Fusiform MCA Aneurysm: Radial Artery Bypass

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This video reviews the methodologies for high-flow radial artery interposition graft and revascularization for management of a fusiform A1 and M1 aneurysm. This is a 36 year old female who presented with an incidental fusiform, partially calcified, A1 and M1 aneurysm. Also involving part of the carotid artery bifurcation. There were some calcification around the superior border of the aneurysm. The operative strategy involved a high-flow radial artery revascularization to one of the M2 branches, followed by definitive occlusion of the internal carotid artery, just distal to the anterior choroidal artery. A right frontotemporal craniotomy was performed. You can see the temporal branch of the MC that is being prepared as the donor site. A segment of the radial artery was harvested and the arteriotomy was completed, under burst suppression. The first anastomosis was performed inter-cranially. Sutures were used at the heel and the toe of the anastomotic site followed by a running suture on the both edges of the anastomosis. Due to the large caliber of these vessels, a running suture is quite effective and efficient. The loops are left rather loose until the entire line is sutured. Subsequently, the loops are tightened and the final knot is laid down. Ample amount of heparin irrigation solution is used to keep the operative field clear. Next, the other line of anastomosis is sutured. Again, you can see the running suture technique for performance of the anastomosis. The loops are tightened. Temper clip is placed. Next, I divert my attention to release of this circulation across the M2. Here's the radial artery interposition graft. It is tunneled toward the neck incision. Here's the opening into the external carotid artery where the proximal end of the radial artery was sutured to the end of the external carotid artery, after it was transected. Similar techniques are used for completion of the anastomosis. Following completion of the anastomosis, at the more proximal end of the graft, a permanent clip was placed on the ICA, just proximal to the bifurcation and distal to the origin of the anterior carotid artery. You can see the morphology of the fuse form aneurysm. Here's an exposure of the ICA within the sub-frontal area via an anterior Sylvian fissure dissection. This completes the definitive proximal occlusion or anterior ligation of the ICA, just proximal to the aneurysm. The flow within the inter-position graft is constituted. ICG demonstrated a healthy flow within the graft into the MCA territory, just to the level of the clip ligation of the ICA. I was satisfied with the results of the revascularization. Here's the anterior carotid artery that is patent. However, the graft failed to remain patent. And I suspect that the proximal anastomosis at the level of the neck to be the cause for the occlusion of the graft. Therefore I used a vascular punch and created another proximal anastomotic site on the common carotid artery and performed another anastomosis at this level. The flow within the graft remained patent following completion of this anastomosis. The suturing technique is very similar to the one described just previously. Thank you.

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