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Christopher J. Stapleton, Gursant S. Atwal, Ahmed E. Hussein, Sepideh Amin-Hanjani and Fady T. Charbel

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.

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Christopher J. Stapleton, Ahmed E. Hussein, Mandana Behbahani, Ali Alaraj, Sepideh Amin-Hanjani and Fady T. Charbel

OBJECTIVE

Cerebral bypasses are performed for the purpose of either flow augmentation for ischemic cerebrovascular disease or flow replacement for vessel sacrifice during complex aneurysm or tumor surgery. Saphenous vein grafts (SVGs) are commonly used interposition grafts. The authors of this study sought to compare the efficacy of autologous versus cadaveric SVGs in a large series of cerebral bypasses using interposition vein grafts with long-term angiographic follow-up.

METHODS

All intracranial bypass procedures performed between 2001 and 2018 were reviewed. Demographic, clinical, angiographic, and operative data were recorded and then analyzed according to SVG type.

RESULTS

A total of 308 consecutive intracranial bypasses were performed during the study period, 53 (17.2%) of which were bypasses with an interposition SVG (38 autologous, 15 cadaveric). At a median follow-up of 2.2 months (IQR 0.2–29.1), 39 (73.6%) bypasses were patent (26 [68.4%] autologous, 13 [86.7%] cadaveric, p = 0.30). Comparing autologous and cadaveric SVG recipients, there were no statistically significant differences in age (p = 0.50), sex (p > 0.99), history of smoking (p = 0.75), hypertension (p > 0.99), diabetes mellitus (p = 0.13), indication for bypass (p = 0.27), or SVG diameter (p = 0.65). While there were higher intraoperative (autologous, 100.0 ml/min, IQR 84.3–147.5; cadaveric, 80.0 ml/min, IQR 47.3–107.8; p = 0.11) and postoperative (autologous, 142.2 ml/min, IQR 76.8–160.8; cadaveric, 92.0 ml/min, IQR 69.2–132.2; p = 0.42) volumetric flow rates in the autologous SVGs compared to those in the cadaveric SVGs, the difference between the two groups did not reach statistical significance. In addition, the blood flow index, or ratio of postoperative to intraoperative blood flow, for each bypass was similar between the groups (autologous, 1.3, IQR 0.9–1.6; cadaveric, 1.5, IQR 1.0–2.3; p = 0.37). Kaplan-Meier estimates showed no difference in bypass patency rates over time between autologous and cadaveric SVGs (p = 0.58).

CONCLUSIONS

Cadaveric SVGs are a reasonable interposition graft option in cerebral revascularization surgery when autologous grafts are not available.