Salvage Maneuvers for Occluded Bypass in Cerebral Revascularization Procedures

- BACKGROUND: Cerebral revascularization is an effective measure for dealing with complicated intracranial aneurysms and ischemic cerebrovascular disease. Intraoperative thrombosis causing bypass occlusion is a severe issue that causes devastating consequences for complications in revascularization. We report our experiences regarding salvage maneuvers for intraoperative thrombosis in cerebral revascularization procedures and discuss the characteristics and culprits. - METHODS: We investigated 720 consecutive patients who u nderwent cerebral revascularization at First Affiliated Hospital of Soochow University from January 2013 to October 2021, including 688 patients who underwent superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and 32 patients who underwent extracranial artery -radial artery (ECA-RA)-MCA bypass. Forty-one patients experienced intracranial aneurysms, and the remaining 679 patients were involved in moyamoya disease, skull base tumors, intracran ial occlusive vascular diseases, or other cerebrovascular diseases. All clinical characteristics, clinical imaging examinations, and neurologic outcomes were studied preoperatively and postoperatively. The patency of bypasses was confirmed by intraoperative Doppler ultrasonography and indocyanine green videoangiography. - RESULTS: Seven intraoperative thromboses, which were confirmed by intraoperative Doppler ultrasonography and indocyanine green videoangiography including STA-MCA bypass (n = 5) and ECA-RA-MCA bypass (n = 2) were observed in 720 patients who underwent cerebral revascularization. The anastomotic stoma remained patent in 6 of 7 patients with intraoperative thrombosis after treatment. One case in STA-MCA bypass failed to be salvaged. Of the 4 intraoperative thrombosis in STA-MCA bypass for moyamoya disease cases being successfully saved, 2 were done so by applying absorbable gelatin powder from absorbable gelatin sponge (Gelfoam, Pfizer, New York, New York, USA) around the site of the anastomosis to relieve the downward compression effect of the donor vessel (STA) on the recipient vessel (M4 segment of MCA). One case in ECA-RA-MCA bypass was salvaged by thrombectomy through donor arteriotomy (radial artery) and reanastomosis. The other case was salvaged by complete reanastomosis. All 7 patients who experienced intraoperative thrombosis achieved favorable outcomes at discharge and the 6 -month follow-up. - CONCLUSIONS: Various factors are responsible for intraoperative thrombosis in cerebral revascularization. Relieving the downward compression effect of the donor vessel STA on the recipient vessel M4 segment of MCA by applying Gelfoam around the site of the anastomosis stoma can be recommended to salvage the intraoperative thrombosis in cerebral revascularization.