Abstract
While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons’ expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.
Keywords: extracranial intracranial bypass, cerebrovascular surgery, microsurgery, plastic surgery
Résumé
Des pontages extracrâniens/intracrâniens (EC/IC) sont régulièrement réalisés par les neurochirurgiens spécialisés en chirurgie neurovasculaire, mais ils peuvent aussi être exécutés en collaboration avec des chirurgiens esthétiques ayant l’expertise de la chirurgie microvasculaire. Dans notre établissement, certains cas de pontage EC/IC ont évolué pour être réalisés par des neurochirurgiens et des chirurgiens esthétiques dans une approche combinée. Compte tenu de l’expertise et de la vaste expérience des chirurgiens esthétiques dans le domaine de la chirurgie microvasculaire, leur compétence peut être utilisée pour la réalisation de la dissection du vaisseau donneur de même que pour le pontage proprement dit. Cet article présente un point de vue canadien sur la collaboration entre chirurgiens esthétiques et neurochirurgiens pour la réalisation de pontages EC/IC ainsi qu’un rapport de cas illustrant l’utilisation d’une veine dorsale de la main en forme de Y comme greffon pour le pontage EC/IC, ce qui n’a pas été décrit dans la littérature à ce jour.
Mots-clés: Pontage extracranien-intracranien, chirurgie cérébrovasculaire, microchirurgie, chirurgie esthétique
Introduction
While extracranial-intracranial (EC-IC) bypass is commonly performed by neurosurgeons with specific expertise in cerebrovascular surgery, they can also be performed together with microvascular plastic surgeons. At our institution, some EC-IC bypass cases have evolved to be performed by neurosurgeons and plastic surgeons in a combined approach. Given the plastic surgeons’ expertise and volume of experience in performing microvascular surgery, their skills are utilized in performing the donor vessel dissection as well as the bypass itself. This paper outlines a Canadian perspective on collaboration between plastic surgeons and neurosurgeons in performing EC-IC bypass along with a case report illustrating the use of a dorsal hand Y-shaped vein graft for EC-IC bypass, which has not been described in the literature to date.
Case Report
A 56-year-old patient presented with a giant partially thrombosed left middle cerebral artery aneurysm which was resistant to treatment over many years. Previous treatments included a clip reconstruction procedure, however, the aneurysm continued to dilate and develop into a partially thrombosed lesion with mass effect (Figures 1 and 2). The plan for this patient was to perform an EC-IC bypass, followed by a resection of the aneurysm. Hypothermic circulatory arrest was used in this case for two reasons: to provide the option of additional control of bleeding during aneurysm decompression and to provide neuroprotection during the cross-clamp time of the procedure. After proximal and distal control around the aneurysm was achieved, a double barrel superficial temporal artery (STA)-M2 bypass was performed using a Y-shaped vein graft from the left dorsal hand which was anastomosed to the distal end of the STA in an end-to-end fashion (Figure 3). A vein graft was harvested as there were no suitable options for two branches of the STA to be used for both anastomoses due to size limitations. Each branch of the vein graft was then anastomosed to two separate M2 branches in an end-to-end fashion. Flow through the bypass was confirmed with Doppler ultrasonography. Postoperatively, the patient developed a stroke secondary to ischemia of the M1 perforators, which was likely related to clip placement on the proximal M1. A postoperative angiogram showed the patent vein graft and anastomosis sites (Figure 4). Two days later, the patient was discharged from the intensive care unit with Glasgow Coma Scale (GCS) 14–15, moderate expressive aphasia, and contralateral arm and leg paresis (arm greater than leg). His aphasia and paresis significantly improved during rehabilitation.
Figure 1.
Three-dimensional (3D) reconstruction of the patient's previous craniotomy (left) and intracranial vascular system with recurrent aneurysm thrombosis and surgical clips before anastomosis (right).
Figure 2.
Preoperative digital subtraction angiogram (left internal carotid injection) of the giant partially thrombosed left MCA aneurysm.
Figure 3.
(A) Y-shaped vein graft from dorsal hand and (B) operative field showing positioning and exposure.
Figure 4.
Postoperative digital subtraction angiography of the brain (left common carotid injection) showing the Y-shaped vein graft, patent bypass, and exclusion of the giant aneurysm from circulation.
Discussion
In some EC-IC bypass cases, a collaborative approach with neurosurgery and plastic surgery may optimize success. Depending on the nature of microsurgical expertise at an institution, neurosurgery can involve plastic surgery to perform the donor vessel preparation and the microvascular anastomosis for the procedure. In this report, a Y-shaped vein graft was used from the dorsal hand to perform a double barrel STA-M2 EC-IC bypass. The use of vessel grafts has been reported frequently in the literature for EC-IC bypass with favorable results. Artery options include radial artery,1–4 and vein options include cephalic vein5,6 and saphenous vein.4,5,7–9 This case is the first one reported in the literature which describes using a dorsal hand vein graft to create a double barrel STA-MCA bypass. The pre-existing literature describing plastic surgery involvement in EC-IC bypass is limited to 3 previous reports - two from Taiwan and one from the United Kingdom, all showing bypass patency in the patients that were imaged postoperatively.5,10,11
Conclusion
Given that microvascular surgery is increasingly being performed by plastic surgeons, the wide experience of plastic surgery in microsurgery can be used advantageously in EC-IC bypass. This study provides a Canadian perspective on planning and performing EC-IC bypass jointly with neurosurgeons and plastic surgeons to improve efficiency and outcomes.
Acknowledgments
None.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Financial Disclosures: None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
Presentation: Presented at the 2024 American Society of Reconstructive Microsurgery Annual Meeting and at the 2024 Canadian Society of Plastic Surgeons Annual Meeting.
ORCID iD: Aneesh Karir https://orcid.org/0000-0003-0003-3542
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