Angiographic Outcomes of Direct and Combined Bypass Surgery in Moyamoya Disease

Abstract

Objective: To identify associated risk factors for the angiographic outcomes after direct and combined bypass surgery in moyamoya disease (MMD).Methods: All direct and combined bypass procedures performed from June 2009 to May 2015 were screened in this prospective cohort study. Patients who acquired presurgical and follow-up catheter angiography were included. Bypass patency and postoperative collateral formation were evaluated. Univariate and multivariate logistic regression analyses were performed to determine the influence factors for bypass patency and postoperative collateral formation.Results: In total, 188 consecutive bypass procedures were included. After an 18-month median follow-up, the anastomosis patency rate was 88.3%. Postoperative collateral formation was associated with the patency of the anastomosis (Gamma = 0.891, p < 0.001). Multivariate logistic regression analysis showed that presence of hemorrhage (OR, 0.298; 95% CI, 0.125–0.709; p = 0.006) was associated with obstructed anastomosis. Among the 188 bypass surgeries, 125 (63.2%) hemispheres had good postoperative collateral formation and 85 (36.8%) had poor postoperative collateral formation. Multivariate logistic regression analysis showed that younger age at operation (OR, 2.396; 95% CI, 1.231–4.664; p = 0.010) was associated with good postoperative collateral formation, while the poor postoperative collateral formation was related to presence of hemorrhage (OR, 0.329; 95% CI, 0.143–0.758; p = 0.009) and dilated anterior choroidal artery (OR, 0.472; 95% CI, 0.240–0.929; p = 0.030).Conclusions: This study has demonstrated that presence of hemorrhage predicts lower patency rates. Younger age at operation was associated with good postoperative collateral formation, while the poor postoperative collateral formation was related to presence of hemorrhage and dilated anterior choroidal artery.

Early Post-operative CT-Angiography Imaging After EC-IC Bypass Surgery in Moyamoya Patients

“…Overall definite bypass patency after 6 to 12 months was excellent with 98.1% and, therefore, slightly higher than reported in the literature (3,4). One bypass which was confirmed to be occluded in the follow-up DSA was already displayed as non-patent in the post-operative CTA.…”

“…Surgical revascularization with direct extracranial-intracranial (EC-IC) bypass is the most common therapy in adult moyamoya patients (1,2). Long-term bypass patency has been shown to be between 88 and 97% in these patients (3)(4)(5)(6). The risk of bypass occlusion appears highest during the first week after surgery and declines over time as the bypass matures (3).…”

“…Digital subtraction angiography (DSA) is the "gold standard" for the imaging of cerebral vessels (3,4,7,8). However, noninvasive techniques, such as computed tomography angiography (CTA) or time-of-flight magnetic resonance angiography (MR-TOF) can also be used to examine the cerebral vessels with high precision (9)(10)(11)(12)(13).…”

Delayed Anastomotic Occlusion after Direct Revascularization in Adult Hemorrhagic Moyamoya Disease

“…Direct revascularization is currently recognized as the superior treatment paradigm for adult hemorrhagic MMD to reduce the incidence of rebleeding [ 9 , 10 , 20 ]. However, hemorrhagic MMD was indicated to be more prone to delayed anastomotic occlusion compared with ischemic MMD, with a long-term graft patency rate of 54.9–77.5% [ 12 , 13 ]. Such a high rate of anastomotic occlusion prompted us to conduct in-depth research on the mechanism of delayed anastomotic occlusion and its impact on the long-term outcomes.…”

“…Recently, direct or combined revascularization has been recognized as the most effective treatment strategy to reduce the risk of future intracranial hemorrhages in hemorrhagic MMD [ 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. However, Zhao et al and Ge et al, from our institution, demonstrated that hemorrhagic presentation predicts lower patency rates (54.9–77.5%) and unsatisfactory neoangiogenesis after direct/combined bypass [ 12 , 13 ]. Such a high rate of delayed anastomotic occlusion prompted us to conduct an in-depth analysis of this phenomenon.…”