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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-MCA Bypass 45
Fig. 2.1c After the superfi cial MCA branch has been dissected free, Spetzler MicroVac suction tubing (P.M.T. Inc, Hopkins,
MN) is placed underneath the vessel to remove the fl uid, which is used to irrigate constantly throughout the bypass.
Fig. 2.1d Before the MCA branch is opened, small temporary clips are placed at either end of the vessel.
Fig. 2.1e The end of the STA is cut at a bevel and slit at the base until it matches the length of the MCA opening.
46 Color Atlas of Cerebral Revascularization
Fig. 2.1f The fi rst suture is placed in the end of the MCA opening and then hooked to the heel of the fi shmouthed STA.
Fig. 2.1g The second suture goes from the other end of the MCA opening to the toe of the fi shmouthed STA.
Fig. 2.1h A running suture is performed along one side of the two vessels. Tightening the loops at the end of the
bypass keeps the edges of the vessels visible. Alternatively, interrupted sutures can be placed.
Fig. 2.1i The vessel loops are tightened.
STA-to-MCA Bypass 47
Fig. 2.1j The two sutures are tied to the previously placed heel and toe knots.
Fig. 2.1k The anastomosis has been completed.
48 Color Atlas of Cerebral Revascularization
Fig. 2.1l Overview of the anastomosis.
STA-to-MCA Bypass 49
Case 2-2
Diagnosis: Moyamoya disease
Bypass: STA-to-MCA
Approach: Right temporal
Fig. 2.2a The course of the STA is
marked on the skin using a Doppler pen
probe.
Fig. 2.2b A narrow strip shave is
performed. In most cases the parietal
division of the STA begins anterior to the
ear and courses superiorly and slightly
posteriorly.
50 Color Atlas of Cerebral Revascularization
Fig. 2.2c The dissected STA is shown. The patient’s shunt crosses the fi eld and has been preserved intact. Fishhooks are
used to retract the edges of the scalp incision, fl attening the operative fi eld. This technique allows the surgeon’s hands
to work closer to the anastomosis.
Fig. 2.2d A cortical branch of the MCA is identifi ed under the arachnoid.
Fig. 2.2e The branch is dissected free.
STA-to-MCA Bypass 51
Fig. 2.2f The Spetzler MicroVac suction tubing (P.M.T. Inc, Hopkins, MN) is placed below the branch to clear any blood
and cerebrospinal fl uid.
Fig. 2.2g Temporary clips are applied.
Fig. 2.2h The STA is apposed to the MCA.
52 Color Atlas of Cerebral Revascularization
Fig. 2.2i The MCA branch is opened with a no. 11 blade.
Fig. 2.2j The opening is expanded with a small pair of microscissors.
Fig. 2.2k A heel stitch 10–0 suture is placed from outside to inside the lumen of the MCA and then from inside to
outside the lumen of the STA so that the knot remains on the outside of the anastomosis.
Fig. 2.2l The heel stitch is tightened.
STA-to-MCA Bypass 53
Fig. 2.2m The toe stitch is placed and tightened.
Fig. 2.2n Each stitch is placed loosely as shown, and then each stitch is tightened in turn.
54 Color Atlas of Cerebral Revascularization
Fig. 2.2o Postoperative angiogram
confi rms excellent fi lling of the MCA
territory through the bypass.
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