The use of high-flow extracranial-intracranial artery bypass in pathology of the cerebral and brachiocephalic arteries: technical features and surgical outcomes

BACKGROUND: Poor outcomes of surgical treatment for complex cerebral aneurysms due to the development of cerebral ischemia were the cause to use cerebral revascularization surgery for this pathology. OBJECTIVE: the study objective was to master a high-flow extracranial-intracranial (EC-IC) artery bypass technique and evaluate its application in surgical treatment of complex and giant cerebral aneurysms as well as complex lesions of the brachiocephalic arteries. MATERIAL AND METHODS: Fifty two patients underwent high-flow IC-EC bypass surgery; of these, 34 patients had complex cerebral aneurysms, and 18 patients had complex stenotic occlusive lesions of the brachiocephalic arteries. After bypass placement, the patients with aneurysms underwent different variants of aneurysm exclusion (trapping or proximal clipping/ligation of the parent artery). All patients underwent follow-up studies of the bypass function and clinical condition in the early postoperative period and 6 and 12 months after surgery. RESULTS: High-flow IC-EC bypass surgery is routinely used in clinical practice of the Novosibirsk Federal Center of Neurosurgery. Fifty one out of the 52 patients were followed-up in a range of 4 to 56 months. According to the direct or CT angiography data, bypasses functioned in 51 (98.1%) patients in the early and long-term postoperative periods. The clinical efficacy (no ischemic changes and improved cerebral perfusion) of high-flow IC-EC bypasses was demonstrated in 31 (91.2%) of 34 patients with aneurysms and in 17 (94.4%) of 18 patients with complex lesions of the brachiocephalic arteries. The total number of surgical complications was 8 (15.4%) cases: 7 complications occurred in patients with aneurysms, and 1 complication developed in a patient with bilateral ICA occlusion. Of these, ischemic complications developed in 4 (7.7%) cases, hemorrhagic complications occurred in 2 (3.8%) cases, and cranial nerve complications were found in 2 (3.8%) cases. One (1.9%) female patient with a giant aneurysm died from hemispheric stroke due to insufficient blood flow through the bypass. CONCLUSION: Implementation of a large number of surgeries enabled improvement of the technique and clarification of the prerequisites for preoperative examination, intraoperative control, and postoperative management of patients. A low mortalits rate suggests this technique for use in clinical practice. The surgery is indicated for the treatment of giant aneurysms of the petrous, cavernous, and clinoid segments of the ICA. In the case of giant supraclinoid aneurysms, the surgery may be combined with removal of thrombotic masses from the aneurysm sac for rapid decompression of the cranial nerves. Application of this surgery for treatment of giant aneurysms of the trunk and bifurcation of the basilar artery is promising but requires further investigation. The surgery is also recommended for improving cerebral perfusion in the setting of complex stenotic occlusive lesions of the BCA: prolonged BCA stenoses, tandem ICA stenoses located in both the extracranial and intracranial segments, nonspecific vasculitis and arteriitis, subcranial aneurysms, kinking etc.