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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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High-Flow Cervical Carotid Artery–to–MCA Bypass 165
Fig. 7.1m Orbital exenteration and removal of the cavernous sinus create a large cavity.
Fig. 7.1n A free fl ap is harvested from the rectus abdominis muscle.
Fig. 7.1o The free graft fl ap is trimmed to fi t the cavity. The artery and vein are anastomosed to the STA and vein.
166 Color Atlas of Cerebral Revascularization
Fig. 7.1p Postoperative CT scan shows the vascularized
pedicle.
Fig. 7.1q Postoperative CT shows the size of the
craniotomy, the absence of the cavernous sinus and orbit,
and the placement of the clip on the distal ICA.
High-Flow Cervical Carotid Artery–to–MCA Bypass 167
Case 7-2
Diagnosis : Left ICA bifurcation recurrent giant
aneurysm
Bypass: Left cervical end-to-end ICA–to–MCA with
saphenous vein graft with fl ow reversal
Approach: Left anterior cervical and left pterional
A 48-year-old woman suff ered a sudden ictus. Eleven years earlier, she had undergone a craniotomy to treat
an aneurysm.
Fig. 7.2a Noncontrast axial CT scan shows a large left
frontal intraparenchymal hemorrhage extending into the
ventricles, especially into the third ventricle.
168 Color Atlas of Cerebral Revascularization
Fig. 7.2b Unsubtracted anteroposterior view of the skull
base at the beginning of patient’s preoperative angiogram
shows evidence of earlier bilateral craniotomies. One
aneurysm clip is on the right, and multiple clips are on
the left.
Fig. 7.2c Lateral left ICA angiogram shows a large recurrent
aneurysm at the bifurcation of the ICA.
High-Flow Cervical Carotid Artery–to–MCA Bypass 169
Fig. 7.2d Anteroposterior angiographic view shows that the
aneurysm has a broad neck.
e
Fig. 7.2e, f Postoperative angiograms show the coils placed to minimize the risk of rebleeding after the patient’s
recent hemorrhage, which left her in a poor grade. Over several weeks she made a good recovery. An attempt at stent
reconstruction failed. Because of the high risk of direct surgery with the old clips, a bypass was planned from the ICA to
the MCA.
f
170 Color Atlas of Cerebral Revascularization
Fig. 7.2g Angiogram shows that after the bypass from the ICA in the
neck to the M2 segment of the MCA was performed, the aneurysm
disappeared completely. The change in blood fl ow eliminated any
other fi lling of the aneurysmal neck.
Fig. 7.2h Later phase angiogram shows fi lling of the MCA and ACA
through the saphenous vein graft.
High-Flow Cervical Carotid Artery–to–MCA Bypass 171
Case 7-3
Diagnosis: Giant left MCA aneurysm
Bypass: ICA to M2 with saphenous vein graft with
ELANA anastomosis
Approach: Left orbitozygomatic
a
Fig. 7.3a, b Preoperative anteroposterior and lateral angiograms show a giant left MCA aneurysm causing ischemic
embolic events. (Courtesy of Albert van der Zwan, MD.)
b
Fig. 7.3c Preoperative three-dimensional angiographic
reconstruction shows the giant left MCA aneurysm.
(Courtesy of Albert van der Zwan, MD.)
172 Color Atlas of Cerebral Revascularization
Fig. 7.3d A segment of the saphenous vein graft that will form the proximal half of the bypass has been sutured to
the supraclinoid ICA. The ELANA catheter is then introduced into the saphenous vein graft and used to punch a hole
through the wall of the ICA. (Photograph courtesy of Albert van der Zwan, MD.)
Fig. 7.3e The previous step is repeated with the segment of the saphenous vein graft that forms the distal half of the
bypass, which is sutured to a distal MCA branch. The two segments of the saphenous vein graft are then anastomosed
to complete the bypass. (Photograph courtesy of Albert van der Zwan, MD.)
f
Fig. 7.3f, g Postoperative anteroposterior and lateral angiograms show the proximal ( arrow ) and distal ( arrowhead )
ELANA anastomosis as well as the end-to-end anastomosis ( double arrowheads ) of the two segments of the saphenous
vein graft of the ICA-to-M2 bypass. (Courtesy of Albert van der Zwan, MD.)
g
Fig. 7.3h Postoperative CT
angiographic reconstruction shows the
ELANA ICA-to-M2 bypass and the clips
trapping the aneurysm. (Courtesy of
Albert van der Zwan, MD.)
174 Color Atlas of Cerebral Revascularization
Case 7-4
Diagnosis: Giant cavernous sinus ICA aneurysm
Bypass: Abdulrauf IMA-to-MCA bypass
Approach: Right pterional with subtemporal ex-
tension
Fig. 7.4a A 57-year-old woman had
progressive CN VI paresis on the right
side. Right ICA angiogram shows a large
cavernous sinus aneurysm. (Courtesy of
Saleem I. Abdulrauf, MD, FACS.)
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