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

Abstract

BACKGROUND: Cerebral bypass is a valuable surgical technique in well-selected patient populations. Updated clinical guidelines and improved surgical techniques warrant a contemporary reevaluation of the complications and patency to inform clinical practice and enhance postoperative patient care. OBJECTIVE: To assess the complication rates and postoperative graft patency for the 3 most common indications for bypass surgery: moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. METHODS: Perioperative notes of 175 consecutive bypass patients at a single institution were retrospectively identified to evaluate the clinical course and complications of surgery. RESULTS: The rate of total postoperative complications between moyamoya disease (9 of 98, 9.2%), intracranial atherosclerotic disease (7 of 57, 12.3%), and intracranial aneurysm (4 of 20, 20%) was not statistically different (P = .33). Immediate postoperative bypass patency was significantly higher in moyamoya disease (90 of 96, 93.8%) and intracranial atherosclerotic disease (48 of 51, 94.1%) than in intracranial aneurysm (13 of 18, 72.2%; P = .02). Intravenous heparin administration during bypass suturing was negatively associated with immediate postoperative patency (87% heparin patency vs 99% no heparin patency; P = .02). Double-barrel bypass trended toward an increased risk of wound healing complications (2 of 13, 15.4%) compared with the single-barrel bypass technique (4 of 156, 2.6%; P = .07). CONCLUSION: Cerebral bypass surgery remains an excellent surgical treatment for moyamoya disease, intracranial atherosclerosis, and intracranial aneurysms. This study suggests bypass is safer in moyamoya disease and intracranial atherosclerosis. Additional studies to clarify the risk of single-barrel vs double-barrel bypass and intraoperative heparin-stratified complications may be beneficial.

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

“…The results and complications reported here are likely to be familiar to most surgeons who perform direct and indirect bypass surgery. The authors reported a total complication rate of 9.2% for moyamoya disease, 12.3% for intracranial atherosclerotic disease, and 20% for bypass for aneurysms, 4 rates which are in line with previous retrospective series and larger prospective studies. 5-9…”

“…The results and complications reported here are likely to be familiar to most surgeons who perform direct and indirect bypass surgery. The authors reported a total complication rate of 9.2% for moyamoya disease, 12.3% for intracranial atherosclerotic disease, and 20% for bypass for aneurysms, 4 rates which are in line with previous retrospective series and larger prospective studies. [5][6][7][8][9] Despite the growing body of literature on the subject of bypass surgery, the procedure remains relatively infrequent, even among surgeons specializing in cerebrovascular disease.…”

“…This technique has gained popularity relatively recently. Although in this series, a trend toward a higher incidence of wound complications was observed, 4 other series have reported that this technique can be performed with low rates of wound complications. 19 The type of incision may play a role here, with linear or curvilinear incisions likely to have less of an issue with wound complications than "Y-shaped" or "T-shaped" incisions.…”

“…In this series, the authors found a negative correlation between heparin administration during suturing and bypass patency (87% with Daniel M. S. Raper, MBBS * Adib A. Abla, MD ‡ heparin vs 99% without, P = .02). 4 This is a counterintuitive finding, and prior experience, along with the mechanism of action of heparin itself, would suggest that the practice is helpful in preventing clot formation in the occluded M4 recipient segment during the suturing of the anastomosis. Other factors, not outlined in the methods of the current report, may contribute to the observation.…”

“…The authors of this single-institution, retrospective series 4 are to be commended for reporting their experience and adding a contemporaneous series to the evidence base of the cerebral bypass literature. The results and complications reported here are likely to be familiar to most surgeons who perform direct and indirect bypass surgery.…”