Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Abstract

Background: Patients with chronic atherosclerotic vessel occlusion and cerebrovascular hemodynamic insufficiency may benefit from extra-intracranial (EC-IC) bypass surgery. Due to demographic changes, an increasing number of elderly patients presents with cerebrovascular hemodynamic insufficiency. So far, little data for EC-IC bypass surgery in elderly patients suffering occlusive cerebrovascular disease are available. We therefore designed a retrospective study to address the question whether EC-IC bypass is a safe and efficient treatment in a patient cohort ≥70 years. Methods: 50 patients underwent EC-IC standard bypass surgery with translocation of the superficial temporal artery to an M2 segment of the medial cerebral artery. Criteria for bypass surgery were presence of symptomatic occlusive cerebrovascular disease of the anterior circulation and proof of a severely restricted or abrogated reserve capacity (detected by H₂O-photon emission tomography or single photon emission computer tomography - before and after forced vessel dilatation by diamox). The incidence of perioperative neurological and surgical complications, bypass patency, bypass function and short-term outcome were retrospectively analyzed. Results: The study cohort consisted of 16 patients ≥70 years (mean = 74.3 years, SE 1.3). It was compared to a cohort of 34 patients <70 years (mean = 61.2 years, SE 1.0). Both groups underwent EC-IC bypass surgery after careful preoperative work-up. Both patient groups did not differ significantly in gender, vascular pathology, previous history of diseases/comorbidity or clinical symptoms. The number of patients which underwent stenting or other endovascular treatments of the internal or common carotid artery prior to EC-IC bypass surgery was significantly higher in the group of patients ≥70 years (37.5 vs. 0%, p < 0.001). Perioperative stroke rate was 0% in both groups and mild morbidity occurred in 18.8 and 14.7%, respectively (p = 0.699). One 84-year-old female patient died due to perioperative endocarditis. Initial bypass patency was 93.8% in patients above the age of 70 years and 97.1% in the younger group (p = 0.542). Secondary occlusion rate was low in both groups (≥70 years: 0% vs. <70 years 3.7%). No new neurologic deficit occurred in patients with a patent bypass during the follow-up period (median 18 ± 13.1 months). Two patients with an initially occluded bypass and one with a secondary bypass occlusion suffered from new neurological symptoms. Conclusions: Our data show comparable safety and efficiency of EC-IC bypass surgery in patients under and above the age of 70 years due to a careful preoperative work-up and a strict indication for bypass surgery.

Modern Appraisal of Patency and Complications in Cerebral Bypass Surgery: A Single Institution Experience

“…These rates are compared with previously reported rates of 95% to 100%, 93.8% to 100%, and 93% to 98%, respectively. [35][36][37][38] Intracranial aneurysm cases are typically more complex and urgent, possibly contributing to the observed discrepancy in graft patency rates between our groups. Prophylactic bypasses that might not have been ultimately necessary may have also contributed to a lower patency rate in these cases.…”

Factors Influencing Long-Term Blood Flow in Extracranial-to-Intracranial Bypass for Symptomatic Internal Carotid Artery Occlusive Disease: A Quantitative Study

“…Vasospasm after SAH is a condition that occurs within 2 weeks of ictus, and further investigation is needed to determine whether there is a benefit in long-term patency for bypass surgery, which requires annual follow-up. By contrast, it has been reported that occlusion of the bypass vessel is more common within the first few months after surgery, 13,15,25 and the short-term effect of cilostazol during this period may be related to the long-term results.…”

“…15 In this report, 15 45% of patients (26/58) underwent double bypass; however, this did not significantly affect patency. A cohort study in Germany 13 compared surgical complications and patency between patients older or younger than 70 years and reported a low rate of occlusion in both groups (≥70 years: 0% vs <70 years: 3.7%) with a median follow-up time of 18 ± 13.1 months. The use of antithrombotic agents was described; however, cilostazol use was not identified in any case.…”

Clinical factors influencing the development of extracranial-intracranial bypass graft for steno-occlusive cerebrovascular disease

“…Although the superior effectiveness of bypass surgery over medical therapy was disproved by the COSS study, 9 subsequent single-center series have shown good shortterm and long-term outcomes for bypass surgery in Japan and Europe. 4,10,11 Although patient backgrounds could have differed in those single-center studies, it is extremely important to develop a technically good, patent bypass and to lower perioperative morbidities, which could lead to differences in procedural effectiveness between studies. We must consider the preoperative risk factors relating to ischemic events or symptomatic hyperperfusion.…”

“…8 Furthermore, other studies have also shown the long-term effectiveness of the ECIC bypass in the prevention of ischemic stroke. 2,4,10 These studies have reported good results or good patency with the bypass surgery.…”