The cut flow index revisited: utility of intraoperative blood flow measurements in extracranial-intracranial bypass surgery for ischemic cerebrovascular disease

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  • Department of Neurosurgery, University of Illinois at Chicago, Illinois
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OBJECTIVE

In extracranial-intracranial (EC-IC) bypass surgery, the cut flow index (CFI) is the ratio of bypass flow (ml/min) to donor vessel cut flow (ml/min), and a CFI ≥ 0.5 has been shown to correlate with bypass patency. The authors sought to validate this observation in a large cohort of EC-IC bypasses for ischemic cerebrovascular disease with long-term angiographic follow-up.

METHODS

All intracranial bypass procedures performed at a single institution between 2003 and 2018 were reviewed. Demographic, clinical, angiographic, and operative data were recorded and analyzed according to bypass patency with univariate and multivariate statistical analyses.

RESULTS

A total of 278 consecutive intracranial bypasses were performed during the study period, of which 157 (56.5%) were EC-IC bypasses for ischemic cerebrovascular disease. Intraoperative blood flow measurements were available in 146 patients, and angiographic follow-up was available at a mean of 2.1 ± 2.6 years after bypass. The mean CFI was significantly higher in patients with patent bypasses (0.92 vs 0.64, p = 0.003). The bypass patency rate was 83.1% in cases with a CFI ≥ 0.5 compared with 46.4% in cases with a CFI < 0.5 (p < 0.0001). Adjusting for age, sex, diagnosis, and single versus double anastomosis, the CFI remained a significant predictor of bypass patency (p = 0.001; OR 5.8, 95% CI 2.0–19.0). A low CFI was also associated with early versus late bypass nonpatency (p = 0.008).

CONCLUSIONS

A favorable CFI portends long-term EC-IC bypass patency, while a poor CFI predicts eventual bypass nonpatency and can alert surgeons to potential problems with the donor vessel, anastomosis, or recipient bed during surgery.

ABBREVIATIONS CFI = cut flow index; COSS = Carotid Occlusion Surgery Study; EC-IC = extracranial-intracranial; ICA = internal carotid artery; MCA = middle cerebral artery; STA = superficial temporal artery; SVDA = single-vessel double anastomosis.

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Contributor Notes

Correspondence Fady T. Charbel: University of Illinois at Chicago, IL. fcharbel@uic.edu.

INCLUDE WHEN CITING Published online September 6, 2019; DOI: 10.3171/2019.5.JNS19641.

Disclosures Dr. Atwal: consultant for Imperative Care. Dr. Charbel: consultant for Transonic Inc.

  • 1

    Abla AA, Gandhoke G, Clark JC, Oppenlander ME, Velat GJ, Zabramski JM, : Surgical outcomes for moyamoya angiopathy at barrow neurological institute with comparison of adult indirect encephaloduroarteriosynangiosis bypass, adult direct superficial temporal artery-to-middle cerebral artery bypass, and pediatric bypass: 154 revascularization surgeries in 140 affected hemispheres. Neurosurgery 73:430439, 2013

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Amin-Hanjani S, Barker FG II, Charbel FT, Connolly ES Jr, Morcos JJ, Thompson BG: Extracranial-intracranial bypass for stroke-is this the end of the line or a bump in the road? Neurosurgery 71:557561, 2012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Amin-Hanjani S, Du X, Mlinarevich N, Meglio G, Zhao M, Charbel FT: The cut flow index: an intraoperative predictor of the success of extracranial-intracranial bypass for occlusive cerebrovascular disease. Neurosurgery 56 (1 Suppl):7585, 2005

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Amin-Hanjani S, Meglio G, Gatto R, Bauer A, Charbel FT: The utility of intraoperative blood flow measurement during aneurysm surgery using an ultrasonic perivascular flow probe. Neurosurgery 62 (6 Suppl 3):13461353, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Amin-Hanjani S, Singh A, Rifai H, Thulborn KR, Alaraj A, Aletich V, : Combined direct and indirect bypass for moyamoya: quantitative assessment of direct bypass flow over time. Neurosurgery 73:962968, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Arnone GD, Hage ZA, Charbel FT: Side-to-side and end-to-side double anastomosis using the parietal-branch of the superficial temporal artery-a novel technique for extracranial to intracranial bypass surgery: 3-dimensional operative video. Oper Neurosurg (Hagerstown) 16:112114, 2019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Arnone GD, Hage ZA, Charbel FT: Single vessel double anastomosis for flow augmentation—a novel technique for direct extracranial to intracranial bypass surgery. Oper Neurosurg (Hagerstown) [epub ahead of print], 2019

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Ashley WW, Amin-Hanjani S, Alaraj A, Shin JH, Charbel FT: Flow-assisted surgical cerebral revascularization. Neurosurg Focus 24(2):E20, 2008

  • 9

    Charbel FT, Meglio G, Amin-Hanjani S: Superficial temporal artery-to-middle cerebral artery bypass. Neurosurgery 56 (1 Suppl):186190, 2005

  • 10

    EC/IC Bypass Study Group: Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313:11911200, 1985

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Guzman R, Lee M, Achrol A, Bell-Stephens T, Kelly M, Do HM, : Clinical outcome after 450 revascularization procedures for moyamoya disease. Clinical article. J Neurosurg 111:927935, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ishikawa T, Houkin K, Kamiyama H, Abe H: Effects of surgical revascularization on outcome of patients with pediatric moyamoya disease. Stroke 28:11701173, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Miyamoto S, Yoshimoto T, Hashimoto N, Okada Y, Tsuji I, Tominaga T, : Effects of extracranial-intracranial bypass for patients with hemorrhagic moyamoya disease: results of the Japan Adult Moyamoya Trial. Stroke 45:14151421, 2014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Morimoto M, Iwama T, Hashimoto N, Kojima A, Hayashida K: Efficacy of direct revascularization in adult Moyamoya disease: haemodynamic evaluation by positron emission tomography. Acta Neurochir (Wien) 141:377384, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Powers WJ, Clarke WR, Grubb RL Jr, Videen TO, Adams HP Jr, Derdeyn CP: Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia: the Carotid Occlusion Surgery Study randomized trial. JAMA 306:19831992, 2011 (Erratum in JAMA 306:2672, 2011)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    White TG, Abou-Al-Shaar H, Park J, Katz J, Langer DJ, Dehdashti AR: Cerebral revascularization after the Carotid Occlusion Surgery Study: what candidates remain, and can we do better? Neurosurg Focus 46(2):E3, 2019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Winkler EA, Yue JK, Deng H, Raygor KP, Phelps RRL, Rutledge C, : National trends in cerebral bypass surgery in the United States, 2002-2014. Neurosurg Focus 46(2):E4, 2019

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Zhao M, Charbel FT, Alperin N, Loth F, Clark ME: Improved phase-contrast flow quantification by three-dimensional vessel localization. Magn Reson Imaging 18:697706, 2000

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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