Revascularization with Saphenous Vein Bypasses for Complex Intracranial Aneurysms

ABSTRACT

Most intracranial aneurysms can be managed with either microsurgical clipping or endovascular coiling. A subset of complex aneurysms with aberrant anatomy or fusiform/dolichoectatic morphology may require revascularization as part of a strategy that occludes the aneurysm or parent artery or both. Bypass techniques have been invented to revascularize nearly every intracranial artery. An aneurysm that will require a saphenous vein bypass is one that cannot be treated with conventional microsurgical clipping or endovascular coiling and also requires deliberate sacrifice of a major intracranial artery as part of the alternative treatment strategy. In the past 7 years the senior author (MTL) has performed a total of 110 bypasses, of which 46 were for aneurysms. Twenty-two of these patients received high-flow extracranial-to-intracranial bypasses using saphenous vein grafts, of which 16 had aneurysms that were giant in size. We review the indications for saphenous vein bypasses for complex intracranial aneurysms, surgical techniques, and clinical management strategies.

KEYWORDS

Subarachnoid hemorrhage - intracranial aneurysm - microsurgery - revascularization - saphenous vein graft - anastomosis

REFERENCES

• 1 Hopkins L N, Budny J L, Spetzler R F. Revascularization of the rostral brain stem.  Neurosurgery. 1982;  10 364-369
• 2 Newell D W, Skirboll S L. Revascularization and bypass procedures for cerebral aneurysms.  Neurosurg Clin N Am. 1998;  9 697-711
• 3 Spetzler R F, Carter L P. Revascularization and aneurysm surgery: current status.  Neurosurgery. 1985;  16 111-116
• 4 Auguste K I, Quiñones-Hinojosa A, Lawton M T. The tandem bypass: subclavian artery-to-middle cerebral artery bypass with dacron and saphenous vein grafts. Technical case report.  Surg Neurol. 2001;  56 164-169
• 5 Ausman J I, Diaz F G, Sadasivan B, Gonzeles-Portillo Jr M, Malik G M, Deopujari C E. Giant intracranial aneurysm surgery: the role of microvascular reconstruction.  Surg Neurol. 1990;  34 8-15
• 6 Carter B S, Ogilvy C S, Putman C, Ojemann R G. Selective use of extracranial-intracranial bypass as an adjunct to therapeutic internal carotid artery occlusion.  Clin Neurosurg. 2000;  46 351-362
• 7 Gurian J H, Martin N A, King W A, Duckwiler G R, Guglielmi G, Vinuela F. Neurosurgical management of cerebral aneurysms following unsuccessful or incomplete endovascular embolization.  J Neurosurg. 1995;  83 843-853
• 8 Hoh B L, Carter B S, Putman C M, Ogilvy C S. Important factors for a combined neurovascular team to consider in selecting a treatment modality for patients with previously clipped residual and recurrent intracranial aneurysms.  Neurosurgery. 2003;  52 732-738 , discussion 738-739
• 9 Hoh B L, Putman C M, Budzik R F, Carter B S, Ogilvy C S. Combined surgical and endovascular techniques of flow alteration to treat fusiform and complex wide-necked intracranial aneurysms that are unsuitable for clipping or coil embolization.  J Neurosurg. 2001;  95 24-35
• 10 Karnchanapandh K, Imizu M, Kato Y, Sano H, Hayakawa M, Kanno T. Successful obliteration of a ruptured partially thrombosed giant M1 fusiform aneurysm with coil embolization at distal M1 after extracranial-intracranial bypass.  Minim Invasive Neurosurg. 2002;  45 245-250
• 11 Lawton M T, Hamilton M G, Morcos J J, Spetzler R F. Revascularization and aneurysm surgery: current techniques, indications, and outcome.  Neurosurgery. 1996;  38 83-92 , discussion 92-94
• 12 Lawton M T, Quiñones-Hinojosa A, Sanai N, Malek J Y, Dowd C F. Combined microsurgical and endovascular management of complex intracranial aneurysms.  Neurosurgery. 2003;  52 263-274 , discussion 274-275
• 13 Lawton M T, Spetzler R F. Surgical management of giant intracranial aneurysms: experience with 171 patients.  Clin Neurosurg. 1995;  42 245-266
• 14 Lawton M T, Spetzler R F. Surgical strategies for giant intracranial aneurysms.  Neurosurg Clin N Am. 1998;  9 725-742
• 15 Lee S Y, Sekhar L N. Treatment of aneurysms by excision or trapping with arterial reimplantation or interpositional grafting. Report of three cases.  J Neurosurg. 1996;  85 178-185
• 16 Sekhar L N, Duff J M, Kalavakonda C, Olding M. Cerebral revascularization using radial artery grafts for the treatment of complex intracranial aneurysms: techniques and outcomes for 17 patients.  Neurosurgery. 2001;  49 646-658 , discussion 658-65
• 17 Sekhar L N, Kalavakonda C. Cerebral revascularization for aneurysms and tumors.  Neurosurgery. 2002;  50 321-331
• 18 Spetzler R F, Fukushima T, Martin N, Zabramski J M. Petrous carotid-to-intradural carotid saphenous vein graft for intracavernous giant aneurysm, tumor, and occlusive cerebrovascular disease.  J Neurosurg. 1990;  73 496-501
• 19 Roski R A, Spetzler R F, Hopkins L N. Occipital artery to posterior inferior cerebellar artery bypass for vertebrobasilar ischemia.  Neurosurgery. 1982;  10 44-49
• 20 Regli L, Piepgras D G, Hansen K K. Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation.  J Neurosurg. 1995;  83 806-811
• 21 Bederson J B, Spetzler R F. Anastomosis of the anterior temporal artery to a secondary trunk of the middle cerebral artery for treatment of a giant M1 segment aneurysm. Case report.  J Neurosurg. 1992;  76 863-866
• 22 Evans J J, Sekhar L N, Rak R, Stimac D. Bypass grafting and revascularization in the management of posterior circulation aneurysms.  Neurosurgery. 2004;  55 1036-1049
• 23 Lemole Jr G M, Henn J, Javedan S, Deshmukh V, Spetzler R F. Cerebral revascularization performed using posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. Report of four cases and literature review.  J Neurosurg. 2002;  97 219-223
• 24 Kunlin J. Treatment of arterial ischemia by long vein grafts.  Rev Chir. 1951;  70 206
• 25 Sabiston Jr D C. The coronary circulation.  Johns Hopkins Med J. 1974;  134 314-329
• 26 Wallman L J. Raymond Madiford Peardon Donaghy.  Surg Neurol. 1978;  9 73-75
• 27 Yasargil M G. Anastomosis between the superficial temporal artery and a branch of the middle cerebral artery. In: Yasargil MG Microsurgery Applied to Neurosurgery Stuttgart, Germany; Georg Thieme Verlag 1969: 105-115
• 28 Lougheed W M, Marshall B M, Hunter M, Michel E R, Sandwith-Smyth H. Common carotid to intracranial internal carotid bypass venous graft. Technical note.  J Neurosurg. 1971;  34 114-118
• 29 Hunt J L, Snyder W H. Late false aneurysm of the carotid artery: repair with extra-intracranial arterial bypass.  J Trauma. 1979;  19 198-200
• 30 Iwabuchi T, Kudo T, Hatanaka M, Oda N, Maeda S. Vein graft bypass in treatment of giant aneurysm.  Surg Neurol. 1979;  12 463-466
• 31 Diaz F G, Umansky F, Mehta B et al.. Cerebral revascularization to a main limb of the middle cerebral artery in the sylvian fissure. An alternative approach to conventional anastomosis.  J Neurosurg. 1985;  63 21-29
• 32 Spetzler R F, Rhodes R S, Roski R A, Likavec M J. Subclavian to middle cerebral artery saphenous vein bypass graft.  J Neurosurg. 1980;  53 465-469
• 33 Fitzpatrick B C, Spetzler R F, Ballard J L, Zimmerman R S. Cervical-to-petrous internal carotid artery bypass procedure. Technical note.  J Neurosurg. 1993;  79 138-141
• 34 Little J R, Furlan A J, Bryerton B. Short vein grafts for cerebral revascularization.  J Neurosurg. 1983;  59 384-388
• 35 Tanaka K, Yonekawa Y, Satou K, Katagiri K, Kouno H. STA-ACA anastomosis with interposed vein graft; a case report [in Japanese].  No Shinkei Geka. 1992;  20 171-176
• 36 Miele V J, Rosen C L, Carpenter J, Rai A, Bailes J E. Vertebral artery to middle cerebral artery bypass with coil embolization of giant ICA aneurysm.  Neurosurgery. 2005;  , In press
• 37 Spetzler R F, Roski R A, Rhodes R S, Modic M T. The “bonnet bypass.” Case report.  J Neurosurg. 1980;  53 707-709
• 38 Kinugasa K, Sakurai M, Ohmoto T. Contralateral external carotid-to-middle cerebral artery graft using the saphenous vein. Case report.  J Neurosurg. 1993;  78 290-293
• 39 Owers N O. Anatomic pathways facilitating middle cerebral artery bypass.  Am Surg. 1987;  53 282-284
• 40 Sundt Jr T M, Piepgras D G, Houser O W, Campbell J K. Interposition saphenous vein grafts for advanced occlusive disease and large aneurysms in the posterior circulation.  J Neurosurg. 1982;  56 205-215
• 41 Sullivan B J, Sekhar L N, Duong D H, Mergner G, Alyano D. Profound hypothermia and circulatory arrest with skull base approaches for treatment of complex posterior circulation aneurysms.  Acta Neurochir (Wien). 1999;  141 1-11 , discussion 11-12
• 42 Berguer R, Morasch M D, Kline R A. A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease.  J Vasc Surg. 1998;  27 852-859
• 43 Berguer R, Andaya L V, Bauer B B. Vertebral artery bypass.  Arch Surg. 1976;  111 976-979
• 44 Takeuchi S, Abe H, Tanaka R, Hayashi J. Aneurysm of a subclavian-vertebral artery saphenous vein bypass graft: case report.  Neurosurgery. 1998;  43 1212-1214
• 45 Santoro A, Passacantilli E, Guidetti G, Dazzi M, Guglielmi G, Cantore G. Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck.  J Neurosurg. 2002;  96 135-139
• 46 Takizawa K, Kamiyama H, Ishikawa T et al.. Vasoreconstructive surgery for the complex basilar trunk aneurysms. Presented at: Abstracts of the First Joint American-Japanese Meeting for Surgical and Endovascular Treatment for Cerebrovascular Disorders February 2001 Hilton Walkoloa Village, Big Island, Hawaii;
• 47 Desai N D, Cohen E A, Naylor C D, Fremes S E. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts.  N Engl J Med. 2004;  351 2302-2309
• 48 Diaz F G, Ohaegbulam S, Dujovny M, Ausman J I. Surgical alternatives in the treatment of cavernous sinus aneurysms.  J Neurosurg. 1989;  71 846-853
• 49 Linskey M E, Sekhar L N, Horton J A, Hirsch Jr W L, Yonas H. Aneurysms of the intracavernous carotid artery: a multidisciplinary approach to treatment.  J Neurosurg. 1991;  75 525-534
• 50 Sekhar L N, Sen C N, Jho H D. Saphenous vein graft bypass of the cavernous internal carotid artery.  J Neurosurg. 1990;  72 35-41
• 51 Sundt Jr T M, Piepgras D G, Marsh W R, Fode N C. Saphenous vein bypass grafts for giant aneurysms and intracranial occlusive disease.  J Neurosurg. 1986;  65 439-450