Side-to-Side Superficial Temporal Artery to Middle Cerebral Artery Bypass Technique: Application of Fourth Generation Bypass in a Case of Adult Moyamoya Disease

Abstract

BACKGROUND Moyamoya disease (MMD) is a rare cause of cerebral hemorrhage and ischemia. Spontaneous development of collateral supply from the external carotid artery (ECA) may limit the use of donor arteries used in standard direct bypass techniques. OBJECTIVE To identify the technical feasibility of side-to-side (S-S) superficial temporal artery to middle cerebral artery (STA-MCA) bypass and demonstrate the application of fourth generational bypass techniques in the treatment of MMD. METHODS S-S bypass was performed in order to maintain distal outflow in the donor STA. Fourth generation bypass techniques, including atypical anastomosis construction and intraluminal suturing were utilized. RESULTS The novel S-S STA-MCA bypass was performed, with patent flow in both recipient MCA and endogenous ECA-ICA collaterals supplied by the distal STA. Technical nuances, including proper alignment of donor vessel, tension reduction, and S-S anastomosis construction with intraluminal suturing technique are essential for successful bypass. Unique flow properties of this bypass were identified, resulting in flow augmentation to the recipient territory compared to standard end-to-side (E-S) techniques. CONCLUSION Fourth generational bypass techniques can be successfully applied to MMD, allowing for novel bypass construction. S-S anastomosis can result in potentially beneficial flow properties compared to standard E-S constructions.

A flow self-regulating STA-MCA bypass based on side to side fashion anastomosis for adult patients with moyamoya disease

“…Moreover, we did not use the intraluminal suturing techniques which specially designed for S-S anastomsis in this study. 4 Instead, we performed a simpler S-S anastomosis using the suturing technique just like that in E-S anastomosis by flipping over the donor STA along its longitudinal axis ( Video, Supplemental Digital Content ). Of course, this technical modification can only be highlighted for a superficial S-S anastomosis, such as S-S fashion STA-M4 bypass.…”

Training model for the intraluminal continuous suturing technique for microvascular anastomosis

“…Traditionally, the majority of anastomoses are performed extraluminally in an interrupted fashion, and the vessels should be placed with little or no tension. However, in some rare cases, the artery cannot be rotated to fully expose the posterior wall for the anastomoses due to the short stump, important perforators, or deep and narrow surgical corridor 6 – 9 . In this situation, the traditional extraluminal interrupted suturing technique could be very difficult to perform on the posterior wall.…”

“…Regardless of how complex the bypasses are, they are all built with three simple anastomoses: end-to-side, end-to-end, and side-to-side 5 . Traditionally, anastomoses should be performed with the extraluminal interrupted technique, and the surgery must be performed under little or no tension to connect the vessels; however, in some rare situations, the extraluminal interrupted technique is not optimal because the vessels are immobile and cannot be rotated 6 – 9 , and anastomosis can be performed effectively through the intraluminal continuous suturing technique, which is also called the “in situ suturing technique”. The intraluminal continuous suturing technique does not require the vessel to be rotated, the posterior wall of the anastomoses should be sutured in an intraluminal fashion after placing the first two anchoring stitches, and the anterior wall can be easily closed in the traditional way; this technique has been effectively used as a standard technique for side-to-side anastomoses 2 , 8 , 10 , 11 , but it can also be applied in end-to-end and end-to-side anastomoses.…”

A Novel Method of End-to-Side Microvascular Anastomosis Using T-Shaped Metal Stents: A Porcine Study

“…Direct bypass in patients with moyamoya disease is classically treated by end-to-side anastomosis of the superficial temporal artery to the M 4 division of the middle cerebral artery. 10 Three-vessel coronary artery disease is currently treated with coronary artery bypass grafting. The left internal mammary artery is used for bypass grafting and offers superior long-term outcomes compared to venous grafting.…”

“…End-to-side anastomosis using metal stents has not yet been reported, although many end-to-side anastomosis procedures have been described in clinical practice. Direct bypass in patients with moyamoya disease is classically treated by end-to-side anastomosis of the superficial temporal artery to the M 4 division of the middle cerebral artery 10 . Three-vessel coronary artery disease is currently treated with coronary artery bypass grafting.…”