Abstract
The aim of the present study was to investigate the use of a radial artery graft (RAG) for bypass of the proximal superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) by posterior oblique transzygomatic subtemporal approach as an alternative to the external carotid artery (ECA) to PCA anastomosis. We conducted an anatomical and technical study at a university hospital. Five adult cadaveric specimens were dissected. A preauricular vertical skin incision was used. The trunk of STA was identified. A 30° oblique posterior zygomatic arch osteotomy and microcraniotomy was performed. The dura of the middle cranial fossa was then opened. The temporal lobe was retracted, the interpeduncular and ambient cisterns were opened, and the P2 segment of the PCA was exposed. The proximal side of the RAG was anastomosed with the proximal STA and the distal side was anastomosed with the P2 segment. The mean caliber of the proximal STA was 2.25 ± 0.35 mm. The mean diameter of the P2 was 2.2 ± 0.2 mm. The average length of the RAG was 56 ± 3.2 mm. The mean caliber of the proximal and the distal sides of the graft was 2.5 ± 0.25 mm and 2.3 ± 0.15 mm, respectively. Because the proximal STA to proximal PCA bypass uses a short RAG and their calibers are over 2 mm, this bypass technique can provide a sufficient blood flow and may be a reasonable alternative over ECA to PCA bypass using long grafts.
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Ugur Türe, Istanbul, Turkey
The authors present a study of the proximal superficial temporal artery (STA) to proximal posterior cerebral artery (PCA) bypass using a radial artery graft in cadavers. They present this technique as another option to revascularize brain tissue. Because it uses a short radial artery graft (RAG), the authors suggest that their technique is superior to the proximal external carotid artery (ECA) to PCA bypass, which uses a long RAG.
Brain revascularization procedures have been done for more than 40 years since Yaşargil and Donaghy developed the extracranial-intracranial (EC-IC) bypass technique. This method was used with increasing frequency in the 1970s and early 1980s. After the results of the EC-IC bypass study, however, the popularity of this procedure declined. Currently, this technique is used to manage neurovascular disorders such as cerebrovascular ischemic disease, moyamoya disease, complex intracranial aneurysms, and some cranial base tumors that require carotid artery resection. However, studies concerning the indications and techniques for bypass surgery are still ongoing. Recently, due to the development of endovascular techniques, vascular neurosurgeons are faced with more problematic cases. Therefore, any study presenting new anastomosis techniques or materials, as well as new combinations of donor and recipient arteries, is more than welcome in the neurosurgical literature.
I would like to commend the authors for their efforts in studying the various approaches for EC-IC bypass techniques. This team has published many other articles about this topic, studying the feasibility of various procedures in cadavers. Now, however, is the time to test these techniques with clinical application. We look forward to seeing their experience with successful examples of their bypass techniques in patients.
Claudius Thomé, Mannheim, Germany
Using cadaveric dissection, Dr. Ulku et al. demonstrate the feasibility of a novel bypass technique in an attempt to revascularize the posterior cerebral circulation. The described procedure is suggested to be an advantageous alternative to available techniques, as it only requires a short radial artery graft between the proximal STA and the P2 segment of the PCA. Intracranial access is achieved via a transzygomatic subtemporal approach.
The anatomical measurements show an excellent agreement of the involved vessel diameters thus providing optimal conditions for successful bypass surgery. Therefore, the presented technique constitutes an alternative to an ECA to PCA bypass with a long graft and to a direct (distal) STA to PCA bypass, which would eliminate one suture site in patients with a prominent STA. Nevertheless, it should be emphasized that this is a cadaveric study and suturing an anastomosis to the P2 via a limited minicraniotomy is clinically a very difficult task in a narrow and deep surgical field. Additionally, even in specialized centers only a limited number of posterior revascularization procedures are performed, as the vast majority of patients with vertebrobasilar insufficiency are treated medically or in selected cases by interventional procedures. Thus, the surgical morbidity as well as the efficacy of revascularization needs to be determined before the technique’s clinical usefulness can be assessed.
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Ulku, C.H., Cicekcibasi, A.E., Cengiz, S.L. et al. Proximal STA to proximal PCA bypass using a radial artery graft by posterior oblique transzygomatic subtemporal approach. Neurosurg Rev 32, 95–99 (2009). https://doi.org/10.1007/s10143-008-0157-1
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DOI: https://doi.org/10.1007/s10143-008-0157-1