Introduction: Bypass surgery is a highly technical procedure performed to treat patients with cerebrovascular diseases. However, intraoperative technical complications in cerebral revascularization have not been studied extensively.
Methods: We analyzed all intracranial bypass procedures performed between 1997 and 2017 by a single surgeon. Technical complications were recorded prospectively and confirmed by manual chart review. Data on patient demographics, diagnosis, bypass type, and graft type were collected. Bypass patency (determined by radiologist reports and manual imaging review), post-operative complications, and return to OR were used as outcome measures. Descriptive statistics were used to compare technical complication rates.
Results: There were 37 (8.6%) intraoperative technical complications among 430 consecutive cases: 25 graft occlusions (5.8%), 6 graft injuries (1.4%), 3 graft twists/kinks (0.7%), and 3 technical suture mistakes (0.7%). Patients presenting with moyamoya disease (15/132; 11.4%) and aneurysms (18/175; 10.3%) had higher technical complication rates than those with occlusive diseases (4/120; 3.3%; p-value=0.035). Additionally, we observed higher complication rates for cases with radial artery grafts (6/36; 16.7%) than those with saphenous vein grafts (0/44; 0.0%) or none (20/285; 7.0%; p-value=0.003). There were no differences in complication rates for number of anastomosis sites, high flow vs. low flow, or between EC-IC and IC-IC bypasses. The vast majority of cases (89.2%; 33/37) were intraoperatively salvaged via reanastomosis combined with local administration of anticoagulants. At last follow-up (average: 10 months; range: 0-17 years), there were 12 occluded bypasses (2.8%) in the series, 3 of which experienced intraoperative complications. Six cases with intraoperative complications (16.2%) had post-operative complications (vasospasm, stroke, and hydrocephalus), and two cases (5.4%) returned to the OR.
Conclusions: In experienced hands, most intraoperative technical complications can be managed successfully with bypass salvage maneuvers. Advance preparation for technical complications as well as close inspection of patency using intraoperative videoangiography are crucial to successful bypass procedures.
Patient Care: By discussing intraoperative complications and management strategies in bypasses, which are highly technical procedures, this research can help improve patient outcomes for bypass surgeries.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of managing intraoperative technical complications for bypasses 2) Discuss individual experiences with technical complications 3) Identify effective tools for intraoperative detection of patency and occlusion management