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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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Subclavian Artery–to–CCA Bypass or Transposition 255
Fig. 11.2g The arteriotomy site is inspected. Note the smooth sides of the arteriotomy created with the aortic punch.
Fig. 11.2h A simple running 6–0 nylon suture is used to complete the anastomosis, which is inspected for hemostasis
after all temporary clips are removed.
Fig. 11.2i The completed anastomosis is shown. The transposed CCA arises from the subclavian artery and is lateral to
the thoracic duct and CN X.
256 Color Atlas of Cerebral Revascularization
Fig. 11.2j Postoperative anterior oblique projection
of a left subclavian artery angiogram shows the left
CCA arising smoothly from the subclavian artery. The
patient tolerated the procedure well and returned to
work within 3 weeks.
Fig. 11.2k MR angiogram obtained 3 years after
surgery confi rms excellent continued patency of the
transposition. The patient remains asymptomatic.
12 STA-to-PCA and STA-to-SCA Bypass
258 Color Atlas of Cerebral Revascularization
The recipient vessels for revascularization of the distal BA territory are the SCA and PCA. In the presence of
normal anatomy, a bypass to either vessel perfuses the top of the BA and both SCAs and PCAs.
The STA is isolated in the same fashion as described in Section 2. An orbitozygomatic craniotomy is
performed. This approach allows anterior mobilization of the temporalis muscle, creating more room for
performing the anastomosis. The craniotomy needs to be fl ush with the fl oor of the middle fossa.
The SCA lies just at or below the tentorial edge. It is often advantageous to cut the edge of the tentorium
to improve access to this artery. Care must be taken to identify and protect CN IV where it lies below the
tentorial edge.
A 10-mm segment of the SCA without perforating vessels is isolated. There must be room for temporary
clips on either side. A dam is placed under the vessel. A small piece of Gelfoam (Pfi zer, New York, NY) also
can be placed underneath the dam to elevate the vessel for easier access. The STA must be long enough that
it can be swung back and forth as the anastomosis is performed. There must be enough redundancy of the
STA that it can lie on fl oor of the middle fossa without tension and can accommodate the temporal lobe as
the lobe assumes its normal position.
The STA-to-PCA bypass is performed in similar fashion, except that the tentorium does not need to be
divided and the temporal lobe needs more mobilization.
Fig. 12.0a Schematic representation shows the fl at exposure needed to
access the PCA and SCA.
STA-to-PCA and STA-to-SCA Bypass 259
Anatomy of the STA-to-PCA Bypass
Fig. 12.0b Both the PCA and SCA are visible at the edge of the tentorium. CN IV has been exposed. (Photograph used
with permission from Journal of Neurosurgery .)
Fig. 12.0c A bypass has been performed between the STA and PCA. (Photograph used with permission from Journal of
Neurosurgery .)
Fig. 12.0d Higher magnifi cation view of an STA-to-PCA anastomosis. (Photograph used with permission from Journal of
Neurosurgery .)
260 Color Atlas of Cerebral Revascularization
Anatomy of the STA-to-SCA Bypass
Fig. 12.0e On the left side, the edge of the tentorium is visualized along with the SCA as it tucks underneath the
tentorium. CN IV is visible. (Photograph used with permission from Journal of Neurosurgery .)
Fig. 12.0f The tentorial edge has been retracted, exposing the full course of the SCA in the ambient cistern.
(Photograph used with permission from Journal of Neurosurgery .)
Fig. 12.0g High power view of CN IV and the SCA. (Photograph used with permission from Journal of Neurosurgery .)
STA-to-PCA and STA-to-SCA Bypass 261
Fig. 12.0h A bypass has been performed between the STA and the SCA. (Photograph used with permission from Journal
of Neurosurgery .)
Fig. 12.0i High power view of the left STA-to-SCA bypass. (Photograph used with permission from Journal of
Neurosurgery .)
262 Color Atlas of Cerebral Revascularization
Case 12-1
Diagnosis: Complete occlusion of the right VA and
severe stenosis of left VA with vestigial
PCoAs
Bypass: STA-to-PCA
Approach: Right pterional with low temporal
exposure
Fig. 12.1a The PCA and SCA are exposed in the ambient cistern.
Fig. 12.1b An STA-to-PCA bypass has been performed.
STA-to-PCA and STA-to-SCA Bypass 263
Fig. 12.1c, d Postoperative early and late lateral
angiograms confi rm patency of the STA-to-PCA
bypass and excellent fi lling of the PCA ( arrow ) and
upper BA territory.
c
d
264 Color Atlas of Cerebral Revascularization
Case 12-2
Diagnosis: Symptomatic stenosis of mid-BA
Bypass: S T A - t o - S C A
Approach: Right subtemporal
Fig. 12.2a The SCA is exposed via a right subtemporal approach. The edge of the tentorium is cut and coagulated, and
a small latex dam is placed beneath the artery to improve visualization.
Fig. 12.2b A short segment of the SCA is isolated between temporary aneurysm clips. The distal end of the STA is
tacked to the SCA at two points in preparation for the end-to-side anastomosis.
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