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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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Fig. 7.7c Overview of the vein graft distended with back bleeding.
Fig. 7.7d The graft has been anastomosed to the stump of the ICA in the neck.
e
Fig. 7.7e, f Right anteroposterior and lateral angiographic projections confi rm excellent feeding of the MCA and ACA
territory through the saphenous vein bypass graft.
f
196 Color Atlas of Cerebral Revascularization
Case 7-8
Diagnosis: Left CCA occlusion
Bypass: Subclavian artery–to–MCA with saphenous
vein graft
Approach: Left pterional and left transverse
supraclavicular
Fig. 7.8a Left anterior oblique arch angiogram
shows complete occlusion of the left CCA at its
origin.
Fig. 7.8b Right anteroposterior CCA angiogram
shows cross fi lling through the ACoA complex of
the left MCA territory. The left A1 segment ( arrow ),
which must carry the collateral blood fl ow to the left
hemisphere, is quite small compared to the normal
right side.
High-Flow Cervical Carotid Artery–to–MCA Bypass 197
Fig. 7.8c A left pterional craniotomy has been performed and the sylvian fissure has been opened widely. The M2
segment is isolated between temporary aneurysm clips. An arteriotomy performed at the bifurcation provides a
wide distal anastomotic site for the saphenous vein graft.
Fig. 7.8d The distal end of the saphenous vein graft is anastomosed to the M2 bifurcation. The temporary clips are
removed and the anastomosis is inspected for hemostasis.
Fig. 7.8e Overview of the craniotomy site and supraclavicular incision used to isolate the subclavian artery. The long
saphenous vein graft, which has been anastomosed to the MCA, is draped over the fi eld.
198 Color Atlas of Cerebral Revascularization
Fig. 7.8f The saphenous vein graft is tunneled subcutaneously from the craniotomy incision to the supraclavicular
incision. One end of a 28-French chest tube exits along the upper margin of supraclavicular incision. After the chest
tube is positioned, the vein graft can be readily passed through the tube by gentle irrigation. The graft is partially
infl ated to eliminate twisting or kinks before the chest tube is removed.
Fig. 7.8g A short segment of the subclavian artery is isolated between vascular clamps and an aortic punch is used to
create a suitable proximal anastomotic site for the saphenous vein graft.
Fig. 7.8h Immediately before the anastomosis is begun, the smooth arteriotomy is inspected. The anastomosis is
completed with 6–0 Prolene (Ethicon, Somerville, NJ).
High-Flow Cervical Carotid Artery–to–MCA Bypass 199
Fig. 7.8i Selective left subclavian artery angiogram
obtained the day after surgery confi rms that the proximal
anastomosis is widely patent.
j
Fig. 7.8j, k Anteroposterior and lateral angiographic views of the cranium from the same injection show the brisk fi lling
of the distribution of the MCA through the saphenous vein graft.
k
8 IMA–to–Cervical ICA Bypass
202 Color Atlas of Cerebral Revascularization
Case 8-1
Diagnosis: Left cervical ICA pseudoaneurysm
Bypass: IMA-to-ICA
Approach: Left anterior cervical
A 70-year-old woman with renal insuffi ciency had undergone a left carotid endarterectomy 5 years earlier.
She now presented with swallowing diffi culty and an expanding, pulsatile mass in the left neck.
Fig. 8.1a MR angiogram shows a large pseudoaneurysm arising from the
cervical portion of the ICA.
Fig. 8.1b The mass is exposed and all of the branches are identifi ed.
IMA–to–Cervical ICA Bypass 203
Fig. 8.1c The aneurysm dome is cut away. The old patch is found within the wall.
Fig. 8.1d The IMA is transected at its highest point before its caliber begins to diminish. The interior is fl ushed with
heparinized saline.
204 Color Atlas of Cerebral Revascularization
Fig. 8.1e The IMA is sewn to the stump of the ICA.
Fig. 8.1f Interrupted sutures are placed at intervals around the circumference of the anastomosis.
Fig. 8.1g The stump of the ICA is oversewn at the bulb.
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