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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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STA-to-PCA and STA-to-SCA Bypass 265
Fig. 12.2c A loose running 10–0 suture is placed along one wall. Waiting to tighten the sutures until they have all been
placed helps the surgeon to visualize the vessel walls for these deep anastomoses, ensures uniform suture tension, and
improves hemostasis.
Fig. 12.2d The anastomosis is completed and inspected for hemostasis.
Fig. 12.2e Low power view shows the completed bypass. The STA must be suffi ciently slack that the graft is not
stretched when the temporal lobe returns to its normal position after the retractor is removed.
266 Color Atlas of Cerebral Revascularization
Fig. 12.2f Overview of the operative fi eld shows the STA coursing over the fl oor of the middle fossa. Drilling the lateral
wall of the middle fossa fl at in relation to the fl oor maximizes subtemporal exposure while minimizing the need for
retraction.
Fig. 12.2g Postoperative lateral angiogram of the right
CCA demonstrates rapid fi lling of the SCAs and right PCA
through the patent bypass ( arrow ).
STA-to-PCA and STA-to-SCA Bypass 267
Fig. 12.2h Magnifi ed postoperative
selective angiogram of the right ECA
shows the STA-to-SCA bypass ( arrow ).
268 Color Atlas of Cerebral Revascularization
Case 12-3
Diagnosis: Complex BA aneurysm
Bypass: Right STA-to-SCA
Approach: Right orbitozygomatic
Fig. 12.3a A 50-year-old man with headaches
underwent angiography, which showed a dissecting BA
aneurysm.
STA-to-PCA and STA-to-SCA Bypass 269
Fig. 12.3b A stent ( arrow ) is placed in the
aneurysm.
Fig. 12.3c Thirteen months after the stent was
placed, further enlargement of the aneurysm was
observed.
270 Color Atlas of Cerebral Revascularization
Fig. 12.3d Angiogram shows progressive enlargement of the
original aneurysm through the stent as well as enlargement distal
to the end of the stent.
e
Fig. 12.3e, f The patient underwent an Alcock test, but no PCoA was identifi ed.
f
STA-to-PCA and STA-to-SCA Bypass 271
Fig. 12.3g Through a right orbitozygomatic approach, the distal BA aneurysm is visible.
Fig. 12.3h The STA is freed and prepared for anastomosis.
Fig. 12.3i The SCA is exposed through the incision in the tentorium.
272 Color Atlas of Cerebral Revascularization
Fig. 12.3j Temporary clips are placed on the SCA.
Fig. 12.3k After the SCA arteriotomy is made, the cut end of the STA is tacked to the SCA with heel and toe sutures.
Fig. 12.3l Continuous running sutures are placed loosely in the back wall of the anastomosis.
Fig. 12.3m The sutures are tightened.
STA-to-PCA and STA-to-SCA Bypass 273
Fig. 12.3n Overview of the exposure shows the STA as it lies below the temporal lobe on its way to the anastomotic site.
274 Color Atlas of Cerebral Revascularization
Fig. 12.3o Three-dimensional
reconstruction shows the STA-to-SCA bypass
( arrows ).
Fig. 12.3p CT angiogram shows the clips above the stent
and below the SCA.
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