抄録
Summary: This report describes the salvage techniques used to achieve postoperative patency of intraoperative bypass graft obstructions in patients who underwent superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. We analyzed 72 patients (79 sides) who underwent STAMCA anastomosis at our hospital between 2006 and 2017. This cohort comprised 35 females and 37 males, whose ages ranged from 9 to 74 years. The incidences of occlusive cerebrovascular disease, moyamoya disease, and cerebral aneurysm were 30 sides in 30 patients, 26 sides in 19 patients, and 23 sides in 23 patients, respectively. In terms of intraoperative bypass occlusion, we evaluated the sites, causes, timing, and type of salvage treatment performed. Intraoperative bypass patency was confirmed using Doppler ultrasonography and indocyanine green video angiography. Postoperative bypass patency was evaluated using three-dimensional computed tomography angiography (3DCTA). Nine patients developed intraoperative acute bypass occlusion (5 occlusive cerebrovascular diseases, 4 moyamoya diseases) were 9, 5, and 4, respectively. Anastomotic thrombus formation was deemed to be the cause of occlusion in 8 patients, while an intraluminal STA thrombus was the cause in 1 patient. Occlusion occurred in the former toward the end of the procedure and it occurred in the latter immediately after anastomosis. In terms of salvage treatment, re-suturing was used for the bypass occlusion in the 8 patients with anastomotic thrombi, while STA reconstruction was used in the patient with the intraluminal STA thrombus. Using 3DCTA, we observed that 8 of the 9 patients who underwent salvage treatment for intraoperative bypass occlusion demonstrated patency after 7 postoperative days. Bypass occlusion during the STA-MCA bypass was attributable to thrombi of the anastomotic sites in a significantly high percentage of patients in whom Doppler ultrasonography revealed a marked reduction in blood flow within a short time. This was true even after confirming graft patency immediately after anastomosis. Patients who developed bypass occlusion secondary to anastomotic site thrombus underwent simultaneous re-suturing and graft patency restoration. We concluded that, in patients undergoing STA-MCA bypasses, Doppler ultrasonography is warranted before wound closure. If poor or diminished blood flow is observed, careful reevaluation and prompt re-suturing are warranted.
