Introduction: The cervical carotid system had been routinely used as a source of donor vessels for radial artery or saphenous vein grafts in EC-IC high flow bypass. Recently, IMax-to-MCA had been described as an alternative with significant reduction of graft length theoretically correlating with improved patency. We advocate the use of the brachiocephalic (BC) vein of the forearm to perform these short segment EC-IC bypasses. BC vein is easily and reliably accessed even in obese patients, have few if any valves with short segments harvested which easily match variability in recipient size.
Methods: The IMax-MCA requires a short graft (<10cm). The proximal anastomosis is performed utilizing end-to-end technique. The end-to-end anastomoses were technically easier to perform than the end-to-side and represent our preference.. Instead of using a radial artery or a saphenous vein as the graft segment, a short segment of brachiocephalic vein was used.
Results: Four patients were treated with IMax-MCA, SC-IC bypass. In three of them the Brachiocephalic vein was utilized. With a paucity of branches, no valves and high quality tissue, the BC vein represents our preference going forward. All patients tolerated the procedure well. Post operative angiography demonstrated good filling of the graft with robust distal flow. Intraoperative flow using the Transonic™ flow probe ranged from 20- 60 cc/min. None of the patients developed vascular complication in the upper arm. All patients tolerated the procedure well.
Conclusions: The IMax-to-MCA high flow bypass is safe and effective and has a number of advantages over EC-IC bypass using the cervical carotid. These advantages include a shorter graft length allowing utilization of the BC vein and an entirely intracranial graft without tunneling with both the proximal and distal anastomoses within the same surgical field. We believe that these modifications may improve patency, reduce graft kinking and effectively eliminate graft compression.
Patient Care: We believe that the SC-IC bypass utilizing the brachiocephalic vein as conduit has many advantages and may be considered when performing an EC-IC bypass. The technique is technically within the accepted difficulty of a standard EC-IC bypass with proximal anastomosis performed more easily than the standard external carotid proximal anastomosis. In addition graft patency may be improved due to shorter graft length, no tunneling and minimal risk of compression with the graft easily viewed along its entire length in a single operative field. These improvements should result in improved patient outcome following these high risk procedures by reducing the risk of stroke associated with postoperative graft occlusion.
Learning Objectives: By the conclusion of this session, participants should be able to describe the option and the importance of a short segment of the BC vein, for high-flow EC-IC bypass.