Dubovoy A V, Ovsyannikov K S, Guzhin V E, Cherepanov A V, Galaktionov D M, Perfil'ev A M, Sosnov A O
Federal Center of Neurosurgery, Novosibirsk, Russia.
Zh Vopr Neirokhir Im N N Burdenko. 2017;81(2):5-21. doi: 10.17116/neiro20178125-21.
Poor outcomes of surgical treatment for complex cerebral aneurysms due to the development of cerebral ischemia were the cause to use cerebral revascularization surgery for this pathology.
the study objective was to master a high-flow extracranial-intracranial (EC-IC) artery bypass technique and evaluate its application in surgical treatment of complex and giant cerebral aneurysms as well as complex lesions of the brachiocephalic arteries.
Fifty two patients underwent high-flow IC-EC bypass surgery; of these, 34 patients had complex cerebral aneurysms, and 18 patients had complex stenotic occlusive lesions of the brachiocephalic arteries. After bypass placement, the patients with aneurysms underwent different variants of aneurysm exclusion (trapping or proximal clipping/ligation of the parent artery). All patients underwent follow-up studies of the bypass function and clinical condition in the early postoperative period and 6 and 12 months after surgery.
High-flow IC-EC bypass surgery is routinely used in clinical practice of the Novosibirsk Federal Center of Neurosurgery. Fifty one out of the 52 patients were followed-up in a range of 4 to 56 months. According to the direct or CT angiography data, bypasses functioned in 51 (98.1%) patients in the early and long-term postoperative periods. The clinical efficacy (no ischemic changes and improved cerebral perfusion) of high-flow IC-EC bypasses was demonstrated in 31 (91.2%) of 34 patients with aneurysms and in 17 (94.4%) of 18 patients with complex lesions of the brachiocephalic arteries. The total number of surgical complications was 8 (15.4%) cases: 7 complications occurred in patients with aneurysms, and 1 complication developed in a patient with bilateral ICA occlusion. Of these, ischemic complications developed in 4 (7.7%) cases, hemorrhagic complications occurred in 2 (3.8%) cases, and cranial nerve complications were found in 2 (3.8%) cases. One (1.9%) female patient with a giant aneurysm died from hemispheric stroke due to insufficient blood flow through the bypass.
Implementation of a large number of surgeries enabled improvement of the technique and clarification of the prerequisites for preoperative examination, intraoperative control, and postoperative management of patients. A low mortalits rate suggests this technique for use in clinical practice. The surgery is indicated for the treatment of giant aneurysms of the petrous, cavernous, and clinoid segments of the ICA. In the case of giant supraclinoid aneurysms, the surgery may be combined with removal of thrombotic masses from the aneurysm sac for rapid decompression of the cranial nerves. Application of this surgery for treatment of giant aneurysms of the trunk and bifurcation of the basilar artery is promising but requires further investigation. The surgery is also recommended for improving cerebral perfusion in the setting of complex stenotic occlusive lesions of the BCA: prolonged BCA stenoses, tandem ICA stenoses located in both the extracranial and intracranial segments, nonspecific vasculitis and arteriitis, subcranial aneurysms, kinking etc.
由于脑缺血的发生，复杂脑动脉瘤手术治疗效果不佳，这是对该病理情况采用脑血运重建手术的原因。
本研究的目的是掌握高流量颅外 - 颅内（EC - IC）动脉搭桥技术，并评估其在复杂和巨大脑动脉瘤以及头臂动脉复杂病变手术治疗中的应用。
52例患者接受了高流量IC - EC搭桥手术；其中，34例患者患有复杂脑动脉瘤，18例患者患有头臂动脉复杂狭窄闭塞性病变。搭桥手术后，患有动脉瘤的患者接受了不同的动脉瘤排除方法（夹闭或结扎载瘤动脉近端）。所有患者在术后早期以及术后6个月和12个月接受了搭桥功能和临床状况的随访研究。
高流量IC - EC搭桥手术在新西伯利亚联邦神经外科中心的临床实践中常规使用。52例患者中有51例在4至56个月的范围内接受了随访。根据直接或CT血管造影数据，51例（98.1%）患者的搭桥在术后早期和长期均发挥了作用。34例患有动脉瘤的患者中有31例（91.2%）以及18例患有头臂动脉复杂病变的患者中有17例（94.4%）显示高流量IC - EC搭桥具有临床疗效（无缺血改变且脑灌注改善）。手术并发症总数为8例（15.4%）：7例并发症发生在患有动脉瘤的患者中，1例并发症发生在双侧颈内动脉闭塞的患者中。其中，缺血性并发症发生4例（7.7%），出血性并发症发生2例（3.8%），颅神经并发症发现2例（3.8%）。1例（1.9%）患有巨大动脉瘤的女性患者因搭桥血流量不足死于半球性卒中。
大量手术的实施使技术得到改进，并明确了患者术前检查、术中控制和术后管理的前提条件。低死亡率表明该技术可用于临床实践。该手术适用于治疗颈内动脉岩骨段、海绵窦段和床突段的巨大动脉瘤。对于巨大鞍上动脉瘤，手术可联合从瘤腔内清除血栓块以快速减压颅神经。将该手术应用于治疗基底动脉主干和分叉处的巨大动脉瘤具有前景，但需要进一步研究。对于头臂动脉复杂狭窄闭塞性病变，如头臂动脉长期狭窄、颅外和颅内段串联颈内动脉狭窄、非特异性血管炎和动脉炎、颅下动脉瘤、血管扭曲等情况，也推荐该手术以改善脑灌注。
