Microsurgical neurovascular anastomosis: The example of superficial temporal artery to middle cerebral artery bypass. Technical principles

Abstract

The superficial temporal artery to the middle cerebral artery (STA-MCA) bypass is a good example of cerebrovascular anastomosis. In this article, we describe the different stages of the procedure: patient installation, superficial temporal artery harvesting, recipient artery exposure, microsurgical anastomosis, and closure of the craniotomy. When meticulously performed, with the observance of important details at each stage, this technique offers a high rate of technical success (patency>90%) with a very low morbi-mortality (respectively 3% and 1%). Some anesthetic parameters have to be considered to insure perioperative technical and clinical success. STA-MCA bypass is a very useful technique for the management of complex or giant aneurysms where surgical treatment sometimes requires the sacrifice and revascularization of a main arterial trunk. It is also a valuable option for the treatment of chronic and symptomatic hemispheric hypoperfusion (Moyamoya disease, carotid or middle cerebral artery occlusion).

EC-IC Bypass; Our experience of cerebral revascularization with intraoperative Dual-Image Video Angiography (Diva)

“…Thines et al . [ 14 ] discussed the role of perfect dural closure to prevent wound complications in the perioperative period.…”

Effect of Adventitial Dissection of Superficial Temporal Artery on the Outcome of Superficial Temporal Artery-Middle Cerebral Artery Bypass in Moyamoya Disease

“…For STA-MCA bypass, periadventitial tissue layers of STA are normally kept intact with removing conjunctive and adventitial tissues only within 1 cm of the distal end for anastomosis [30] [2, 31, 32]. In the present study, denervation was achieved by removal adventitia and surrounding fascia at 4-5 cm of the distal end of STA.…”

“…Part of the donor vessel under the bone flap was unfolded to fit the bone flap and the dura to reduce the bending. There were 8 patients in the control group in which adventitial and conjunctive tissue were dissected and removed no more than 1 cm from distal end of STA [2]. The patency of anastomosis was determined using intraoperative near-infrared indocyanine green angiography (ICGA).…”

“…Superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery is a technique that allows low blood flow supply from the extracranial carotid to the distal MCA [1, 2]. STA-MCA bypass procedure has been adopted for the treatment of cerebrovascular occlusive disease and as an adjunct treatment for complex intracranial aneurysms [1].…”

Is Precise Targeting of the Recipient Artery in a Superficial Temporal Artery–Middle Cerebral Artery Anastomosis Crucial?

“…The most commonly selected recipient has been an easily accessible distal branch of the MCA (M3 or M4), preferably away from the craniotomy edges, with a large enough caliber matching a donor STA branch and proper wall thickness/ Target versus Nontarget Bypass Katano et al 445 stiffness without atherosclerotic change. 23 In the Visual group of the present study, the surgeons essentially selected the recipient artery in the manner just described during the operation. Peña-Tapia et al 24 reported a contrivance that allowed them to perform a 3-cm craniotomy at exactly the most suitable site with a transparent plastic template indicating a horizontal line as an orbitomeatal line and a 5-cm straight vertical line to mark the target point.…”