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PubMedDate not supplied

Cerebral revascularization: proximal external carotid to distal middle cerebral artery bypass with a synthetic tube graft.

A right proximal external carotid to distal middle cerebral artery bypass with a prosthetic tube graft was performed in a patient with intermittent cerebral ischemia due to middle cerebral artery stenosis. The patient was relieved of his symptoms, and he was neurologically normal 3 months after operation. Angiography 3 months postoperatively revealed flow through the graft and excellent filing of the middle cerebral circulation, both retrograde and antegrade. Early results suggest that an expanded polytetrafluoroethylene graft may be useful as a vascular conduit if suitable autogenous vessels are unavailable or have failed.

Blood Vessel Prosthesis↗
PubMed1989

[Results of simultaneous myocardial and cerebral revascularization surgery].

Out of 3,678 patients who underwent aorto-coronary bypass between May, 1979 and October, 1987 at the La Pitié Hospital, Paris, 48 had simultaneous myocardial and cerebral revascularization. Operative mortality rate was 4.2 p. 100. Peri-operative myocardial infarction occurred in 3 cases (6.2 p. 100). No neurological complication was observed. The survival rate at 5 years (operative mortality included) was 74.8 +/- 8.66 p. 100. These results obtained in patients with multiple arterial disease are in agreement with those found in the literature. The lack of neurological complications is in favour of a systematic combined surgical treatment of severe carotid and coronary lesions.

Aged↗
PubMedDate not supplied

Symptomatic cavernous sinus aneurysms: management and outcome after carotid occlusion and selective cerebral revascularization.

BACKGROUND AND PURPOSE: Therapeutic internal carotid artery (ICA) occlusion for symptomatic intracavernous artery aneurysms can result in ischemic infarction despite normal clinical balloon test occlusion (BTO). We evaluated outcomes in patients with symptomatic cavernous sinus aneurysms in whom clinical BTO was normal, who underwent carotid occlusion with selective bypass surgery guided by physiologic BTO using quantitative cerebral blood flow (CBF) analysis by means of stable xenon-enhanced CT. METHODS: After a normal clinical BTO, 26 consecutive patients with symptomatic cavernous sinus aneurysms underwent a baseline xenon-enhanced CT CBF analysis followed by a second CBF analysis, during which repeat BTO was performed. Patients with a decrease in cortical CBF to below 30 mL/100 g/min were considered moderate risk and those with greater than 30 mL/100 g/min were low risk for developing postocclusion ischemic infarction. Moderate-risk patients underwent cerebral revascularization followed by proximal carotid occlusion. Low-risk patients underwent carotid occlusion alone. Patients were clinically followed up for at least 3 months after carotid occlusion. All patients underwent head CT at least 1 month after carotid occlusion. RESULTS: Eight patients were moderate risk and 18 low risk. Mean follow-up was 15.3 months. Mean CT follow-up was 10.2 months. No low-risk patient developed a postocclusion ischemic deficit by examination or infarct by CT. One patient in the moderate-risk group developed right hemiparesis and a left posterior middle cerebral artery infarction by CT 2 months after carotid occlusion. CONCLUSION: In this series, BTO combined with quantitative CBF analysis was a safe and reliable technique for identification of patients at risk for ischemic infarction after carotid occlusion, despite a normal clinical BTO.

Balloon Occlusion↗
PubMed2005

Cerebral revascularization by endovascular techniques.

The minimally invasive approach to managing patients with ischemic and hemorrhagic stroke by endovascular intervention has made tremendous progress over the past years. Early recognition of stroke, improved ability to accurately diagnose the site of pathological abnormality with advanced imaging techniques and advances in treatment alternatives have led to better patient outcomes. Endovascular techniques for cerebral revascularization, a leading new therapeutic approach in the treatment of cerebrovascular disease, play a major role in both the management of acute stroke and secondary prevention. Selective intra-arterial thrombolysis for acute stroke has been performed for more than two decades with increasing success. Neurovascular therapies for secondary prevention include angioplasty of extracranial and intracranial vessels, as well as procedures for arterial reconstruction.

Carotid Arteries↗
PubMed1987

Hemodynamic and metabolic effects of cerebral revascularization.

Pre- and postoperative positron emission tomography (PET) was performed in six patients undergoing extracranial to intracranial bypass procedures for the treatment of symptomatic extracranial carotid occlusion. The six patients were all men, aged 52 to 68 years. Their symptoms included transient ischemic attacks (five cases), amaurosis fugax (two cases), and completed stroke with good recovery (one case). Positron emission tomography was performed within 4 weeks prior to surgery and between 3 to 6 months postoperatively, using oxygen-15-labeled CO, O2, and CO2 and fluorine-18-labeled fluorodeoxyglucose. Cerebral blood flow (CBF), cerebral blood volume (CBV), cerebral metabolic rates for oxygen and glucose (CMRO2 and CMRGlu), and the oxygen extraction fraction (OEF) were measured in both hemispheres. Preoperatively, compared to five elderly control subjects, patients had increased CBV, a decreased CBF/CBV ratio, and decreased CMRO2, indicating reduced cerebral perfusion pressure and depressed oxygen metabolism. The CBF was decreased in only one patient who had bilateral carotid occlusions; the OEF, CMRGlu, and CMRO2/CMRGlu and CMRGlu/CBF ratios were not significantly different from control measurements. All bypasses were patent and all patients were asymptomatic following surgery. Postoperative PET revealed decreased CBV and an increased CBF/CBV ratio, indicating improved hemodynamic function and oxygen hypometabolism. This was associated with increased CMRO2 in two patients in whom the postoperative OEF was also increased. The CMRGlu and CMRGlu/CBF ratio were increased in five patients. Changes in CBF and the CMRO2/CMRGlu ratio were variable. One patient with preoperative progressive mental deterioration, documented by serial neuropsychological testing and decreasing CBF and CMRO2, had improved postoperative CBF and CMRO2 concomitant with improved neuropsychological functioning. It is concluded that symptomatic carotid occlusion is associated with altered hemodynamic function and oxygen hypometabolism. Cerebral revascularization results in decreased CBV, indicating improved hemodynamic reserve, but does not consistently improve oxygen metabolism.

Aged↗
PubMed1981

Neurological response to hyperbaric oxygen--a criterion for cerebral revascularization.

Twenty-two patients with cerebral infarction secondary to occlusion of a carotid or middle cerebral artery were exposed to hyperbaric oxygen at 1.5 atmospheres absolute pressure. Ten of the patients demonstrated improved motor function during hyperbaric exposure. Seven of these patients had successful surgical revascularization and no recurrence of neurological deficit. In 3 patients who were not successfully revascularized, the neurological deficit recurred. It is concluded that response to hyperbaric oxygen may be of use in the selection of patients with neurological deficit who will benefit from surgical revascularization of the brain.

Adult↗
PubMedDate not supplied

Cerebral revascularization by axillary-carotid bypass.

Revascularization for symptomatic proximal common carotid severe stenosis or occlusion frequently requires a bypass procedure. Subclavian-carotid bypass is probably the most frequently performed operation. In the past 5 years 13 patients underwent an alternative operation, axillary-carotid bypass, which may be technically easier than subclavian-carotid bypass and just as durable. The graft is placed under the clavicle, in an easily constructed tunnel not involving the true thoracic outlet, deep to the sternocleidomastoid muscle and internal jugular vein. Five distal anastomoses were made to the common carotid (2 greater saphenous vein, 2 Dacron and 1 Gortex grafts), 4 to the internal carotid (all vein) and 4 to the external carotid (all vein, 1 sequential with a end-side anastomosis to the ipsilateral vertebral). There were no perioperative deaths. One stroke occurred in a patient with a Dacron graft to the common carotid who also had a concomitant ipsilateral carotid endarterectomy. All grafts were open by Doppler exam at a mean follow-up of 2 1/2 years. Improved cerebral hemodynamics was confirmed in 11 patients by Gee oculoplethysmography. These early results support the use of the axillary artery as a donor for extracranial cerebral revascularization when the proximal common carotid is occluded or severely stenotic.

Aged↗
PubMedDate not supplied

Carotid cross-over bypass. Cerebral revascularization after ligation of common carotid artery.

A rationale is presented for extra-anatomic carotid cross-over bypass to maintain or restore blood flow to the internal carotid artery distal to sites of disruption and ligation of a common carotid artery. Anatomic evidence indicates that the attachment of the carotid sheath to the hyoid bone is a barrier to spread of infection cephalad to that level. A patient with infected and disrupted right common carotid artery associated with an esophageal fistula was treated by double ligation of the artery. Contralateral hemiplegia 48 hours later forced consideration of cerebral revascularization. Left carotid angiography demonstrated patent cerebral vessels on the right, with retrograde filling of the right internal carotid artery to the bifurcation. These findings were interpreted as consistent with technical feasibility of external carotid to external carotid cross-over vein bypass in a suprahyoid location, avoiding reconstruction in an infected area and resulting in prompt recovery of function.

Brain↗
PubMed2005

Moyamoya disease in adults: the role of cerebral revascularization.

Moyamoya disease is a disorder characterized by bilateral progressive steno-occlusion of the terminal internal carotid arteries with associated development of a fragile network of basal collateral vessels. It most commonly presents in children, but is also frequently seen in adults, especially in the third or fourth decade of life. Adults afflicted with this disease have very different clinical characteristics as compared with children. For example, adults more commonly present with hemorrhage than cerebral ischemia, while children present with cerebral ischemia nearly 75% of the time and very rarely present with hemorrhage. This significantly impacts treatment considerations for the adult-onset moyamoya patient, as cerebral revascularization, though well accepted in the context of cerebral ischemia, is relatively controversial for the prevention of rehemorrhage. The purpose of this article is to review the pertinent general features of moyamoya disease, examine the clinical characteristics associated with the adult-onset form of this disease, and provide a detailed discussion regarding the indications, operative techniques, and outcomes of direct and indirect revascularization surgical procedures.

Journal Article↗
PubMed1986

Concomitant coronary and cerebral revascularization under cardiopulmonary bypass.

The question as to whether a staged or a combined surgical approach is safer in the management of patients with coexistent coronary and extracranial cerebrovascular disease has been widely investigated and debated. Advances in myocardial protection techniques have reduced cardiac morbidity and mortality and have rendered a combined approach as safe as a staged approach, if not safer. There have been no similar advances in cerebral protection, particularly for high-risk patients with bilateral disease. In this series, 32 consecutive patients with coexistent advanced coronary and extracranial vascular disease underwent cerebral and coronary revascularization that used the combined approach. Cerebral revascularization was performed under hypothermic cardiopulmonary bypass on 30 of these patients. There was no operative mortality, no hematoma formation, and no reoperation. Blood loss, length of hospital stay, and total cost were similar to those for isolated coronary bypass procedures.

Aged↗
PubMed2005

Moyamoya disease--diagnosis and treatment: indirect cerebral revascularization at the Sheba Medical Center.

Moyamoya disease is a cerebral vasculopathy characterized mainly by progressive narrowing of the major intracranial vessels. While more common and having a familial predilection in the Far East, it can also develop in association with some common hereditary diseases and can be acquired after environmental exposure. In the young its manifestations are the result of cerebral ischemia. Adults usually suffer from repeated incidents of intracerebral hemorrhage. Surgical revascularization of ischemic cerebral territories plays a major role in their treatment. We review the literature and present our series of three adult and five pediatric patients; these patients were diagnosed at our institution and treated with indirect revascularization techniques.

Adult↗
PubMed2004

Superficial temporal artery-to-middle cerebral artery bypass grafting for cerebral revascularization.

Superficial temporal artery-to-middle cerebral artery bypass procedures are an important tool in the armamentarium of cerebrovascular surgeons for the treatment of carotid occlusion and revascularization for complex aneurysms and brain tumors. This article enumerates the essential steps in performing superficial temporal artery-to-middle cerebral artery bypass procedures. The nuances of this technique reflect the extensive experience of the senior authors.

Anastomosis, Surgical↗
PubMed2005

Cerebral revascularization model in a swine.

The purpose of this study was to analyze the suitability of the cerebral vasculature of the pig regarding a revascularization procedure. In two 60 kg pigs the femoral artery was exposed and canulated for selective angiography and interventional procedures. After the angiography, the pigs were brought to the animal OR for craniotomy and analysis of the intracranial cerebral arteries and the surgical exposure of the carotid arteries under the microscope. Angiography demonstrated the presence of a true internal-, external carotid artery and vertebral arteries. Both the vertebral and internal carotid arteries are feeding a rete mirabilis both at the cranial base and the cranio-cervical junction. At these sites further advancement of the angiography catheter was not possible. Out of these rete mirabilis, an intracranial carotid artery and an intracranial vertebral artery were formed, respectively. The intracranial cerebral vessels were of the dimension of 1 mm and less. The extracranial portion of the internal carotid artery was 2.5 mm of diameter. From these findings, we conclude that a direct cerebral revascularization procedure of the intracranial vessels is not possible in the swine. However, a global revascularization procedure on the extracranial portion of the internal carotid artery is thus feasible, both using a low- and high-flow anastamosis technique.

Animals↗
PubMedDate not supplied

Brain tissue pO2 and pCO2 levels before and after cerebral revascularization.

Microvascular surgical techniques have made possible the improvement of cerebral blood flow, as demonstrated by angiography and by regional cerebral blood flow research. In this study, simultaneous mass spectrometer determinations of brain tissue and blood pO2 and pCO2 levels were used to evaluate the effectiveness of common carotid-supraclinoid carotid anastomoses (CC-SCA) in dogs. With blood pCO2 maintained at a constant level, the baseline brain tissue pO2 and pCO2 levels were recorded. During the CC-SCA procedure, which involved brain retraction and temporary vascular occlusion, brain tissue pO2 levels fell to 40% of baseline and pCO2 levels rose by 35%. Following restoration of flow via the anastomosis, the brain tissue pO2 and pCO2 levels again reached baseline.

Animals↗
PubMed1975

Use of the axillary artery in complex cerebral revascularization.

Two cases of complex common carotid and innominate artery disease managed by axillocarotid autogenous saphenous vein bypass are presented, including a detailed description of the operative technique. The results in each case were gratifying. Although the concept of extra-anatomic repair is not new, this modification in operative technique expands the surgeon's armamentarium. The ease and safety of exposure and anastomosis of the axillary artery combine to make it the preferable donor vessel for extra-anatomic cerebral revascularization in the poor-risk, elderly patient population.

Age Factors↗