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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. 14.2l The direct PICA-to-PICA reanastomosis is performed.
PICA-to-PICA Bypass 315
Fig. 14.2m The temporary clips are removed.
Fig. 14.2n Intraoperative ICG angiogram confi rms
patency of the PICA-to-PICA direct reanastomosis.
316 Color Atlas of Cerebral Revascularization
Case 14-3
Diagnosis: Complex right PICA aneurysm
Bypass: Direct end-to-end PICA-to-PICA
Approach: Right far lateral
a
Fig. 14.3a, b Axial CT scans of a 38-year-old woman show severe SAH.
b
PICA-to-PICA Bypass 317
Fig. 14.3c Anteroposterior angiogram shows signifi cant right VA
disease associated with dissection of the VA, which was occluded at
the skull base.
Fig. 14.3d The normal left VA feeds the right VA ( white arrow )
through retrograde fl ow to fi ll the right PICA (white arrowhead) . The
dissecting aneurysm (black arrow) is seen on the cranial loop of the
distal right PICA.
318 Color Atlas of Cerebral Revascularization
Fig. 14.3e Through a right far lateral approach, the VA is identifi ed.
Fig. 14.3f The proximal portion of the PICA is exposed.
Fig. 14.3g The complex dissecting PICA aneurysm is identifi ed.
Fig. 14.3h The aneurysm is further exposed.
PICA-to-PICA Bypass 319
Fig. 14.3i The distal portion of the PICA is identifi ed.
Fig. 14.3j Temporary clips are applied to the PICA proximally and distally to the aneurysm.
320 Color Atlas of Cerebral Revascularization
Fig. 14.3k The PICA is cut distal to the aneurysm.
Fig. 14.3l The PICA is cut proximal to the aneurysm.
Fig. 14.3m The two cut ends of PICA are prepared for a direct end-to-end anastomosis.
Fig. 14.3n The fi rst stitch is placed.
PICA-to-PICA Bypass 321
Fig. 14.3o The anastomosis is almost complete.
Fig. 14.3p A polytetrafl uoroethylene sheet is placed around the anastomosis to prevent further dissection of the
abnormal PICA.
322 Color Atlas of Cerebral Revascularization
Fig. 14.3q ICG angiogram shows the
patency of the bypass proximal ( arrow )
and distal (arrowhead) to the wrapping.
PICA-to-PICA Bypass 323
Case 14-4
Diagnosis: Previously coiled, large recurrent right
PICA aneurysm
Bypass: PICA-to-VA direct reanastomosis
Approach: Right far lateral
a b
Fig. 14.4a, b Anteroposterior and lateral VA angiograms show a successfully coiled PICA aneurysm.
324 Color Atlas of Cerebral Revascularization
Fig. 14.4c CT scan shows the coiled aneurysm
with some regrowth.
Fig. 14.4d Angiogram performed a year later
showed regrowth at the base of the aneurysm.
The patient had recurrent symptoms of brainstem
compression.
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