Side-to-Side and End-to-Side Double Anastomosis Using the Parietal-Branch of the Superficial Temporal Artery—A Novel Technique for Extracranial to Intracranial Bypass Surgery: 3-Dimensional Operative Video

Abstract

In this 3-dimensional video, we perform a side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery (STA) to provide flow augmentation in a symptomatic 59-yr-old male with bilateral internal carotid artery occlusion at the origin, and left M1 segment occlusion. The patient suffered multiple left hemispheric strokes despite maximal medical therapy and was found to have poor hemodynamic reserve in the left hemisphere during evaluation with regional and global blood oxygenation level-dependent functional magnetic resonance imaging with CO2-challenge as well as quantitative magnetic resonance angiography and noninvasive optimal vessel analysis pre- and post-acetazolamide challenge. Postoperatively, the patient did very well and his hemodynamic studies improved significantly. The importance of this technique relies on the fact that we are using a single donor vessel to perform 2 anastomoses, and carries the following advantages: (1) the frontal STA branch remains intact and therefore can still be used at a later time if further revascularization is needed; (2) wound complications related to devascularizing the scalp from harvesting both STA branches are reduced; (3) 2 vascular territories are augmented (frontal and temporal) while using a single donor; (4) we are maximizing donor potential and optimizing cut flow index (CFI; total bypass flow postanastomosis divided by bypass cut flow) by flow augmenting 2 separate vascular beds therefore increasing demand. To explain that fourth point further: if the STA donor is able to carry a maximum 100 mL/min when cut, and after performing the first anastomosis bypass flow is only 37 mL/min, CFI will be 37/100 = 0.37, reflecting low demand, a poor indicator of graft patency, as previously published.1,2 By adding a second anastomosis which demands an additional 60 mL/min from the same STA donor, CFI (60 + 37)/100 improves to 1. Institutional Review Board approval was obtained for the review of patient chart and video files. Informed consent was obtained directly from the patient via telephone regarding use of media for educational and publication purposes.

The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms

“…When the literature was reviewed, other examples of fourthgeneration bypass were found (Table 2). 4,6,19,[33][34][35]39,43,60 The application of sophisticated bypass techniques to address complex aneurysms is the bright spot in the shrinking aneurysm market.…”

The Identification of Factors That Influence the Quality of Bypass Anastomosis and an Evaluation of the Usefulness of an Experimental Practical Scale in This Regard

“…This elucidates why both techniques are used by neurosurgeons. 5,11,20 The time taken to perform the bypass Ensuring that the vessel is closed timeously in a bypass procedure is stressful for the surgeon as delays are associated with adverse brain effects. However, the performance and quality of the bypass are more relevant than stitching the vessels within the stipulated timeframe (of 20 minutes).…”

“…Vital steps need to be taken to ensure the quality of vascular anastomosis during bypass surgery. [1][2][3][4][5][6][7][8][9][10][11] It is critical to ensure that the time taken to minimise blood flow during the procedure is as brief as possible as this is a significant source of stress for the neurosurgeon 12,13 and can impact on the quality of suturing.…”

Surgical techniques and indications for treatment of adult moyamoya disease

“…The unused STA branch improves scalp perfusion to reduce potential wound complications, proving particularly useful in patients with diabetes or peripheral vascular disease. The preserved branch can also be saved for future bypass if needed (13,57). These bypasses can provide up to 50% more flow than a single bypass (39).…”