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

Clinical article

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Object

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

Methods

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.

Results

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.

Conclusions

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: hanjani@uic.edu.

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.

Headings

Figures

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    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).

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    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.

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