass, excluding the aneurysm by clipping the parental artery. Repeated ICG FLOW 800 angiography confirmed bypass patency and adequate blood flow. The aneurysm’s exclusion from circulation was confirmed by digital subtraction angiography postoperatively. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21183

Can concomitant above-knee femoropopliteal bypass with artificial graft affect the outcome of femorofemoral bypass with artificial graft?

Objectives Few have studied the effect of concomitant femoropopliteal (FEM-POP) bypass surgery on the outcome of femorofemoral (FEM-FEM) bypass in patients with peripheral arterial disease (PAD). This study was aimed to analyze the risk relationship of concomitant FEM-POP bypass on the patency of FEM-FEM bypass. Methods From March 2009 to April 2020, a total of 27 patients who underwent FEM-FEM bypass surgery using polytetrafluoroethylene grafts were retrospectively analyzed according to concomitant FEM-POP bypass surgery. The mean follow-up duration was 38.20 ± 34.56 months. Results The overall primary patency of the FEM-FEM bypass grafts in all 27 patients was 83.7, 78.5, and 72.0 at one, two, and 3 years, respectively. The overall limb salvage rate was 100, 94.1, and 86.9 at one, two, 3 years, respectively. Among them, ten patients underwent FEM-FEM bypass only (group 1). The other 17 patients needed a concomitant FEM-POP bypass and these patients were classified into three groups (group 2, ipsilateral FEM-POP, n = 5; group 3, crossover FEM-POP, n = 6; and group 4, bilateral FEM-POP, n = 6) The comparison of the primary patency of group 1 with the concomitant FEM-POP groups (sum of groups 2, 3, and 4, that is, group 5, n = 17) revealed a statistically significant improved patency for FEM-FEM bypasses not requiring concomitant infra-inguinal bypass ( p = .036). Among the concomitant FEM-POP groups, group 2 had the lowest primary patency of the FEM-FEM bypass significantly ( p = 0.07). The limb salvage rate of group 4 was significantly low. Conclusions A concomitant FEM-POP bypass influenced the outcome of FEM-FEM bypass surgery. In conclusion, compromised infra-inguinal runoff at either extremity requiring concomitant FEM-POP bypass significantly worsens long-term FEM-FEM bypass patency. In addition, a concomitant bilateral FEM-POP bypass is a risk factor affecting the limb salvage rate in FEM-FEM bypass.

Combined standard bypass and parent artery occlusion for management of giant and complex internal carotid artery aneurysms

BackgroundComplex aneurysms do not have a standard protocol for treatment. In this study, we investigate the safety and efficacy of microsurgical revascularization combined with parent artery occlusion (PAO) in giant and complex internal carotid artery (ICA) aneurysms.MethodsBetween 1998 and 2017, 41 patients with 47 giant and complex ICA aneurysms were treated by an a priori planned combined treatment strategy. Clinical and radiological outcomes were stratified according to mRS and Raymond classification. Bypass patency was assessed. Median follow-up time was 3.9 years.ResultsAfter successful STA–MCA bypass, staged endovascular (n=37) or surgical (n=1) PAO was executed in 38 patients following a negative balloon occlusion test. Intolerance to PAO led to stent/coil treatments in two patients. Perioperative bypass patency was confirmed in 100% of completed STA–MCA bypass procedures. Long-term overall bypass patency rate was 99%. Raymond 1 occlusion and good outcome were achieved in 95% and 97% (mRS 0–2) of cases, respectively. No procedure-related mortality was encountered. Eighty-four percent of patients with preoperative cranial nerve compression syndromes improved during follow-up.ConclusionsThe combined approach of STA-MCA bypass surgery followed by parent artery occlusion achieves high aneurysm occlusion and low morbidity rates in the management of giant and complex ICA aneurysms. This combined indirect approach represents a viable alternative to flow diversion in patients with cranial nerve compression syndromes or matricidal aneurysms, and may serve as a backup strategy in cases of peri-interventional complications or lack of suitable endovascular access.

One-donor, two-recipient extracranial-intracranial bypass series for moyamoya and cerebral occlusive disease: rationale, clinical and angiographic outcomes, and intraoperative blood flow analysis

OBJECTIVE Cerebral extracranial-intracranial (EC-IC) direct bypass is a commonly used procedure for ischemic vasculopathy. A previously described variation of this technique is to utilize one donor artery to supply two recipient arteries, which the authors designate as 1D2R. The purpose of this study is to present a single surgeon’s series of 1D2R direct bypasses for moyamoya and ischemia using detailed clinical, angiographic, and intraoperative blood flow measurement data. To the authors’ knowledge, this is the largest series reported to date. METHODS Hospital, office, and radiographic imaging records for all patients who underwent cerebral revascularization using a 1D2R bypass by the senior author were reviewed. The patients’ demographic information, clinical presentation, associated medical conditions, intraoperative information, and postoperative course were obtained from reviewing the medical records. RESULTS A total of 21 1D2R bypasses were performed in 19 patients during the study period. Immediate bypass patency was 100% and was 90% on delayed follow-up. The mean initial cut flow index (CFI(i)) was 0.64 ± 0.33 prior to the second anastomosis and the mean final value (CFI(f)) was 0.94 ± 0.38 after the second anastomosis (p < 0.001). The overall bypass flow increased on average by 50% (mean 17.9 ml/min, range −10 to 40 ml/min) with the addition of the second anastomosis. There was no significant difference in the overall flow measurements when the end-to-side anastomosis or side-to-side anastomosis was performed first. There was a statistically significant difference in the proportion of patients with a modified Rankin Scale (mRS) score of 0 or 1 postoperatively compared to preoperatively (p < 0.01). Through the application of Poiseuille’s law, the authors analyzed flow dynamics, deduced the component vascular resistances based on an analogy to electrical circuits and Ohm’s law, and introduced the new concepts of “second anastomosis relative augmentation” and “second anastomosis sink index” in the evaluation of 1D2R bypasses. CONCLUSIONS The application of the 1D2R technique in a series of 19 consecutive patients undergoing direct EC-IC bypass for flow augmentation demonstrated high patency rates, statistically significantly higher CFIs compared to 1D1R, and improved mRS scores at last clinical follow-up. Additionally, the technique allows a shorter dissection time and preserves blood flow to the scalp. The routine utilization of intraoperative volumetric flow measurements in such surgeries allows a deeper understanding of the hemodynamic impact on individual patients.

The effect of the stented iliac lesions TASC-II C, D on the femoropopliteal bypass patency: Propensity score-matched observational study

Introduction Concurrent stenting of complex iliac lesions during infrainguinal bypasses can increase the complexity of a case and impact outcomes. Objective Our aim was to evaluate the effect of inflow stenting of TASC-II C, D iliac lesions on femoropopliteal bypass patency. Methods A retrospective observational cohort study of patients who underwent femoropopliteal bypass with TASC-II C, D iliac artery stenting (hybrid group) or without inflow lesions (non-hybrid group) was conducted. After propensity score matching, 120 patients were included in the non-hybrid group and 60 patients in the hybrid one. The median follow-up was 432 (193; 1313) days in the hybrid group and 472 (196; 1376) days in the non-hybrid group ( p = 0.94). Results No significant differences were found between the groups in 30-day morbidity and serious adverse events. At 3 years, primary and secondary bypass patency for the hybrid group and non-hybrid group were 62.2% versus 59.9% ( p = 0.36) and 63.7% versus 64.3% ( p = 0.077), respectively. The primary patency of the iliac stents in patients of the hybrid group was 95% at 3 years. The estimated hazard ratio for primary patency for hybrid versus non-hybrid was 0.77, with 90% CI: 0.50–1.21; the noninferiority upper bound being 1.31, which corresponds to a 10% additive noninferiority margin for probabilities. The 3 years of freedom from amputation in patients with chronic limb-threatening ischemia was 94.1% and 75.0% in the hybrid and non-hybrid groups, respectively ( p = 0.09). Conclusion The outcomes of the femoropopliteal bypass in hybrid surgery supplemented with stenting of TASC-II C, D iliac lesions was similar to femoropopliteal bypass with intact inflow arteries.

Open Surgical Secondary Interventions are More Durable than Endovascular Interventions for Lower Extremity Bypass Stenosis or Occlusion

Objectives: Lower extremity bypasses often require secondary interventions to maintain patency. Our objectives were to characterize effectiveness of secondary interventions to maintain or restore bypass graft patency, and to compare outcomes of open and endovascular interventions. Methods: We reviewed patients who underwent lower extremity bypass at our institution from 2007 to 2010. We recorded the index bypass and subsequent ipsilateral interventions performed through 2018 or until loss of secondary patency. Patient, procedure, and anatomic data were collected. Endovascular intervention was compared with open/hybrid intervention. For outcome analysis, patency measures were defined relative to the time of the secondary intervention rather than the time of the index bypass. Results: 174 secondary interventions (56 open/hybrid, 118 endovascular; 42 for graft occlusion, and 132 for stenosis) treating 228 lesions in 97 bypasses were available for study. The index bypass was most commonly performed for tissue loss (71.1%), utilized a tibial artery target (57.7%), and used single-segment great saphenous vein (59.8%) rather than alternative vein (32.0%) or prosthetic (8.2%). A higher portion of open/hybrid interventions (51.8%) were done for graft occlusion than endovascular interventions (11.0%, P < .001). Mean follow-up for secondary interventions was 3.5 years. A multivariate Cox proportional hazards model identified female gender, prior MI, anticoagulation, occlusion, and endovascular intervention as predictors of loss of primary patency. Intervention for occlusion predicted poorer primary and secondary patency. Endovascular intervention was associated with poorer primary patency as compared to open intervention and a trend toward poorer secondary patency. Conclusions: Both open and endovascular secondary interventions on lower extremity bypasses are low-risk procedures that offer acceptable patency. Although more commonly performed in the setting of graft occlusion, open surgical interventions show improved durability compared to endovascular interventions. Some patients, including those with occluded grafts, may benefit from more liberal use of open surgical intervention to restore bypass patency.

Cerebral Bypass for Aneurysms in the Era of Flow Diversion: Single-Surgeon Case Series

BACKGROUND With recent advances in endovascular treatments of brain aneurysms such as flow diverters, the role of cerebral revascularization needs to be re-evaluated. OBJECTIVE To evaluate the contemporary indications and outcomes of cerebral revascularization for brain aneurysms. METHODS A retrospective evaluation of a prospectively maintained database was performed to review clinical and imaging data of all the patients who underwent cerebral revascularization for brain aneurysms over the past 10 yr. RESULTS Among 174 cerebral revascularizations, 40 (in 36 patients) were done for the treatment of aneurysms. In total, 9 patients underwent combined endovascular treatment and surgical revascularization. Immediate aneurysm occlusion was achieved in 30 patients (83.3%). Immediate postoperative bypass patency was confirmed in 33 patients (92%). Postoperative neurological deficit was observed in 4 patients (11.1%). There were 2 mortalities in the postoperative period. Aneurysm total occlusion rate was 91% at 1 yr. Thirty patients had 1 yr clinical and radiological follow-up. Clinical evaluations showed modified Rankin Scale 2 or less in 25 patients at 1 yr. Bypass patency was confirmed in 27 (90%). Patients with fair/poor outcome were all in the subarachnoid hemorrhage group. Twenty-one patients had follow-up studies for 3 yr or beyond with no evidence of stroke or aneurysm recurrence. CONCLUSION Our results support that cerebral revascularization can be regarded as a viable and durable treatment option for these challenging aneurysms with acceptable morbidity. Cerebral bypass should be offered in selected cases where standard endovascular or surgical treatment is not efficacious or curative.

Critical limb ischemia potential gene therapy strategies

Revascularization is accomplished in 90–95% of CLI patients, according to current data. These findings indicate the increasing involvement of endovascular options (tibial angioplasty) in the last 5 years, indicated in the phrase "endovascular first" and often used in relativized indication. How long this more rigorous under-the-knee treatment will endure in a group of vascular patients with diabetes is uncertain. There is no reliable long-term evidence on how often and/or how quickly these patients need to be hospitalized to have their limbs amputated or CLI treatment. "10-30% of CLI patients can not be revascularized," most sources say.Vascular doctors require precise tools to analyze results to manage treatment for patients with limb-threatening ischemia. Historically, bypass-patency rates, amputation of larger limbs, and death were the most often used endpoints for measuring therapeutic efficacy. Because they're easy to recognize and document, they're important in clinical research. While more difficult to define and track, quality of life and functional status are more probable predictors of success.Amputation is not always necessary when standard revascularization is no longer an option for the patient, based on this paper's findings. Not every CLI patient is the same, and the effects of careful wound care alone in selected high-risk patients should not be overlooked. Also, some of the procedures/therapies discussed in this article may be appropriate for certain individuals. These techniques can be employed in patients with resting pain or non-healing wounds who have extensive minor artery disease, and no distal artery targets for standard open or endovascular revascularization, according to a literature review. As a reason, they are considered a last resort treatment when amputation seems to be the only plausible alternative decision. The hardest component of a vascular medicine specialist's work is to decide whether treatment is suitable for a given patient.

Effects and safety of aspirin use in patients after cerebrovascular bypass procedures

ObjectSuperficial temporal artery to middle cerebral artery (STA-MCA) bypass is the most effective treatment for Moyamoya disease (MMD). In this study, we aimed to assess whether aspirin improves STA-MCA bypass patency and is safe in patients with MMD.MethodsWe performed a retrospective medical record review of patients with ischaemic-onset MMD who had undergone STA-MCA bypass at two hospitals between January 2011 and August 2018, to clarify the effects and safety of aspirin following STA-MCA bypass. The neurological status at the last follow-up (FU) was compared between patients with FU bypass patency and occlusion.ResultsAmong 217 identified patients (238 hemispheres), the mean age was 41.4±10.2 years, and 51.8% were male; the indications for STA-MCA bypass were stroke (48.2%), followed by a transient ischaemic attack (44.0%). Immediate bypass patency was confirmed in all cases. During the FU period (1.5±1.5 y), 15 cases were occluded at FU imaging, resulting in an overall cumulative patency rate of 94%. The patency rates were 93% and 94% in the short-term FU group (n=131, mean FU time 0.5±0.2 years) and long-term FU group (n=107, mean FU time 4.1±3.5 years), respectively. The STA-MCA bypass patency rate in the aspirin group was higher than that in the non-aspirin group (98.7% vs 89.7%; HR 1.57; 95% CI 1.106 to 2.235; p=0.012). No significant difference in the FU haemorrhagic events was observed between the aspirin and non-aspirin groups.ConclusionsAmong adult patients with ischaemic-onset MMD undergoing STA-MCA bypass procedures, aspirin might increase the bypass patency rate, without increasing the bleeding risk. FU bypass patency may be associated with a better outcome. Additional studies, especially carefully designed prospective studies, are needed to address the role of aspirin after bypass procedures.

Intraoperative Transradial Angiogram

Intraoperative angiogram (IOA) is a valuable tool for cerebrovascular surgery. It confirms surgical outcomes for a variety of pathologies. It allows early identification of any residue or compromise of a parent vessel. This chapter will delve into the advantages, limitations, and technical nuances of IOA via a radial approach. IOA is a valuable tool for cerebrovascular surgery. IOA allows early diagnosis and identification of any residue and obviates the need for postoperative diagnostic angiogram. It confirms surgical outcomes for a variety of pathologies such as aneurysm occlusion and parent vessel patency, arteriovenous malformation resection, dural fistula ligation, bypass patency, and adequate carotid revascularization after endarterectomy. Though there are alternatives, such as indocyanine green fluorescence (ICGA) angiography, formal angiography remains the gold standard as it overcomes the limitations of ICGA. Femoral access has been the main approach for IOA with an excellent safety profile. Recently the radial approach has been gaining wide interest among neurointerventionalists, and there are several advantages for the radial approach over the femoral approach in IOA.