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Giant ICA Bifurcation Aneurysm: Radial Artery Bypass

Transcript

Let's review the techniques for high flow radial artery bypass for management of complex and giant cerebral aneurysms. This is a very young patient who presented with progressive right-sided hemiparesis. and on imaging evaluation was diagnosed with a six centimeter left-sided, partially thrombotic, partially calcified aneurysm at the level of the internal carotid artery bifurcation. Primary clip ligation of this aneurysm was themed essentially impossible. And its trapping was deemed the most safe and effective method to exclude this anuresym from the circulation, therefore, a high flow bypass using the radial artery graft was planned for revascularization of the MC tree. After the aneurysm was definitively ligated at the level of the ICA. Left front Temporal Craniotomy was performed. The neck was propared, the left arm was used as the radial artery was harvested. Here's the opening within the neck, the proximal anastomosis was performed per first as the length of the radial artery was noted to be slightly short. Despite maximal removal of the artery from the arm, a punch was used to create the proper anastomotic site at the level of the internal carotid artery in the neck. Following completion of the anastomosis at the neck, this vessal was tunneled toward the cranial incision. Here you can see the location or the proximal anastomosis at the level of the ICA. Subsequently the anterior limb of the Sylvian fissure was dissected, the ICA was exposed. You can see the origin of the M one from the broad neck of the aneurysm. Next the M two trunk and more specifically the temporal trunk was exposed skeletonized and prepared using papaverine soaked gel foam for performance of the distal anastomosis. Direct Moto evoke potentials where I use for monitoring a distal donor end is being prepared. A six millimeter arteriotomy was performed on the temporal M2 trunk due to this slightly short length of the bypass graft. The initial running suture was done via the inside of the vessel. A 9-0 suture was used. Felt that the running technique is quite effective in these large size vessels. Here's another suture at the heel of the anastomosis to keep the vessels more appropriately approximated before the running suture is further advanced. Again you can see that this suturing technique is performed from within the lumen of the vessel after that level of the anastomosis is completed. The more superficial limb is also performed. Temporary clips are removed. Hemostasis is attained micro Doppler, ultrasonography confirms adequate flow the ICA is dissected a little on the skull base and a permanent clip is implanted distal to the anterior caroidal artery. Here's the intercaroidal artery origin. So the perforator is at the level of the ICA bifurcation, are also apparent. Here's the PCoA, here's the permanent clip Intraoperative fluorescence angiography reveals good flow within the bypass graft ICG confirms similar findings. However, you can see some retrograde flow through the A1 into the aneurysm. Even has another view of this retrograde floor through the ICG. Intraoperative angiogram confirms the retrograde flow from the A1, causing refilling of the aneurysm sack. Subsequently a permanent clip was placed across A1 ipsilaterally just distal to the IC bifurcation, aneurysm appears very relaxed. It is trapped now. There's the M1 origin and post operative angiogram demonstrates complete entrapment of aneurysm with adequate filling and patency of the radial bypass graft, and this patients and hemiparesis has significantly improved after surgery. Thank you.

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