Letter: 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

Abstract

To the Editor:We thank Dr Rennert and Dr Russin for their comments regarding our surgical video case. 1,2 As in many high-volume centers, we rely on multidisciplinary cerebrovascular discussions for treatment decision-making, but ultimately, the final decision lies with the patient and the treating surgeon. This patient had undergone endovascular treatments before presenting to the senior author. Upfront open surgical treatment could have also been considered.The salvage bypass surgery was performed less than 6 hours after an attempted mechanical thrombectomy with partial revascularization. The patient initially improved after the thrombectomy; however, their examination again redeteriorated, and rather than performing another endovascular treatment, a bypass strategy was pursued. As the authors state, revascularization surgeries-especially emergency rescue cases-can be challenging due to the difficulty of obtaining adequately trained OR staff and auxiliary surgical services for graft harvest, particularly overnight and on weekends.We considered the external carotid as a donor artery; however, in the setting of a high bifurcation, small external carotid artery, or even an absent external carotid artery, we routinely consider the common carotid artery as a donor site. In this case, the crossclamp time for the common carotid artery anastomosis was approximately 8 to 10 minutes, which is less than an average carotid endarterectomy in our center which takes approximately 15 to 20 minutes.As Dr Russin and Dr Rennert correctly stated, there is a widening gap between open and endovascular training and subsequent expertise. This case demonstrates the continued need for open cerebrovascular expertise and multidisciplinary input in managing complex cerebrovascular pathology.

In Reply: Letter: 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

“…We thank the authors for their thoughtful response to our commentary and their clarification of additional patient history. 1-3 Their thoughtful attention to detail and courage is exactly what is needed when facing such daunting pathology. We again congratulate them on their management and tenacity in the face of a very difficult problem.…”