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External carotid internal carotid bypass and internal carotid artery ligation in 1 stage operation for intra cavernous and giant carotid aneurysm

External carotid internal carotid bypass and internal carotid artery ligation in 1 stage operation for intra cavernous and giant carotid aneurysm

Neurological Surgery 11(10): 1037-1046

The combined 1-stage operations, STA-MCA anastomosis and internal carotid artery (ICA) ligation (or trapping) were carried out in 11 cases (age: 18-79 yr) of ICA aneurysms which were inaccessible for a direct operation because of their locations and sizes. First the STA-MCA anastomosis was performed under induced hypotension to check whether any ischemic signs appeared. This was followed by proximal ICA ligation when no ischemic signs were observed. In all 11 cases, the anastomosis was patent. The aneurysms disappeared. Neither cerebral ischemia nor rebleeding from the aneurysms was seen during the long follow-up. The mean value of the bypass flow was 119 ml/min which was twice as much as that in the cases of other occlusive cerebrovascular diseases and which was about 1/3 of the blood flow of the ICA. Cerebral blood flow measurements through 133Xe inhalation method revealed that there was no difference in rCBF values between the operated and non-operated sides and that their values were within normal limits. The postoperative blood pressure was unchanged in 42% of the 11 cases, temporarily elevated and thereafter normalized in 33% and persistently elevated in 25%. Ophthalmodynamometry showed that the pressure of the central retinal artery decreased postoperatively in a degree of 5-10% in comparison to the non-operated side. No visual impairment was observed postoperatively. These combined operations, STA-MCA anastomosis and ICA ligation, were beneficial cerebral ischemia. Inta-arterial pressure measurements of the STA and MCA suggested that the 1-stage operations of these 2 procedures are better than the 2-stage operations for the patency of the anastomosis because the pressure gradient between the donor and recipient vessel is increased (from 10.3 to 49.3 mm Hg) by this technique. Temporary ICA clamp for 30 min under induced hypotension in local anesthesia is useful to check whether the 1-stage operations can be tolerated or not. EC/IC bypass with an interposed saphenous vein graft is a more beneficial surgical technique than a routine STA-MCA anastomosis, because an immediate and larger amount of bypass flow can be obtained.

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