Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation

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✓ The authors report their initial experience with the use of interposition saphenous vein grafts between the external carotid artery and the proximal posterior cerebral artery. The indications, results, and technical aspects of the operation are reviewed. All patients accepted for surgery were at high risk for a posterior circulation infarct, and all patients with ischemic symptomatology had continued to progress while on anticoagulant drugs or anti-platelet agents. Thus, all patients were at high risk, and 11 of the 14 patients operated on were confined to bed before surgery. Intraoperative graft flows varied from 35 to 170 ml/min, and postoperative graft flows ranged from 75 to 311 ml/min in the patent grafts. There were three early graft occlusions and two late graft occlusions; these all occurred in patients with relatively low flows at the time of surgery (40 ml/min or lower). Subdural hygroma was the next most frequent complication to graft occlusion. It was thought to be caused by the pulsating graft anastomosed to a major vessel through a small opening in the basal arachnoid, which provided a new path for cerebrospinal fluid flow in patients with a degree of preexisting atrophy. One patient with a large aneurysm in the posterior circulation underwent proximal intracranial clipping of the vertebral artery and bypass grafting simultaneously. There were seven excellent results and two good results in nine patients in whom the graft remained patent. In the five patients with graft occlusion, there were two minor strokes, two major strokes, and one death.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Cerebral Vascular Research Center, Room 4–437, Alfred Building, St. Mary's Hospital, Rochester, Minnesota 55901.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 2. Postoperative series of angiograms, subtraction technique. Upper: Lateral view revealing good flow through the bypass graft, with retrograde filling of the basilar artery to the point of its origin from the junction of the vertebral arteries. Lower: Anteroposterior projection indicating the contour and shape of the saphenous vein bypass graft. There is filling of the opposite posterior cerebral artery.

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    Case 8. Postoperative angiograms, subtraction technique. Left: Lateral view indicates good perfusion of the posterior circulation to the midpoint of the basilar artery. Right: Anteroposterior view indicating the path of the saphenous bypass graft into the posterior cerebral artery, with filling of both posterior cerebral arteries through the graft and perfusion of the upper two-thirds of the basilar artery.

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    Case 12. Preoperative angiogram of the vertebral artery aneurysm. The aneurysm arose from a dominant vertebral artery, which was a primary source of blood supply to the basilar artery and both posterior cerebral arteries. The aneurysm originated at the apex of the loop in the vertebral artery, but at surgery was found to have a very thick wall with a partially calcified base which displaced several different types of aneurysm clips proximally onto the parent artery.

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    Case 12. Sequential postoperative angiograms demonstrating good filling of both posterior cerebral arteries through the saphenous interposition bypass graft. There was some retrograde filling down the basilar artery, but the basilar artery also filled through a very small right vertebral artery. Note the aneurysm clip across the left vertebral artery just proximal to the point of origin of the anterior inferior cerebellar artery.

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    Operative sketch of a bypass graft placed through a modified pterional approach. The opening in the Sylvian fissure is exaggerated here in order to better illustrate the proximal anatomy. This approach, used earlier in the series, was abandoned in favor of the subtemporal approach (see Fig. 6). ICA = internal carotid artery; CCA = common carotid artery; ECA = external carotid artery; PCA = posterior cerebral artery; SCA = superior cerebellar artery.

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    A: Operative sketches of the subtemporal approach currently used for exposure of the posterior cerebral artery for bypass grafting. This approach minimizes brain retraction and yet provides an adequate space for suture manipulation with a single blade of the self-retaining retractor. B: Diagram of the vein following completion of the proximal and distal anastomoses. The tunnel for the vein passes from the medial aspect of the temporalis muscle to the subgaleal space over the zygoma through subcutaneous tissue anterior to the ear, and then through a fascial plane deep to the parotid gland to join the external carotid artery (ECA) at the level of the digastric muscle. ICA = internal carotid artery.

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