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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. 1.2m Postoperative three-dimensional CT
angiogram confi rms patency of the direct anastomosis
( arrows ).
Fig. 1.2n Postoperative MR images show no ischemic region. The patient was normal
at 3 years old.
16 Color Atlas of Cerebral Revascularization
Case 1-3
Diagnosis: Left A2 giant aneurysm
Bypass: A3-to-A3
Approach: Bifrontal hemispheric with trapping of
aneurysm and side-to-side anastomosis of pericallosal arteries
Fig. 1.3a Unenhanced axial CT scan of a 64-year-old man
with thromboembolic symptoms shows a hyperdense
interhemispheric mass with intraventricular hemorrhage in
the occipital horns.
ACA Bypass 17
Fig. 1.3b Anteroposterior angiogram shows a complex serpiginous channel traversing the
aneurysm, implying that most of the aneurysm is thrombosed. These aneurysms are not
amenable to direct reconstruction.
Fig. 1.3c The distal segment of A2 is visible as it emerges from the aneurysm and divides into pericallosal and
callosomarginal branches. Thrombus can be seen within the lumen of the artery.
18 Color Atlas of Cerebral Revascularization
Fig. 1.3d A clip applied on the distal A2 stops fl ow through the aneurysm. A2 is divided and the
extruding thrombus is visible.
Fig. 1.3e The two pericallosal arteries are placed side by side over a dam and temporarily occluded
while barbiturates are administered to the patient.
ACA Bypass 19
Fig. 1.3f A side-to-side A3-to-A3 anastomosis is completed interhemispherically distal to the
aneurysm.
g
Fig. 1.3g, h Postoperative anteroposterior ( g ) and lateral ( h ) left ICA angiograms confi rm obliteration of the aneurysm
and fi lling of the territories of both distal ACAs through the bypass.
h
20 Color Atlas of Cerebral Revascularization
Case 1-4
Diagnosis: Left fusiform A2 aneurysm
Bypass: A3-to-A3
Approach: Interhemispheric
Fig. 1.4a The left ICA lateral angiogram shows a fusiform
aneurysm involving the left A2.
Fig. 1.4b Through a right interhemispheric approach, the A3 to be sacrifi ced is located at the bottom of the
interhemispheric fi ssure. The front of the head is to the right and the right side of the patient is down.
ACA Bypass 21
Fig. 1.4c No adjacent pericallosal branch is available, so a callosomarginal branch is freed from the gyrus
above.
Fig. 1.4d The callosomarginal branch is gradually mobilized to bring it close to the pericallosal artery
deep to it.
Fig. 1.4e The falx is slit and a branch from the pericallosal artery is mobilized from its sulcus to allow the
pericallosal artery to be further mobilized.
22 Color Atlas of Cerebral Revascularization
Fig. 1.4f One small branch on the callosomarginal artery must be sacrifi ced to permit the arteries to be
apposed without tension.
Fig. 1.4g The two vessels lie parallel on a blue dam.
Fig. 1.4h A temporary clip is applied across both vessels.
Fig. 1.4i A second clip is applied distally in the same fashion.
ACA Bypass 23
Fig. 1.4j Each vessel is incised.
Fig. 1.4k Fine microscissors are used to extend the cuts and make them equal in length in both vessels.
24 Color Atlas of Cerebral Revascularization
Fig. 1.4l A suture is placed outside to inside at one apex, then reversed and passed from inside the lumen to the
outside of the other vessel and knotted.
Fig. 1.4m A suture is placed at the other apex with the knot on the outside. The needle is then placed from the
outside to the inside of the lumen, and the anastomosis of the back wall is performed on the inside of the vessels.
The last stitch is then passed again to the outside.
Fig. 1.4n The back wall sutures are tightened and the needle is passed to the outside where the suture is tied to
the second apex knot.
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