Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease

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✓ The authors report their experience with the use of saphenous vein bypass grafts for treating advanced occlusive disease in the posterior circulation (77 patients, all of whom had failed medical management and showed severe ischemic symptoms), deteriorating patients with giant aneurysms of the posterior circulation (nine patients), progressive ischemia in the anterior circulation (26 patients, none of whom had a normal examination), and giant aneurysms in the anterior circulation (20 patients, all of whom presented with mass effect or subarachnoid hemorrhage). Graft patency in the first 65 cases treated was 74%. However, after significant technical changes of vein-graft preparation and construction of the proximal anastomosis, patency in the following 67 cases was 94%. Excellent or good results (including relief of deficits existing prior to surgery) were achieved in 71% of patients with advanced occlusive disease in the posterior circulation, 44% of those with giant aneurysms of the posterior circulation, 58% of those with ischemia of the anterior circulation, and 80% of those with giant aneurysms of the anterior circulation. Mean graft blood flow at surgery in the series was 100 ml/min for posterior circulation grafts and 110 ml/min for anterior circulation grafts. Experience to date indicates that this is a useful operation, and is particularly applicable to patients who are neurologically unstable from advanced intracranial occlusive disease in the posterior circulation or with giant aneurysms in the anterior circulation. The risk of hyperperfusion breakthrough with intracerebral hematoma restricts the technique in patients with progressing ischemic symptoms in the anterior circulation, and the intolerance of patients with fusiform aneurysms in the posterior circulation to the iatrogenic vertebrobasilar occlusion limits the applicability of this approach to otherwise inoperable lesions in that system.

Article Information

Address reprint requests to: Thoralf M. Sundt, Jr., M.D., Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905.

© AANS, except where prohibited by US copyright law.

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    Technique of harvesting the vein graft. A: The great saphenous vein is harvested from the leg or thigh. There is considerable variability from patient to patient in the size of this vessel and in the number of branches. B: Small branches are ligated with 5-0 Prolene stick-ties and large branches with 3-0 silk stick-ties. Sometimes it is preferable to close large tributary vessels with a running 5-0 suture rather than ligate the vessel with a larger suture, as the simple ligation with a tie sometimes distorts the lumen of the vein. The vein should be left in situ after the tributaries have been ligated and harvested only after exposure of the intracranial recipient vessel and the cervical carotid arteries. The Garrett orientation line should be placed in the adventitia of the vein before it is harvested: there is frequently 360° to 720° rotation of the vein with distention after it is harvested, and the proper orientation cannot be determined. C: The vein is distended with the Shiley distention kit to 200 mm Hg. The vein is worked between the index finger and thumb under cold heparinized saline solution until the vasospasm is overcome.

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    Exposure of the posterior circulation. The posterior cerebral artery is exposed through a subtemporal approach. The temporal muscle is turned with the scalp flap. The craniotomy should extend to the floor of the middle fossa.

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    The path of a completed vein bypass graft. The graft ascends deep to the parotid gland to enter a deep subcutaneous plane anterior to the tragus of the ear. It then curves over the zygoma and through the temporal muscle to cross the floor of the middle fossa to the posterior cerebral artery at the margin of the tentorium. ECA = external carotid artery; CCA = common carotid artery.

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    Construction of the angled end-to-side intracranial anastomosis using an 8-0 monofilament nylon suture. A: The posterior cerebral artery is opened with a broken razor blade after the vessel is occluded with soft temporary clips. B: The vein graft is spatulated and the apices affixed to the ends of the arteriotomy with two sutures cut to a length of 2.5 cm. C: The two sutures are now run from the two ends on the medial wall of the arteriotomy and tied together near the midpoint. D: The self-retaining retractor is then repositioned over the vein graft placing slight tension on the graft and opening the lateral aspect of the arteriotomy. E: Lastly, the lateral walls are closed with running sutures.

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    End-to-end anastomosis between a vein graft and the stump of the external carotid artery (ECA). The vein graft and ECA are both prepared in a fish-mouthed fashion (A) and then the anastomosis is completed with 12 to 14 interrupted 5-0 or 6-0 Prolene sutures (B). This is currently our most common type of construction for the proximal anastomosis. ICA = internal carotid artery; CCA = common carotid artery.

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    Enlargement of a proximal anastomosis with a roof-patch graft (steps A through D). This technique is used in cases where the external carotid artery (ECA) or the saphenous vein are smaller than average. If necessary, an anastomosis should be reopened acutely on the operating table for patch-grafting in cases in which the graft pulse appears to be inadequate. Placement of a roof-patch graft in these instances has usually resulted in a very significant improvement in the quality of the pulse and consequently in the long-term patency of the graft. ICA = internal carotid artery; CCA = common carotid artery.

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    Proximal anastomosis between a saphenous vein and the stump of the internal carotid artery (ICA). This technique is illustrated in a patient with a giant aneurysm undergoing ICA ligation with a simultaneous saphenous vein bypass graft. The bulb of the ICA is preserved for the anastomosis. The vein graft and ICA are both prepared in a fish-mouthed fashion and then sewn end-to-end with 12 to 14 interrupted 5-0 or 6-0 sutures. ECA = external carotid artery; CCA = common carotid artery.

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    Steps A, B, and C are followed to perform an endarterectomy in the common (CCA), internal (ICA), and external (ECA) carotid arteries in cases in which there is significant stenosis of the ECA. In such cases, the ECA cannot be reconstructed without also involving the CCA and ICA. A shunt is routinely employed in these cases as it is not possible to monitor these patients with cerebral blood flow measurements and electroencephalograms. Following endarterectomy, the ECA is usually divided just distal to its origin and the saphenous vein graft is sewn to the stump with interrupted sutures. Both the saphenous vein and the margin of the ECA are spatulated and then the site of the anastomosis is enlarged with a saphenous vein roof-patch as illustrated in Fig. 6.

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    Postoperative angiogram in a typical case of occlusive disease of the posterior circulation demonstrating a double-barreled saphenous vein bypass graft with one limb (small arrow) anastomosed to a branch of the middle cerebral artery. The main trunk of the vein is anastomosed end-to-side to the posterior cerebral artery (large arrow). There is retrograde flow in the basilar artery to the point of the anterior inferior cerebellar artery, identified by arrowhead.

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    Radiographic findings in a 66-year-old man who underwent surgery because of headaches, progressing ataxia, a left hemiparesis, and progressive loss of function of the fifth to eighth cranial nerves. Left: Preoperative computerized tomography scan showing a very large mass in the left cerebellopontine angle. Center: Preoperative angiogram confirming the presence of a giant aneurysm which was largely thrombosed. The patient underwent placement of a saphenous vein bypass graft between the right external carotid artery and the proximal right posterior cerebral artery, combined with a trapping procedure of the aneurysm. It was hoped that the aneurysm had occluded the origin of the pontine perforating vessels and that the patient would therefore tolerate basilar artery occlusion if provided with an adequate distal flow. Right: Postoperative angiogram demonstrating good flow through the graft. However, the patient developed typical signs and symptoms of basilar artery occlusion following surgery.

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    Angiograms in a 60-year-old man who presented with a 3-month history of progressive deterioration in mental function, loss of vision in the left eye, episodes of dysequilibrium, and progressive loss of function in the left hand. On examination, he had a mild left hemiparesis. Left: Preoperative angiogram showing diffuse atherosclerosis not only involving the carotid artery at its bifurcation but extending distally to the point where the vessel enters the base of the skull. There is also separate involvement of the artery in the parasiphon area. The right internal carotid artery is occluded. Right: Angiogram after the placement of a saphenous vein bypass graft from the right subclavian artery to the right middle cerebral artery. The vein graft now supplies both anterior cerebral arteries and has a potential for supplying the left middle cerebral artery group. This patient has done well postoperatively.

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    Preoperative studies in a woman who was admitted to the hospital with a 4-year history of headache, loss of vision in the left eye, and diplopia. On neurological examination, she had a total left third nerve palsy and a visual field defect compatible with left optic nerve compression. Left: Computerized tomography scan demonstrating a giant aneurysm arising in the left parasellar area. Right: Angiogram confirming the presence of a giant aneurysm, which only partially fills.

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    Postoperative angiograms in the same patient as depicted in Fig. 12 demonstrating good flow through the saphenous vein bypass graft, which extends from the stump of the ligated internal carotid artery in the neck to the M2 segment of the middle cerebral artery. Follow-up neurological examination was normal except for a partial third nerve palsy. Ultimately, the headaches disappeared and the patient is now fully employed.

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    Intraoperative graft blood flows (in ml/min) through grafts in the anterior and posterior circulation indicate in general a slightly higher proportion of high flows in the anterior than in the posterior circulation procedures. The mean graft flow for anterior circulation procedures was 110 ml/min, and mean graft flow for posterior circulation procedures was 100 ml/min.

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