Wound healing complications after revascularization for moyamoya vasculopathy with reference to different skin incisions

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Moyamoya vasculopathy (MMV) is a steno-occlusive cerebrovascular disease that can be treated by a surgical revascularization. All the revascularization techniques influence the blood supply of the scalp, with a risk for wound healing disorders. The authors’ aim was to analyze the wound healing process in the patients who underwent a direct or combined bypass surgery with a focus on different skin incisions.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors retrospectively identified all the patients with MMV who were treated surgically in their institution. Subsequently, they analyzed demographic data, clinical symptoms, surgical treatment, and detailed history of complications. Based on the evolution of their surgical techniques and the revascularization strategy to be used, the authors applied the following skin incisions: linear incision, curved incision, incomplete Y incision, and complete Y incision. Group comparisons regarding wound healing disorders were performed with significance testing using Fisher’s exact test.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>The authors identified 172 patients with MMV (61.6% moyamoya disease, 7% unilateral moyamoya disease, 29.7% moyamoya syndrome, and 1.7% unilateral moyamoya syndrome), of whom 124 underwent bilateral operations. One-quarter of the patients were juveniles. A total of 236 hemispheres were included in the analysis, of which 27.9% were treated by a combined procedure with encephalomyosynangiosis. Overall, 5.1% major and 1.7% minor wound complications occurred. The overall wound complication rate was lower in direct revascularization compared to combined revascularization (3% vs 15.2%). The lowest incidence of wound healing disorders was found in the linear incision group for the parietal superficial temporal artery branch (1.6%), followed by the incomplete Y incision group for the frontal branch of the superficial temporal artery (3.8%) in the direct bypass group. In the combined revascularization cohort, major or minor wound disorders appeared in 14.3% and 4.8%, respectively, in the complete Y incision group and in 4.2% (for both major and minor) in the curved incision group. The complete Y incision caused significantly more wound healing disorders compared to the remaining incision types (17.1% vs 3.1%, p = 0.007).</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Wound healing disorders are one of the major complications of revascularization surgery. Their incidence depends on the revascularization strategy and skin incision applied, with a complete Y incision giving the worst results.</jats:p></jats:sec>

Limits and pitfalls of indirect revascularization in moyamoya disease and syndrome

“…A relevant technical aspect in surgical revascularization procedures is represented by skin incision. Acker et al analyzed different skin incisions and detected a lower overall wound complication rate in direct revascularization as compared to combined revascularization (3% vs 15.2%) [71]. Their observations emphasized that the complete Y incision may negatively impact wound healing in a significant way, leading to a higher rate of wound healing disorders in comparison to other type of skin incision (17.1% vs 3.1%) [71].…”

“…Acker et al analyzed different skin incisions and detected a lower overall wound complication rate in direct revascularization as compared to combined revascularization (3% vs 15.2%) [71]. Their observations emphasized that the complete Y incision may negatively impact wound healing in a significant way, leading to a higher rate of wound healing disorders in comparison to other type of skin incision (17.1% vs 3.1%) [71]. In order to mitigate these complications, Yokoyama et al suggested three fundamental steps: (a) three-dimensional simulation imaging to confirm STA anatomy; (b) meticulous dissection of the STA on the epigaleal layer to protect the galeal layer; (c) careful consideration of the risk of scalp ischemia during any phase of surgery, until skin closure is completed [72].…”

Current Surgical Options for Moyamoya Disease

“…A direct bypass can also lead to radiological hyperperfusion (incidence between 18% and 50%) that can progress to hemorrhage complications in approximately 1.7% [ 3 , 13 ]. Other less common risks but not negligible are bypass occlusion (less than 2%), which can be multifactorial and surgical technique-dependent, scalp-healing issues (1.7% to 5.1%) [ 14 ], seizures, and subdural hematoma, for which patients should be well informed [ 13 ].…”

“…While this line of thought has generally been entertained by clinicians, leading to increased use of combined bypass in the management of MMD, a quantitative assessment of the results show unpredictable outcomes across individual patients [ 15 ]. While several studies report the advantages of using direct bypass over indirect bypass in managing patients with MMD, it is unclear whether the use of direct bypass alone has any clear advantage in clinical outcomes over the use of combined bypass in the management of MMD, despite the former’s angiographic superiority [ 3 , 11 , 14 ]. According to Cho et al [ 2 ], combined bypass should be performed in adult MMD patients symptomatic from MCA and ACA regions instead of complex direct bypass surgery.…”

Bed-sore and Associated Factors Among Patients Admitted at Surgical Wards of Wolaita Sodo University Teaching and Referral Hospital, Southern Ethiopia

“…It improves Sodo University Teaching and Referral Hospital, Southern Ethiopia healing and prevents complications of existing pressure ulcer. This is because nurses have a responsibility to monitor patient's skin in order to plan, implement and evaluate interventions that maintain skin integrity by using their knowledge and skill [3,[13][14][15][16][17].…”