Uchida Tatsuya, Yoshino Masanori, Ito Shinji, Hara Takayuki
Department of Neurosurgery, Toranomon Hospital, Tokyo, Japan.
Department of Pathology, Toranomon Hospital, Tokyo, Japan.
NMC Case Rep J. 2017 Aug 24;4(4):111-113. doi: 10.2176/nmccrj.cr.2017-0037. eCollection 2017 Oct.
Bypass surgery is often used in the treatment of large and giant aneurysms. Major complications that often arise during the perioperative period include cranial nerve palsy, ischemic complications, and hyperperfusion. However, there have been a few reports about late onset complications such as anastomotic aneurysms. In particular, anastomotic aneurysm after high flow bypasses has never been reported. A 57-year-old woman who had been suffering from left eye pain was diagnosed with a large aneurysm of the left internal carotid artery (ICA) in the cavernous portion. She was treated with high flow bypass surgery using radial artery graft and proximal ICA ligation. One and a half year after surgery, a de novo aneurysm (7.5 mm in maximum diameter) was detected in the anastomotic site. To prevent rupture, the aneurysm was resected and the middle cerebral artery (MCA) was reconstructed via superficial temporal artery (STA)-MCA bypass. Postoperative course was uneventful and the anastomotic aneurysm did not recur until 2 years after second surgery. Histological evaluation of the anastomotic aneurysm demonstrated loss of smooth muscle cells and proliferation of neointima, features consistent with a true aneurysm. Interestingly, the above changes were prominent in the radial artery graft while the MCA was almost histologically intact. As such, intraoperative intimal damage and postoperative hemodynamic stress to the radial artery graft may be a cause of aneurysm formation. Anastomotic aneurysm may occur after high flow bypass, necessitating careful postoperative follow-up.
旁路手术常用于治疗大型和巨大动脉瘤。围手术期经常出现的主要并发症包括颅神经麻痹、缺血性并发症和高灌注。然而，关于迟发性并发症如吻合口动脉瘤的报道较少。特别是，高流量旁路术后的吻合口动脉瘤从未有过报道。一名57岁患有左眼疼痛的女性被诊断为海绵窦段左颈内动脉（ICA）大型动脉瘤。她接受了使用桡动脉移植物的高流量旁路手术和近端ICA结扎术。术后一年半，在吻合部位检测到一个新生动脉瘤（最大直径7.5毫米）。为防止破裂，切除了动脉瘤，并通过颞浅动脉（STA）-大脑中动脉（MCA）旁路重建了大脑中动脉。术后过程顺利，直到第二次手术后两年吻合口动脉瘤未复发。对吻合口动脉瘤的组织学评估显示平滑肌细胞丢失和内膜增生，这些特征与真性动脉瘤一致。有趣的是，上述变化在桡动脉移植物中很明显，而MCA在组织学上几乎完好无损。因此，术中对桡动脉移植物的内膜损伤和术后血流动力学应激可能是动脉瘤形成的原因。高流量旁路术后可能发生吻合口动脉瘤，需要仔细的术后随访。
