Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

Abstract

Thrombosis and occlusion after stent-assisted coiling of aneurysms are well-known occurrences, with an incidence ranging from 5% to 20%. [1][2][3][4][5][6] Bypass techniques remain relevant in the cerebrovascular neurosurgeon's armamentarium for the treatment of complex ruptured and unruptured aneurysms that may not be amenable to or have failed endovascular treatment. When a high-flow bypass is required for this purpose, radial artery grafts are especially effective. [30][31][32][33][34][35][36][37][38] We present a case of a 57-year-old woman who presented with acute left-sided hemiparesis after redo coiling of a recurrent giant right internal carotid artery terminus aneurysm that had previously undergone Atlas stentassisted coiling. She underwent mechanical thrombectomy with TICI2b revascularization, but despite this intervention, she progressed to complete hemiplegia the following morning. Therefore, the patient underwent radial artery harvesting, cervical carotid neck exposure, and a pterional craniotomy. A common carotid-M2 direct bypass was performed using a radial artery interposition graft with complete flow restoration to the entire middle cerebral artery distribution. This surgical video reviews the case presentation, surgical anatomy, operative technique, and postoperative course and outcome. The patient gave verbal consent for participation in the procedure and surgical video.

Letter: Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

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To the Editor:We thank Dr Rennert and Dr Russin for their comments regarding our surgical video case. 1,2 As in many high-volume centers, we rely on multidisciplinary cerebrovascular discussions for treatment decision-making, but ultimately, the final decision lies with the patient and the treating surgeon. This patient had undergone endovascular treatments before presenting to the senior author.

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Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

“…Therefore, surgical management remains an important modality for the management of many giant aneurysms. 5,18 We read with great interest the article by Nguyen et al 19 The authors present a patient with a giant internal carotid artery (ICA) terminus aneurysm, which was successfully managed with use of high-flow bypass as a rescue technique after parent artery thrombosis in the setting of repeat coiling. The patient received initial treatment with stent-assisted coiling at an outside institution, which was complicated with ICA occlusion requiring mechanical thrombectomy.…”

Commentary: Common Carotid Artery to Middle Cerebral Artery Bypass With Radial Interposition Graft for Internal Carotid Artery (ICA) Occlusion After Stent-Coil Embolization of Giant ICA Terminus Aneurysm: 2-Dimensional Operative Video

“…1 Although rescue bypass for flow replacement in cases of iatrogenic vessel injury or occlusion requires the same technical maneuvers as other bypasses, there are often additional challenges that arise with these procedures related to acute time limitations and suboptimal surgical conditions (i.e., unscheduled cases with potentially unfamiliar staff and sequelae from evolving injuries or blood loss including brain edema and coagulopathies). Nguyen et al 2 should thus be commended for their report detailing the successful salvage extracranial-to-intracranial high-flow bypass with a radial artery interposition graft and internal carotid artery (ICA) occlusion for the treatment of acute hemispheric hypoperfusion after repeated endovascular treatment of a giant ICA terminus aneurysm.…”