Let's review the basic principles of their superficial temporal artery to a middle cerebral artery revascularization technique for Carotid Artery Occlusion. This is a 58 year old male who presented with left sided hemispheric TIA symptoms. On imaging, he was known to have a complete left ICA occlusion. Furthermore, CT angiogram demonstrated the dominance of the frontal branch of the superficial temporal artery. He only went at left sided STMC bypass. The frontal branch again was dominant of the STA, therefore, a Standard Curvilinear Incision is used. However, the STA was harvested from underneath the scalp flap. Harvesting the STA from underneath the scalp flap can be somewhat more technically challenging, but is possible. In this case for me to be able to expose a reasonable part of the temporal lobe to make the anastomosis possible. This incision was used. And as you can see, the STA was harvested from underneath the scalp flap. I follow the route of the STA, used the scissors to create the, dissection plains and follow the route of this branch. Vessel loops are used for handling the vessel. You can see I'm dissecting underneath the vessel to seam confidentially release, this branch of the STA. Here's the final result, it's left connected. A piece of glove is used to wrap the vessel and protected during the drilling. A large cotton is used to cover the vessel. Craniotomy was completed. The dura was open in a cruciate fashion. His sizable cortical vessel is apparent. Arachnoid bands are opened. The vessel, in other words the, recipient vessel is released. Slight state of hypertension is instituted upon temporary occlusion of the recipient vessel. The end of the donor vessel is prepared. The adventitious cleaned out of the soft tissues. You can see, I place it, piece of gel foam soaked in preparing on the recipient vessel during the preparation of the donor vessel. The end of the donor vessel is fish-mouthed to increase the surface of the anastomosis. Temporal clips are placed to trap the piece of the, or the segment of the, recipient cortical vessel. Next, an arteriotomy is completed. A five or six millimeter arteriotomy is relatively adequate. Appropriate micro scissors for bypass procedures are used to ensure a smooth and relatively linear arteriotomy line. Ample amount of heparin irrigation is used to keep the field clean 9-0 sutures are used for astomosing the heel and the toe of the donor vessel. Here's the heel, that is sutured first. Next, the toe is sutured. I used intermittent suturing technique using tenosuture. I believe a non-running or the intermittent pattern of suturing, minimizes the risk of stenosis at the anastomosis line. I avoid directly handling the sutures to minimize the risk of their breakage. Here's one of the sutures at the end of the, one of the suture lines. Here's the other suture line. The edges of the vessels are very carefully handled. Both ends are carefully inspected. In other words, both edges are carefully inspected. Here's the completion of the anastomosis. ICG angiogram demonstrates, very patent anastomosis. Here's the closure, again, making sure the donor vessel is not constricted either by the dural closure or the muscle itself, as well as the craniotomy on flap. And the post operative angiogram demonstrates, a very healthy anastomosis providing flow to the distal MCA branches without an evidence of ischemia on the CT scan. And this patient recovered nicely from his operation and has not had any more episodes of TIA since his surgery. Thank you.
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