Surgical Strategies for Cerebral Revascularization in Patients with Limited Bypass Conduit Options and Unexpected Intraoperative Difficulties.

Abstract

Cerebral bypass procedures are complex and require substantial experience and skills and thorough preoperative planning. Cerebrovascular surgeons face increasingly complex bypass cases because most routine cases are managed by endovascular means, and because increasing numbers of patients have complex medical problems that affect available and suitable bypass conduit options. We report the cases of several patients undergoing cerebral bypass with limited bypass conduit alternatives, in whom there were unexpected intraoperative difficulties requiring complex solutions. The neurological surgery department database was reviewed to identify patients who had undergone cerebral bypass procedures during a 13-year period in whom there were limited available bypass conduits, and in whom unexpected intraoperative difficulties were encountered during cerebral bypass. Patient outcomes and graft patency were evaluated for 13 patients including 6 with ischemia, 3 with giant aneurysms, 2 with mycotic aneurysms, 1 with dissecting aneurysm, and 1 with gunshot-induced pseudoaneurysm. Median duration of follow-up was 43 months. In 12 of 13 patients, bypass graft/grafts were patent on the last computed tomography angiogram. In 1 patient, a prophylactic bypass procedure, the graft was not filling, probably because of lack of demand. Two patients died during follow-up of unrelated causes. Cerebrovascular surgeons should be versatile in dealing with patients with complex bypass. When there are limited available conduit options, we find that collaboration with other surgical specialties (e.g., plastics and vascular) is helpful. In patients in whom extreme intraoperative difficulties are expected, thorough preoperative planning with multiple backup plans should be exercised, as described in this report.