Safety of early endovascular catheterization and intervention through extracranial-intracranial bypass grafts

Clinical article

Restricted access


The goal of this study was to demonstrate feasibility and evaluate technical aspects of early endovascular access through extracranial-intracranial (EC-IC) bypass grafts.


Patients undergoing endovascular interventions through the graft in the acute postoperative period following EC-IC bypass are presented. Results, complications, and technical nuances are reviewed.


Fourteen endovascular procedures were performed in 5 patients after EC-IC bypass for ruptured aneurysms in 4 patients and posterior circulation ischemia in 1 patient. In 2 patients, a saphenous vein graft (SVG) was used to bypass the common carotid artery (CCA) to the middle cerebral artery (MCA). One patient underwent a superficial temporal artery (STA)–MCA bypass, and in 2 other patients the STA stump was connected to the intracranial circulation via an interposition SVG. The interval from surgery to endovascular intervention spanned 2–18 days; the indication was intracranial vasospasm in all patients. One case involved angioplasty of the proximal anastomosis on postoperative Day 14. All other interventions entailed proximal access through the bypass conduit for intraarterial infusion of vasodilators. Significant vasospasm of the STA itself was encountered in 2 patients during endovascular manipulation, and it was treated with intraarterial nitroglycerin. There were no cases of anastomotic disruption.


Endovascular catheterization and intervention involving a recent EC-IC bypass is feasible. The main limitation in this series was catheter-induced vasospasm involving the STA. A vein graft may be the more appropriate option in patients with subarachnoid hemorrhage who may require subsequent endovascular intervention for vasospasm.

Abbreviations used in this paper: CCA = common carotid artery; EC-IC = extracranial-intracranial; ECA = external carotid artery; ICA = internal carotid artery; MCA = middle cerebral artery; OA = occipital artery; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; RA = radial artery; SAH = subarachnoid hemorrhage; STA = superficial temporal artery; SVG = saphenous vein graft; VA = vertebral artery.

Article Information

Address correspondence to: Sepideh Amin-Hanjani, M.D., Department of Neurosurgery, Room 451N, Neuropsychiatric Institute, MC-799, University of Illinois at Chicago, 912 South Wood Street, Chicago, Illinois 60612. email:

Please include this information when citing this paper: published online September 23, 2011; DOI: 10.3171/2011.8.JNS11747.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 1. Anteroposterior views of the left CCA injection. A: Preoperative angiography study showing an M1 aneurysm. B: A 3D reconstruction demonstrating circumferential involvement of the parent vessel. C: Postoperative angiography study demonstrating a patent SVG bypass and trapping of the M1 aneurysm segment. D: Angiography study showing vasospasm on postoperative Day 8, including within the MCA's M2 branches (arrowheads). E: Angiography study showing resolution of vasospasm following infusion of verapamil through the SVG; the microcatheter tip within the SVG is seen (circle).

  • View in gallery

    Case 3. A: Axial CT angiogram demonstrating parenchymal hemorrhage within the temporal lobe (arrow) and an MCA bifurcation aneurysm (arrowhead), with the M2 branch arising from the aneurysm rather than the bifurcation. B: Postoperative angiography study, with lateral view of the ECA injection showing the patent STA graft; the anastomosis is indicated by the arrow. C: Angiography study visualizing vasospasm within the bypassed territory. D: Study identifying thromboembolus within the MCA branch after infusion of intraarterial verapamil (arrow). E: Study showing that infusion of integrilin resulted in disruption and distal migration of the thrombus (arrow).

  • View in gallery

    Case 5. Anteroposterior views of the left ECA injection. A: Postoperative angiography study demonstrating patent graft; the STA-SVG anastomosis (arrow) is shown. B: Angiography study showing angioplasty performed for persistent STA vasospasm; the arrow indicates the tip of the guide catheter within the origin of the STA, and the arrowhead marks the site of balloon angioplasty of the STA-SVG anastomosis. C: Study revealing that angioplasty resulted in exacerbation of vasospasm proximally (arrow) and distally, with consequent flow cessation (arrowheads). D: Study showing that prolonged infusion of nitroglycerin relieved the STA spasm.


  • 1

    Alaraj AAshley WW JrCharbel FTAmin-Hanjani S: The superficial temporal artery trunk as a donor vessel in cerebral revascularization: benefits and pitfalls. Neurosurg Focus 24:2E72008

  • 2

    Amin-Hanjani SCharbel FT: Is extracranial-intracranial bypass surgery effective in certain patients?. Neurol Clin 24:7297432006

  • 3

    Bejjani GKBank WOOlan WJSekhar LN: The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 42:9799871998

  • 4

    Brisman JLEskridge JMNewell DW: Neurointerventional treatment of vasospasm. Neurol Res 28:7697762006

  • 5

    Colby GPCoon ALTamargo RJ: Surgical management of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 21:2472612010

  • 6

    Hacein-Bey LConnolly ES JrMayer SAYoung WLPile-Spellman JSolomon RA: Complex intracranial aneurysms: combined operative and endovascular approaches. Neurosurgery 43:130413131998

  • 7

    Hirashima YNakamura SEndo SKuwayama NNaruse YTakaku A: Elevation of platelet activating factor, inflammatory cytokines, and coagulation factors in the internal jugular vein of patients with subarachnoid hemorrhage. Neurochem Res 22:124912551997

  • 8

    Hoh BLOgilvy CS: Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine. Neurosurg Clin N Am 16:501516vi2005

  • 9

    Levy EIBoulos ASFessler RDBendok BRRinger AJKim SH: Transradial cerebral angiography: an alternative route. Neurosurgery 51:3353422002

  • 10

    McGuinness BGandhi D: Endovascular management of cerebral vasospasm. Neurosurg Clin N Am 21:2812902010

  • 11

    Mohit AASekhar LNNatarajan SKBritz GWGhodke B: High-flow bypass grafts in the management of complex intracranial aneurysms. Neurosurgery 60:2 Suppl 1ONS105ONS1232007

  • 12

    Molyneux AKerr RStratton ISandercock PClarke MShrimpton J: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomized trial. J Stroke Cerebrovasc Dis 11:3043142002

  • 13

    Natarajan SKHauck EFHopkins LNLevy EISiddiqui AH: Endovascular management of symptomatic spasm of radial artery bypass graft: technical case report. Neurosurgery 67:7947982010

  • 14

    Qureshi AIHussain MSNasar AKirmani JFDivani AAAhmed S: Intracranial hemorrhages associated with intravenous platelet glycoprotein IIB/IIIA receptor inhibitors in the United States. Cardiovasc Drugs Ther 19:3713732005

  • 15

    Qureshi AILuft ARSharma MGuterman LRHopkins LN: Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: part I—Pathophysiological and pharmacological features. Neurosurgery 46:134413592000

  • 16

    Qureshi AILuft ARSharma MGuterman LRHopkins LN: Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: part II—Clinical aspects and recommendations. Neurosurgery 46:136013762000

  • 17

    Reardon MJConklin LDReardon PRBaldwin JC: Coronary artery bypass conduits: review of current status. J Cardiovasc Surg (Torino) 38:2012091997

  • 18

    Regli LPiepgras DGHansen KK: Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation. J Neurosurg 83:8068111995

  • 19

    Sayama CMLiu JKCouldwell WT: Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus 21:3E122006

  • 20

    Sekhar LNDuff JMKalavakonda COlding M: Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients. Neurosurgery 49:6466582001

  • 21

    Surdell DLHage ZAEddleman CSGupta DKBendok BRBatjer HH: Revascularization for complex intracranial aneurysms. Neurosurg Focus 24:2E212008

  • 22

    Suzuki SJahan RDuckwiler GRFrazee JMartin NViñuela F: Contribution of endovascular therapy to the management of poor-grade aneurysmal subarachnoid hemorrhage: clinical and angiographic outcomes. J Neurosurg 105:6646702006




All Time Past Year Past 30 Days
Abstract Views 72 72 15
Full Text Views 75 75 0
PDF Downloads 148 148 0
EPUB Downloads 0 0 0


Google Scholar