Frisoli Fabio A, Catapano Joshua S, Singh Rohin, Lawton Michael T
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Oper Neurosurg. 2021 Aug 16;21(3):E252-E253. doi: 10.1093/ons/opab123.
Dissecting fusiform posterior inferior cerebellar artery (PICA) aneurysms are rare and challenging.1,2 One common treatment is occlusion of the aneurysm and parent artery via an endovascular approach without revascularization.3 Revascularization of the artery requires an open microsurgical bypass or endovascular placement of a newer-generation flow diverter.4 We present an end-to-side reanastomosis of the PICA for treatment of a dissecting fusiform left PICA aneurysm with anatomy deemed unfavorable for endovascular treatment in a 62-yr-old man with subarachnoid hemorrhage. After discussions regarding risks, benefits, and alternatives to the procedure, the family consented to surgical treatment. A far-lateral craniotomy was performed, with partial condylectomy to widen the exposure. The cisterna magna was opened, and the dentate ligament was cut to visualize the vertebral artery. The PICA was identified and traced distally to the aneurysmal segment, which was circumferentially diseased. Perforators were noted immediately distal to the aneurysm. The aneurysm was then trapped, and the afferent artery was transected and brought to the sidewall of the distal artery. The recipient site was trapped with temporary clips, and a linear arteriotomy was made. An end-to-side reanastomosis was performed, temporary clips were removed, and hemostasis was achieved. Postoperative angiography confirmed bypass patency and preservation of the PICA perforators. Conventional reanastomosis of the parent artery after aneurysm excision is achieved by end-to-end reanastomosis. In contrast, we performed an unconventional end-to-side reanastomosis to revascularize the PICA while leaving the efferent artery in situ to protect its medullary perforators. This bypass is an example of a fourth-generation bypass.5,6 Used with permission from the Barrow Neurological Institute, Phoenix, Arizona.
解剖性梭形小脑后下动脉（PICA）动脉瘤罕见且具有挑战性。1,2一种常见的治疗方法是通过血管内途径闭塞动脉瘤和载瘤动脉，不进行血管重建。3动脉的血管重建需要开放显微外科旁路手术或新一代血流导向装置的血管内植入。4我们报道了一例62岁蛛网膜下腔出血男性患者，因解剖结构不利于血管内治疗，对其解剖性梭形左侧PICA动脉瘤进行PICA端侧再吻合术。在讨论了该手术的风险、益处和替代方案后，患者家属同意手术治疗。 行远外侧开颅术，部分髁突切除术以扩大显露范围。打开枕大池，切断齿状韧带以显露椎动脉。识别PICA并向远端追踪至动脉瘤段，该段呈环形病变。在动脉瘤远端立即可见穿支。然后夹闭动脉瘤，切断传入动脉并将其带到远端动脉的侧壁。用临时夹夹闭受体部位，做一线形动脉切开。进行端侧再吻合，移除临时夹，实现止血。术后血管造影证实旁路通畅且PICA穿支得以保留。 动脉瘤切除后载瘤动脉的传统再吻合是通过端端再吻合实现的。相比之下，我们进行了非传统的端侧再吻合，以使PICA血管重建，同时将传出动脉原位保留以保护其髓质穿支。这种旁路是第四代旁路的一个例子。5,6经亚利桑那州凤凰城巴罗神经学研究所许可使用。
