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An anatomic study for a modified technique for bypass of the external carotid artery to the proximal middle cerebral artery

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Abstract

We aimed to evaluate whether bypass of the external carotid artery (ECA) to the middle cerebral artery (MCA) can be established by a short saphenous vein graft in order to increase the anastomosis patency. The method was performed to ten adult cadaver sides. We described a modified technique for bypass of the ECA to the M2 segment of MCA. The diameters of the vessels and graft length were measured by using an electronic micrometer. The mean diameter of the superior, middle, and inferior trunks of the MCA with trifurcation were 1.7 ± 0.15, 2.2 ± 0.25, and 2.0 ± 0.2 mm, respectively, whereas the mean diameter of the superior and inferior trunks of the MCA with bifurcation were 2.1 ± 0.2 and 2.3 ± 0.3 mm, respectively. The mean diameter of the ECA was 3.75 ± 0.4 mm. The mean length of the saphenous vein graft was 71.5 ± 3.9 mm. The high-flow ECA to proximal MCA bypass using a short venous graft can supply enough blood flow to establish cerebral revascularization with a straighter route.

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Authors and Affiliations

  1. Department of Neurosurgery, Meram Medical Faculty, Selcuk University, Konya, Turkey

    Sahika Liva Cengiz & Mehmet Erkan Ustun

  2. Department of Otolaryngology, Meram Medical Faculty, Selcuk University, Akyokus, 42080, Konya, Turkey

    Kayhan Ozturk

  3. Department of Anatomy, Meram Medical Faculty, Selcuk University, Konya, Turkey

    Aynur Emine Cicekcibasi & Ahmet Salbacak

Authors
  1. Sahika Liva Cengiz
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  2. Kayhan Ozturk
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  3. Aynur Emine Cicekcibasi
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  4. Ahmet Salbacak
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  5. Mehmet Erkan Ustun
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Correspondence to Kayhan Ozturk.

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Comments

Bektap Acikgoz, Zonguldak, Turkey

In this cadaver study, the authors have shown the possibility of using a short saphenous graft for anastomosis between external carotid artery and proximal middle cerebral artery. The vein graft was inserted into the cranial cavity from an artificial drill hole made in the sphenoid bone very near to crista infratemporalis.

The caliber of the graft material is supposed to overcome the problem of insufficient blood supply from superficial temporal artery bypass and bending, kinking, and thrombosis problems of long vein grafts from external carotid artery. Clinical studies in selected cases will show us more for the vulnerability of this technique.

Michael T. Lawton, San Francisco, USA

This report provides anatomical and technical data on the submandibular–infratemporal interpositional carotid artery bypass. This bypass connects the cervical external carotid artery to the middle cerebral artery with a saphenous vein graft that is tunneled through a burr hole in the middle cranial fossa floor. The authors found good caliber matches between donor and recipient arteries and the vein graft, and shortening of the graft length to 7 cm (approximately half the standard length of a graft tunneled in the preauricular space). Shorter grafts increase long-term patency rates; the deep course protects the graft from external trauma or inadvertent occlusion; and a straight course decreases the likelihood of graft kinking. However, these advantages are theoretical. Couldwell and colleagues first reported this technique and, to my knowledge, have the only published clinical experience with the technique. I have been hesitant to use this bypass because it requires tunneling that is completely blind and skirts some critical structures in the infratemporal fossa. However, I am impressed with its elegance and advantages. Surely, time spent in the laboratory doing cadaver dissections like these will lead to wider application of this technique.

Kazuhiko Nozaki, Shiga, Japan

The authors performed thoughtful studies using cadaver dissection in order to evaluate whether a modified ECA–MCA bypass could be established with a short saphenous vein graft. Because long grafts with a complex course can increase the risk of kinking and torsion of the graft and reduce the rate of good patency, their modified bypass with a short and straight course is reasonable for raising graft patency. Moreover, their techniques seem to be feasible and safe. Clinical concerns include bypass patency in patients, well-developed venous network around the temporal pole and middle cranial fossa in some patients, and possible and intractable CSF leakage into the infratemporal fossa. Further clinical data analysis from their group may be provided in order to describe the feasibility and safety of their method.

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Cengiz, S.L., Ozturk, K., Cicekcibasi, A.E. et al. An anatomic study for a modified technique for bypass of the external carotid artery to the proximal middle cerebral artery. Neurosurg Rev 31, 303–308 (2008). https://doi.org/10.1007/s10143-008-0138-4

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  • DOI: https://doi.org/10.1007/s10143-008-0138-4

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