Cerebral Bypass Using the Descending Branch of the Lateral Circumflex Femoral Artery: A Case Series

Abstract

BACKGROUND: When performing extracranial to intracranial (EC-IC) and intracranial to intracranial (IC-IC) bypass, the choice of donor vessel and interposition graft depends on several factors: vessel size and accessibility, desired blood flow augmentation, revascularization site anatomy, and pathology. The descending branch of the lateral circumflex femoral artery (DLCFA) is an attractive conduit for cerebrovascular bypass. OBJECTIVE: To present our institutional experience using DLCFA grafts for cerebral revascularization. METHODS: Retrospective review of perioperative data and outcomes for patients undergoing cerebrovascular bypass surgery using a DLCFA graft from 2016 to 2019. RESULTS: Twenty consecutive patients underwent EC-IC bypass using a DLCFA interposition graft. Bypass indications included 13 (65%) intracranial aneurysms, 4 (20%) medically refractory atherosclerotic large artery occlusions (internal carotid artery or middle cerebral artery), 2 (10%) internal carotid artery dissections, and 1 (5%) patient with moyamoya disease. Most commonly, a donor superior temporal artery was bypassed to a recipient middle cerebral artery (14 of 20; 70%). Two cases demonstrated graft spasm. Graft occlusion occurred in one patient and was asymptomatic. Perioperative bypass surgery-related ischemia occurred in 3 patients: 1 patient with insufficient bypass flow, 1 patient with graft stenosis because of an adventitial band, and 1 patient with focal status epilepticus in the bypassed territory resulting in cortical ischemia. One donor site hematoma occurred. The median (range) modified Rankin scale (mRS) score on follow-up was 1.5 (1-4) at 7.8 (1-27) months, with most patients achieving good functional outcomes (mRS ≤2). CONCLUSION: The DLCFA is a versatile graft for cerebral revascularization surgery, demonstrating good outcomes with minimal graft harvest site morbidity and an acceptable graft patency rate.

Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series

“…This also avoids the need for dissection of the often torturous OA or harvest of an interposition graft (as needed with other EC-IC options), or performance of a deep anastomosis (as needed with excision and re-anastomosis/re-implantation strategies) (9,33). In cases where the contralateral PICA is not favorable for side-to-side IC-IC bypass, the DLCFA is well-sized for PICA revascularization and can be used as an interposition graft with a V3, OA, or even the contralateral PICA as a donor vessel (10,11). Regardless of the bypass strategy used, when combined with endovascular sacrifice of the proximal PICA (and VA as needed), extended skull base approaches to reach the distal VA/PICA origin anterolateral to the brainstem can be avoided.…”

“…This strategy avoids the need for long interposition grafts to reach into the interhemispheric fissure from the external carotid artery (ECA) circulation for ACA revascularization, while also avoiding surgical manipulation of the perforator rich A1/A2 region for aneurysms with expected scarring or wall friability. For PCA revascularizations as part of combined treatments of complex proximal PCA aneurysms, IC-IC constructs are less favorable, and we prefer to use a DLCFA interposition graft to connect the OA to a P3 or P4 vessel (again avoiding a timeconsuming full OA dissection) (7,10,11). This can be followed by proximal PCA endovascular sacrifice, avoiding temporal lobe retraction and potential venous compromise from an additional open subtemporal approach, as well as the manipulation of often sub-optimally visualized sensitive proximal PCA perforators.…”

“…Management and planning of combined open revascularization and endovascular treatment of all patients in this series was based on multidisciplinary (open and endovascular) neurosurgical review of the patient, and neurovascular and pathologic anatomy. Surgical details for open revascularization strategies are described previously (7)(8)(9)(10)(11). All patients were maintained on aspirin in the peri-operative and post-operative period to promote bypass patency.…”

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series

“…It also limits total ischemia time, with the mean clip time of 45 minutes in this series comparable with reported clip times from single-vessel IC-IC or EC-IC anastomoses. 19,20 Surgical efficiency is also optimized with this technique using an expedited transition to back wall suturing for side-to-side anastomosis 18 and running stitches along all anastomosis sites. Despite the theoretical occlusion risk of the triple vessel anastomosis and the potential for multiterritory stroke with bypass occlusion or during cross-clamping, the 100% patency rate in this series is in line with the reported high patency rates of singleanastomosis IC-IC and medium-flow to high-flow EC-IC constructs.…”

Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

“…The remaining open cerebrovascular cases are increasing in complexity and require innovative and multidisciplinary surgical teams. [3][4][5][6][7][8][9][10][11] The current trends are creating an ever-increasing divide between the skills and judgment required for endovascular vs open cerebrovascular surgery. Adding to this increasing gulf are the varied training paths to endovascular practice.…”