Hara Takayuki, Arai Shintaro, Goto Yoshiaki, Takizawa Tsuguhito, Uchida Tatsuya
Department of Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
Acta Neurochir Suppl. 2016;123:57-64. doi: 10.1007/978-3-319-29887-0_8.
During surgery for cerebral aneurysm, revascularization techniques are occasionally needed to (1) treat an aneurysm (trapping or flow alteration); (2) preserve blood flow during temporary parent artery occlusion (insurance); and (3) repair accidentally injured vessels (troubleshooting). Herein we present our surgical case experiences.
Revascularization modalities were employed in 33 (7.6 %) of 452 cases of surgically treated aneurysms. The aneurysm locations and associated required bypass procedures were: (1) 7 middle cerebral artery (MCA) aneurysms with 7 superficial temporal artery (STA)-MCA bypass procedures; (2) 10 internal carotid artery (ICA) aneurysms with 9 high-flow and 1 STA-MCA procedures; (3) 10 vertebro-basilar artery aneurysms with 2 high-flow, 6 occipital artery (OA)-posterior ICA, and 1 STA-superior cerebellar artery (SCA) procedures; (4) 1 posterior cerebral artery (PCA) aneurysm with OA-PCA bypass; and (5) 5 anterior cerebral artery aneurysms with 4 A3-A3 and 1 A3-STA-A3 procedure. Curative bypasses for aneurysmal treatment, temporary bypasses, and troubleshooting procedures were performed in 25, 3, and 5 cases, respectively.
Among the 26 aneurysms treated via curative bypass, 16 aneurysms that were trapped or clipped using revascularization techniques had better outcomes (no aneurysmal rupture and 1 perforator infarction), whereas among the 10 aneurysms that could not be trapped or clipped and were thereby treated via flow alteration (e.g., bypass plus proximal artery clipping), 2 developed symptomatic infarction and 2 exhibited aneurysmal rupture after partial thrombosis. Patients whose bypass procedures were used for temporary parent artery occlusion (insurance) or troubleshooting had no complications.
Complex aneurysm clipping or trapping using bypass techniques yielded good results. In particular, perforator vessel ischemia still requires resolution. Flow alteration techniques leading to aneurismal thrombosis carried the risks of ischemic and hemorrhagic complications when applied to intracranial aneurysms. Bypasses for temporary use or troubleshooting were quite effective.
在脑动脉瘤手术期间，有时需要血管重建技术来（1）治疗动脉瘤（夹闭或血流改变）；（2）在临时阻断载瘤动脉期间维持血流（保障措施）；以及（3）修复意外损伤的血管（故障排除）。在此我们展示我们的手术病例经验。
在452例接受手术治疗的动脉瘤病例中，33例（7.6%）采用了血管重建方式。动脉瘤的位置及相关所需的搭桥手术如下：（1）7例大脑中动脉（MCA）动脉瘤，行7例颞浅动脉（STA）-MCA搭桥手术；（2）10例颈内动脉（ICA）动脉瘤，9例行高流量搭桥手术，1例行STA-MCA手术；（3）10例椎基底动脉动脉瘤，2例行高流量搭桥手术，6例行枕动脉（OA）-颈内动脉后交通支搭桥手术，1例行STA-小脑上动脉（SCA）手术；（4）1例大脑后动脉（PCA）动脉瘤，行OA-PCA搭桥手术；以及（5）5例大脑前动脉动脉瘤，4例行A3-A3搭桥手术，1例行A3-STA-A3手术。分别有25例、3例和5例进行了用于治疗动脉瘤的根治性搭桥手术、临时搭桥手术及故障排除手术。
在通过根治性搭桥手术治疗的26例动脉瘤中，16例采用血管重建技术夹闭或包裹的动脉瘤预后较好（无动脉瘤破裂，1例穿支梗死），而在10例无法夹闭或包裹从而通过血流改变治疗（如搭桥加近端动脉夹闭）的动脉瘤中，2例出现症状性梗死，2例在部分血栓形成后出现动脉瘤破裂。用于临时阻断载瘤动脉（保障措施）或故障排除的搭桥手术患者无并发症发生。
使用搭桥技术进行复杂的动脉瘤夹闭或包裹效果良好。特别是，穿支血管缺血问题仍需解决。导致动脉瘤血栓形成的血流改变技术应用于颅内动脉瘤时存在缺血性和出血性并发症的风险。临时使用或用于故障排除的搭桥手术相当有效。
