Automated end-to-side anastomosis to the middle cerebral artery: a feasibility study

Laboratory investigation

Amadé Bregy Department of Neurosurgery, Inselspital Bern, University of Bern;

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Alex Alfieri Department of Neurosurgery, Inselspital Bern, University of Bern;

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Stefanos Demertzis Cardiocentro Ticino, Lugano;

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Pasquale Mordasini Department of Neurosurgery, Inselspital Bern, University of Bern;

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Anna Katharina Jetzer Department of Neurosurgery, Inselspital Bern, University of Bern;

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Dominique Kuhlen Department of Neurosurgery, Inselspital Bern, University of Bern;

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Thomas Schaffner Institute of Pathology, University of Bern, Switzerland;

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Ralph Dacey Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri; and

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Hans-Jakob Steiger Department of Neurosurgery, Heinrich-Heine-Universität, Düsseldorf, Germany

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Michael Reinert Department of Neurosurgery, Inselspital Bern, University of Bern;

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Object

The treatment of complex cerebrovascular or skull base pathological conditions necessitates a microsurgical blood flow preservation or augmentative revascularization procedure as either an adjunctive safety measure or a definitive treatment. The brain is susceptible to ischemia, and procedure-related risks can be minimized by the reduction of occlusion time or the use of a nonocclusive technique. The authors therefore analyzed the feasibility of an automatic device (C-Port xA, Cardica) designed for constructing an end-to-side anastomosis with or without flow interruption for a middle cerebral artery (MCA) bypass in a human cadaveric model and in an in vivo craniotomy simulation model.

Methods

Four Thiel-fixated human head specimens were prepared using 8 standard pterional craniotomies. The sylvian fissure was opened to access the anterior circulation and in particular the MCA. The length of the individual vessel segments was measured. The C-Port xA was tested on each of the 8 exposures. In addition the C-Port xA was deployed in an in vivo craniotomy simulator model in 10 New Zealand rabbits (a total of 20 anastomoses) by using the abdominal aorta jump graft model.

Results

Short-term patency was assessed by angiography and histological findings. In all 8 sylvian exposures, construction of an MCA anastomosis with the aid of the C-Port xA was feasible. All 20 jump graft anastomoses performed in the in vivo craniotomy simulator were found to be patent.

Conclusions

The anatomical studies as well as the in vivo craniotomy simulation studies demonstrated that the dimensions of the automated end-to-side anastomosis device are suitable for an extracranial–intracranial high-flow bypass on the MCA. Further miniaturization and special adaptation of this device would allow bypass procedures to more proximal intracranial vessels.

Abbreviations used in this paper:

ePTFE = expanded polytetrafluoroethylene; FDA = Food and Drug Administration; ICA = internal carotid artery; MCA = middle cerebral artery.
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