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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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PICA-to-PICA Bypass 325
Fig. 14.4e Operative view shows the PICA and the opened aneurysm with the compacted coils. Temporary clips have
been placed on the VA proximal and distal to the PICA.
Fig. 14.4f The coils are cut with microscissors.
Fig. 14.4g Coils are removed to provide suffi cient room for primary clipping.
326 Color Atlas of Cerebral Revascularization
Fig. 14.4h A temporary clip is removed from the VA. At this point, there was signifi cant hemorrhage from the base of
the aneurysm because the permanent clip at its base had ruptured the neck of the aneurysm from the VA.
Fig. 14.4i The PICA has been removed distal to the aneurysm and reimplanted onto the VA.
Fig. 14.4j Completed reimplantation of PICA to the VA.
PICA-to-PICA Bypass 327
Fig. 14.4k Postoperative anteroposterior angiogram
shows the residual coil mass.
l
Fig. 14.4l, m Anteroposterior and lateral angiographic views show excellent fi lling of the PICA reimplanted onto the VA.
m
15 FA-to-VA Bypass
330 Color Atlas of Cerebral Revascularization
Fig. 15.1a Angiogram of a 56-year-old man who developed VA insuffi ciency shows
occlusion of his right VA and severe stenosis of his left VA.
Case 15-1
Diagnosis: VA insuffi ciency
Bypass: FA-to -VA
Approach: Left anterior cervical
b,c
Fig. 15.1b, c Angioplasty was performed, followed
by stenting, and his symptoms resolved.
FA-to-VA Bypass 331
Fig. 15.1d After a new onset of VA insuffi ciency, a repeat angiogram showed
occlusion of the VA.
Fig. 15.1e Late-phase angiogram showing fl ow in distal VA after the VA
was reconstituted ( arrow ) through small branches from the ECA.
332 Color Atlas of Cerebral Revascularization
Fig. 15.1f The left VA is exposed in the transverse foramen at the level of C3-C4.
Fig. 15.1g The exposure of the VA is extended and a temporary clip is placed on the superior end of the segment.
Fig. 15.1h The VA is divided at the inferior end of the exposure.
Fig. 15.1i The VA is mobilized superiorly. Plaque limits backfl ow.
FA-to-VA Bypass 333
Fig. 15.1j An endarterectomy is performed.
Fig. 15.1k After the endarterectomy is performed, the cut end of the VA is visible. Blood now backfl ows freely.
334 Color Atlas of Cerebral Revascularization
Fig. 15.1l The left facial artery was identifi ed at its origin on the ECA, clipped distally, and cut. It was anastomosed
directly to the distal portion of the VA.
Fig. 15.1m The anastomosis is complete.
n
Fig. 15.1n, o Intraoperative ICG angiograms confi rm the patency of the facial artery-to-VA
anastomosis.
o
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