Extracranial to intracranial by-pass anastomosis: Review of our preliminary experience from a low volume center in Egypt

Abstract

Background:Cerebral revascularization is a useful microsurgical technique for the treatment of steno-occlusive intracranial ischemic disease, complex intracranial aneurysms that require deliberate occlusion of a parent artery and invasive skull base tumors. We describe our preliminary experience with extracranial-to-intracranial by-passes at a low volume center; and discuss clinical indications and microsurgical techniques, challenges in comparison to large advanced referral centers.Materials and Methods:Twenty-seven patients with hemodynamic ischemia or complex aneurysms or skull base tumors were operated at Cairo University Hospitals in the period between May 2009 and June 2014. All patients operated by a low flow by-pass were operated through a superficial temporal artery to middle cerebral artery (MCA) anastomosis. All patients chosen for a high flow by-pass were operated using a radial artery graft interposed between the MCAs distally and the common or the external carotid artery proximally. Patency was confirmed at the end of surgery using appearance on the table and confirmed after surgery by transcranial color-coded duplex or computed tomography angiography. All patient data were prospectively collected and retrospectively analyzed at the end of surgery.Results:Nineteen patients (70.4%) were operated upon for flow augmentation and eight patients (29.6%) were operated upon for flow replacement. A total of 30 anastomoses were performed. All except one were patent which gives a patency rate of 96.3%. There was one death in the present series resulting from a hyperperfusion syndrome. 89.5% of patients with hemodynamic ischemia stopped having symptoms after surgery. All but one patient operated for hemodynamic ischemia showed a considerable cognitive improvement after surgery. None of the patients operated upon for flow replacement showed improvement of oculomotor nerve function in spite of adequate intraoperative decompression. All patients treated for flow replacement showed the absence of recurrence on follow-up.Conclusion:Our initial results for both low and high flow by-pass procedures in our low volume center indicate that such complex surgical procedures are possible with results comparable to those obtained in other larger referral centers throughout the world. This procedure not only represents a more definitive treatment when compared to other endovascular or radiation treatments but is also much less costly when compared to other treatment modalities.

EC‐IC bypass for cerebral revascularization following skull base tumor resection: Current practices and innovations

“…Fifteen articles were added to the study from searching the references of papers encountered through the literature search. After the second group reviewed the remaining 78 articles, 27 were selected that had sufficient data about extracranial‐intracranial bypass for tumors that could be analyzed in the final review (Table ) …”

“…Knowledge can be gained by reviewing the literature and building on those advances and experience. Approximately 368 reported cases exist of cerebral revascularization following large vessel sacrifice for tumor resection with vascular replacement through EC‐IC bypass. This excludes case reports and case series with less than three patients.…”

“…Of the studies included in the review, many articles did not indicate whether total resection of the tumor was achieved. Many articles report that tumor‐free survival can be achieved with an aggressive approach .…”

“…Alexis Carrel is credited for performing the first vascular anastomotic procedure in 1914. His techniques allowed for innovations and new surgical solutions for pathology in vascular surgery, cerebrovascular surgery, and microsurgery . In 1953, Conley performed a saphenous vein graft (SVG) bypass of the cervical internal carotid artery (ICA) to accomplish tumor resection .…”

“…His techniques allowed for innovations and new surgical solutions for pathology in vascular surgery, cerebrovascular surgery, and microsurgery . In 1953, Conley performed a saphenous vein graft (SVG) bypass of the cervical internal carotid artery (ICA) to accomplish tumor resection . In 1969, the idea of creating new arteries or replacing existing arteries that supply cerebral prefusion was tested with the first EC‐IC bypass surgery by Donaghy and Yasargil .…”