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External carotid artery-radial artery graft-posterior cerebral artery bypass for complex vertebrobasilar aneurysms: efficacy and analysis of outcome in a single center

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Abstract

The purpose of this research was to demonstrate the effectiveness and clinical outcome of an external carotid artery-radial artery graft-posterior cerebral artery (ECA-RAG-PCA) bypass in the treatment of complex vertebrobasilar artery aneurysms (VBANs) in a single-center retrospective study. An ECA-RAG-PCA bypass may be a last and very important option in the treatment of complex VBANs when conventional surgical clip** or endovascular interventions fail to achieve the desired outcome. This study retrospectively analyzed the clinical presentation, case characteristics, aneurysm location, size and morphology, choice of surgical strategy, complications, clinical follow-up, and prognosis of the patients enrolled. The data involved were analyzed by the appropriate statistical methods. A total of 24 patients with complex VBANs who met the criteria were included in this study. Eighteen (75.0%) were male and the mean age was 54.1 ± 8.83 years. The aneurysms were located in the vertebral artery, the basilar artery, and in the vertebrobasilar artery with simultaneous involvement. All patients underwent ECA-RAG-PCA bypass surgery via an extended middle cranial fossa approach, with 8 (33.3%) undergoing ECA-RAG-PCA bypass only, 3 (12.5%) undergoing ECA-RAG-PCA bypass combined with aneurysm partial trap**, and 12 (50.0%) undergoing ECA-RAG-PCA bypass combined with proximal occlusion of the parent artery. The average clinical follow-up was 22.0 ± 13.35 months. The patency rate of the high-flow bypass was 100%. At the final follow-up, 15 (62.5%) patients had complete occlusion of the aneurysm, 7 (29.2%) patients had subtotal occlusion of the aneurysm, and 2 (8.3%) patients had stable aneurysms. The rate of complete and subtotal occlusion of the aneurysm at the final follow-up was 91.7%. The clinical prognosis was good in 21 (87.5%) patients and no procedure-related deaths occurred. Analysis of the good and poor prognosis groups revealed a statistically significant difference in aneurysm size (P = 0.034, t-test). Combining the results of this study and the clinical experience of our center, we propose a surgical algorithm and strategy for the treatment of complex VBANs.

The technical approach of ECA-RAG-PCA bypass for complex VBANs remains important, even in an era of rapid advances in endovascular intervention. When conventional surgical clip** or endovascular intervention has failed, an ECA-RAG-PCA bypass plays a role that cannot be abandoned and is a very important treatment option of last resort.

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Data Availability

Data available on request from the authors. The data that support the findings of this study are available from the corresponding author, [**aoguang Tong], upon reasonable request.

References

  1. Awad AJ, Mascitelli JR, Haroun RR, De Leacy RA, Fifi JT, Mocco J (2017) Endovascular management of fusiform aneurysms in the posterior circulation: the era of flow diversion. Neurosurg Focus 42(6):E14. https://doi.org/10.3171/2017.3.Focus1748

    Article  PubMed  Google Scholar 

  2. Griessenauer CJ, Ogilvy CS, Adeeb N et al (2018) Pipeline embolization of posterior circulation aneurysms: a multicenter study of 131 aneurysms. J Neurosurg 130(3):923–935. https://doi.org/10.3171/2017.9.Jns171376

    Article  PubMed  Google Scholar 

  3. Hara T, Arai S, Goto Y, Takizawa T, Uchida T (2016) Bypass surgeries in the treatment of cerebral aneurysms. Acta Neurochir Suppl 123:57–64. https://doi.org/10.1007/978-3-319-29887-0_8

    Article  PubMed  Google Scholar 

  4. Lawton MT, Lang MJ (2019) The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms. J Neurosurg 130(5):1409–1425. https://doi.org/10.3171/2019.1.Jns182156

    Article  PubMed  Google Scholar 

  5. Tayebi Meybodi A, Huang W, Benet A, Kola O, Lawton MT (2017) Bypass surgery for complex middle cerebral artery aneurysms: an algorithmic approach to revascularization. J Neurosurg 127(3):463–479. https://doi.org/10.3171/2016.7.Jns16772

    Article  PubMed  Google Scholar 

  6. Abla AA, Lawton MT (2014) Anterior cerebral artery bypass for complex aneurysms: an experience with intracranial-intracranial reconstruction and review of bypass options. J Neurosurg 120(6):1364–1377. https://doi.org/10.3171/2014.3.Jns132219

    Article  PubMed  Google Scholar 

  7. Kaku Y, Takei H, Miyai M, Yamashita K, Kokuzawa J (2016) Surgical treatment of complex cerebral aneurysms using interposition short vein graft. Acta Neurochir Suppl 123:65–71. https://doi.org/10.1007/978-3-319-29887-0_9

    Article  PubMed  Google Scholar 

  8. Zhu W, Liu P, Tian Y et al (2013) Complex middle cerebral artery aneurysms: a new classification based on the angioarchitecture and surgical strategies. Acta Neurochir (Wien) 155(8):1481–1491. https://doi.org/10.1007/s00701-013-1751-8

    Article  PubMed  Google Scholar 

  9. Butterfield JT, Chen CC, Grande AW, Jagadeesan B, Tummala R, Venteicher AS (2021) The rate of symptomatic ischemic events after passing balloon test occlusion of the major intracranial arteries: meta-analysis. World Neurosurg 146:e1182–e1190. https://doi.org/10.1016/j.wneu.2020.11.134

    Article  PubMed  Google Scholar 

  10. Kalani MY, Ramey W, Albuquerque FC et al (2014) Revascularization and aneurysm surgery: techniques, indications, and outcomes in the endovascular era. Neurosurgery 74(5):482–497. https://doi.org/10.1227/neu.0000000000000312. (discussion 497-488)

    Article  PubMed  Google Scholar 

  11. Kulcsár Z, Wetzel SG, Augsburger L, Gruber A, Wanke I, Rüfenacht DA (2010) Effect of flow diversion treatment on very small ruptured aneurysms. Neurosurgery 67(3):789–793. https://doi.org/10.1227/01.Neu.0000372920.39101.55

    Article  PubMed  Google Scholar 

  12. Kulcsár Z, Houdart E, Bonafé A et al (2011) Intra-aneurysmal thrombosis as a possible cause of delayed aneurysm rupture after flow-diversion treatment. AJNR Am J Neuroradiol 32(1):20–25. https://doi.org/10.3174/ajnr.A2370

    Article  PubMed  PubMed Central  Google Scholar 

  13. Alghamdi F, Morais R, Scillia P, Lubicz B (2015) The silk flow-diverter stent for endovascular treatment of intracranial aneurysms. Expert Rev Med Devices 12(6):753–762. https://doi.org/10.1586/17434440.2015.1093413

    Article  PubMed  CAS  Google Scholar 

  14. Maybaum J, Henkes H, Aguilar-Pérez M et al (2021) Flow diversion for reconstruction of intradural vertebral artery dissecting aneurysms causing subarachnoid hemorrhage-a retrospective study from four neurovascular centers. Front Neurol 12:700164. https://doi.org/10.3389/fneur.2021.700164

    Article  PubMed  PubMed Central  Google Scholar 

  15. Phillips TJ, Wenderoth JD, Phatouros CC et al (2012) Safety of the pipeline embolization device in treatment of posterior circulation aneurysms. AJNR Am J Neuroradiol 33(7):1225–1231. https://doi.org/10.3174/ajnr.A3166

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  16. Siddiqui AH, Monteiro A, Hanel RA et al (2023) Triple therapy versus dual-antiplatelet therapy for dolichoectatic vertebrobasilar fusiform aneurysms treated with flow diverters. J Neurointerv Surg 15(7):655–663. https://doi.org/10.1136/jnis-2022-019151

    Article  PubMed  Google Scholar 

  17. Davies JM, Lawton MT (2014) Advances in open microsurgery for cerebral aneurysms. Neurosurgery 74(Suppl 1):S7-16. https://doi.org/10.1227/neu.0000000000000193

    Article  PubMed  Google Scholar 

  18. Yasargil MG, Krayenbuhl HA, Jacobson JH 2nd (1970) Microneurosurgical arterial reconstruction. Surgery 67(1):221–233

    PubMed  CAS  Google Scholar 

  19. Costa M, Baldoncini M, Tataryn ZL et al (2021) Microsurgical clip** of carotid-ophthalmic tandem aneurysms: case report and surgical nuances. Medicina (Kaunas) 57(7):731–740. https://doi.org/10.3390/medicina57070731

    Article  PubMed  Google Scholar 

  20. Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K (2005) Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation. J Neurosurg 102(1):132–147. https://doi.org/10.3171/jns.2005.102.1.0132

    Article  PubMed  Google Scholar 

  21. Coert BA, Chang SD, Marks MP, Steinberg GK (2005) Revascularization of the posterior circulation. Skull Base 15(1):43–62. https://doi.org/10.1055/s-2005-868162

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tomizawa M, Hori S, Nishimura N et al (2020) Arterial reconstruction using the donor’s gonadal vein in living renal transplantation with multiple renal arteries: a case report and a literature review. BMC Nephrol 21(1):190. https://doi.org/10.1186/s12882-020-01848-z

    Article  PubMed  PubMed Central  Google Scholar 

  23. Matsukawa H, Tanikawa R, Kamiyama H et al (2017) Graft occlusion and graft size changes in complex internal carotid artery aneurysm treated by extracranial to intracranial bypass using high-flow grafts with therapeutic internal carotid artery occlusion. Neurosurgery 81(4):672–679. https://doi.org/10.1093/neuros/nyx075

    Article  PubMed  Google Scholar 

  24. Morton RP, Moore AE, Barber J et al (2014) Monitoring flow in extracranial-intracranial bypass grafts using duplex ultrasonography: a single-center experience in 80 grafts over 8 years. Neurosurgery 74(1):62–70. https://doi.org/10.1227/neu.0000000000000198

    Article  PubMed  Google Scholar 

  25. Eller JL, Sasaki-Adams D, Sweeney JM, Abdulrauf SI (2012) Localization of the internal maxillary artery for extracranial-to-intracranial bypass through the middle cranial fossa: a cadaveric study. J Neurol Surg B Skull Base 73(1):48–53. https://doi.org/10.1055/s-0032-1304556

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kra**a A, Chrobok V (2014) Radiological diagnosis and management of epistaxis. Cardiovasc Intervent Radiol 37(1):26–36. https://doi.org/10.1007/s00270-013-0776-y

    Article  PubMed  Google Scholar 

  27. Sato K, Ogoh S, Hirasawa A, Oue A, Sadamoto T (2011) The distribution of blood flow in the carotid and vertebral arteries during dynamic exercise in humans. J Physiol 589(Pt 11):2847–2856. https://doi.org/10.1113/jphysiol.2010.204461

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  28. Lee SH, Ahn JS, Kwun BD, Park W, Park JC, Roh SW (2015) Surgical flow alteration for the treatment of intracranial aneurysms that are unclippable, untrappable, and uncoilable. J Korean Neurosurg Soc 58(6):518–527. https://doi.org/10.3340/jkns.2015.58.6.518

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  29. Nussbaum ES, Kallmes KM, Lassig JP, Goddard JK, Madison MT, Nussbaum LA (2018) Cerebral revascularization for the management of complex intracranial aneurysms: a single-center experience. J Neurosurg 131(4):1297–1307. https://doi.org/10.3171/2018.4.Jns172752

    Article  Google Scholar 

  30. Lu X, Huang Y, Zhou P, Zhu W, Wang Z, Chen G (2021) Cerebral revascularization for the management of complex middle cerebral artery aneurysm: a case series. Exp Ther Med 22(2):883. https://doi.org/10.3892/etm.2021.10315

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  31. Kurşun B, Uğur L, Keskin G (2018) Hemodynamic effect of bypass geometry on intracranial aneurysm: a numerical investigation. Comput Methods Programs Biomed 158:31–40. https://doi.org/10.1016/j.cmpb.2018.02.008

    Article  PubMed  Google Scholar 

  32. Spetzler RF, Riina HA, Lemole GM Jr (2001) Giant aneurysms. Neurosurgery 49(4):902–908. https://doi.org/10.1097/00006123-200110000-00022

    Article  PubMed  CAS  Google Scholar 

  33. Drake CG (1969) The surgical treatment of vertebral-basilar aneurysms. Clin Neurosurg 16:114–169. https://doi.org/10.1093/neurosurgery/16.cn_suppl_1.114

    Article  PubMed  CAS  Google Scholar 

  34. Drake CG (1975) Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms. J Neurosurg 43(3):255–274. https://doi.org/10.3171/jns.1975.43.3.0255

    Article  PubMed  CAS  Google Scholar 

  35. Goehre F, Kamiyama H, Noda K et al (2016) Technical description of the medial and lateral anterior temporal approach for the treatment of complex proximal posterior cerebral artery aneurysms. World Neurosurg 86:490–496. https://doi.org/10.1016/j.wneu.2015.09.068

    Article  PubMed  Google Scholar 

  36. Nakase H, Kamada Y, Aoki H, Goda K, Morimoto T, Sakaki T (2000) Clinical study on recurrent intracranial aneurysms. Cerebrovasc Dis 10(4):255–260. https://doi.org/10.1159/000016067

    Article  PubMed  CAS  Google Scholar 

  37. Asgari S, Wanke I, Schoch B, Stolke D (2003) Recurrent hemorrhage after initially complete occlusion of intracranial aneurysms. Neurosurg Rev 26(4):269–274. https://doi.org/10.1007/s10143-003-0285-6

    Article  PubMed  Google Scholar 

  38. Han HJ, Lee W, Kim J et al (2022) Incidence rate and predictors of recurrent aneurysms after clip**: long-term follow-up study of survivors of subarachnoid hemorrhage. Neurosurg Rev 45(5):3209–3217. https://doi.org/10.1007/s10143-022-01828-x

    Article  PubMed  Google Scholar 

  39. Wang X, Tong X, Liu J, Shi M, Shang Y, Wang H (2023) Petrous carotid to upper posterior circulation bypass for the treatment of basilar trunk aneurysm: a novel high-flow intracranial-intracranial skull base bypass for posterior circulation. Oper Neurosurg (Hagerstown) 24(3):301–309. https://doi.org/10.1227/ons.0000000000000510

    Article  PubMed  Google Scholar 

  40. Sia SF, Morgan MK (2013) High flow extracranial-to-intracranial brain bypass surgery. J Clin Neurosci 20(1):1–5. https://doi.org/10.1016/j.jocn.2012.05.007

    Article  PubMed  Google Scholar 

  41. Raper DMS, Rutledge WC, Winkler EA et al (2020) Controversies and advances in adult intracranial bypass surgery in 2020. Oper Neurosurg (Hagerstown) 20(1):1–7. https://doi.org/10.1093/ons/opaa276

    Article  PubMed  Google Scholar 

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Acknowledgements

We thank Hu Wang and Hong Ji for the clinical data support and all the patients treated in our medical center.

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Author notes

  1. **aoguang Tong

    Present address: School of Medicine, Nankai University, Huanhu Hospital Affiliated to Nankai University, Tian** Huanhu Hospital, No. 6, Jizhao Road, **nan District, Tian**, China

Authors and Affiliations

  1. School of Medicine, Nankai University, 94 Wei** Road, 300071, Tian**, China

    Meng Zhang & **aoguang Tong

  2. Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tian** Medical University, Tian**, China

    **angchen Wu, Litian Huang & **ngdong Wang

  3. School of Medicine, Nankai University, Huanhu Hospital Affiliated to Nankai University, Tian** Huanhu Hospital, No. 6, Jizhao Road, **nan District, Tian**, China

    Kaiming Gao

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Contributions

The corresponding author **aoguang Tong contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Meng Zhang, **angchen Wu, Kaiming Gao, Litian Huang, and **ngdong Wang. The first draft of the manuscript was written by Meng Zhang and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to **aoguang Tong.

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Ethics approval and consent to participate

This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of Tian** Huanhu Hospital approved this study. Written informed consent was obtained from all individual participants included in the study and all enrolled patients or their families before conducting this clinical study. We followed the principle of confidentiality and respected any wishes of the patients.

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Zhang, M., Wu, X., Gao, K. et al. External carotid artery-radial artery graft-posterior cerebral artery bypass for complex vertebrobasilar aneurysms: efficacy and analysis of outcome in a single center. Neurosurg Rev 46, 192 (2023). https://doi.org/10.1007/s10143-023-02101-5

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