Han Qingdong, Wang Zongqi, Zhou Peng, Ren Shuaiyu, Hui Pinjing, Yan Yanhong, Huang Yabo
Department of neurosurgery, the First affiliated hospital of soochow university, Suzhou, China.
Department of neurosurgery, the First affiliated hospital of soochow university, Suzhou, China.
World Neurosurg. 2024 Jan;181:e640-e647. doi: 10.1016/j.wneu.2023.10.104. Epub 2023 Oct 27.
Cerebral revascularization is an effective measure for dealing with complicated intracranial aneurysms and ischemic cerebro-vascular disease. Intra-operative thrombosis causing bypass occlusion is a severe issue that cause devastating consequences for complication in revascularization. We report our experiences regarding salvage maneuvers for intraoperative thrombosis in cerebral revascularization procedures and discuss the characteristics and culprits.
We investigated 720 consecutive patients who underwent cerebral revascularization at the First Affiliated Hospital of Soochow University from January 2013 to October 2021, including 688 patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and 32 patients who underwent extracranial artery-radial artery (ECA-RA)-MCA bypass. Forty-one patients experienced intracranial aneurysms, and the remaining 679 patients was involved in moyamoya disease (MMD), skull base tumors, intracranial occlusive vascular diseases, or other cerebrovascular diseases. All clinical characteristics, clinical imaging examinations and neurological outcomes were studied pre- and postoperatively. The patency of bypasses was confirmed by intraoperative doppler ultrasonography and indocyanine green (ICG) videoangiography.
Seven intraoperative thromboses, which were confirmed by intraoperative doppler ultrasonography and ICG videoangiography, including STA-MCA bypass (n=5) and ECA-RA-MCA bypass (n=2), were observed in 720 patients who underwent cerebral revascularization. The anastomotic stoma remained patent in 6 of 7 patients with intraoperative thrombosis after treatment. One case in STA-MCA bypass failed to be salvaged. Of the four intraoperative thrombosis in STA-MCA bypass for MMD being successfully saved, two were salvaged by applying gelfoam around the site of the anastomosis to relieve the downward compression effect of the donor vessel(STA) on the recipient vessel(M4 segment of MCA).One case in ECA-RA-MCA bypass were salvaged by thrombectomy through donor arteriotomy (radial artery) and reanastomosis. The other case was salvaged by complete reanastomosis. All seven patients who experienced intraoperative thrombosis achieved favorable outcomes at discharge and the 6-month follow-up.
Various factors are responsible for intraoperative thrombosis in cerebral revascularization. Relieving the downward compression effect of the donor vessel STA on the recipient vessel M4 segment of MCA by applying gelfoam around the site of the anastomosis stoma, can be recommend to salvage the intraoperative thrombosis in cerebral revascularization.
脑血运重建是治疗复杂颅内动脉瘤和缺血性脑血管疾病的有效措施。术中血栓形成导致搭桥闭塞是一个严重问题，会给血运重建并发症带来毁灭性后果。我们报告了在脑血运重建手术中处理术中血栓形成的挽救措施的经验，并讨论了其特点和原因。
我们调查了2013年1月至2021年10月在苏州大学附属第一医院接受脑血运重建的720例连续患者，其中688例行颞浅动脉（STA）-大脑中动脉（MCA）搭桥术，32例行颅外动脉-桡动脉（ECA-RA）-MCA搭桥术。41例患者患有颅内动脉瘤，其余679例患者患有烟雾病（MMD）、颅底肿瘤、颅内闭塞性血管疾病或其他脑血管疾病。对所有患者术前和术后的临床特征、临床影像学检查及神经功能结果进行研究。搭桥通畅情况通过术中多普勒超声和吲哚菁绿（ICG）血管造影术确认。
在720例接受脑血运重建的患者中，通过术中多普勒超声和ICG血管造影术确认发生了7例术中血栓形成，其中STA-MCA搭桥术5例，ECA-RA-MCA搭桥术2例。7例术中血栓形成患者中，6例经治疗后吻合口保持通畅。1例STA-MCA搭桥术患者未能挽救成功。在4例成功挽救的MMD患者的STA-MCA搭桥术中的术中血栓形成中，2例通过在吻合口周围应用明胶海绵来减轻供体血管（STA）对受体血管（MCA的M4段）的向下压迫作用而挽救成功。1例ECA-RA-MCA搭桥术患者通过经供体动脉（桡动脉）切开取栓并重新吻合而挽救成功。另1例通过完全重新吻合而挽救成功。所有7例发生术中血栓形成的患者出院时及6个月随访时均取得了良好预后。
脑血运重建术中血栓形成由多种因素导致。通过在吻合口周围应用明胶海绵减轻供体血管STA对受体血管MCA的M4段的向下压迫作用，可推荐用于挽救脑血运重建术中的术中血栓形成。
