The plastic surgeon's role in extracranial-to-intracranial bypass using a reverse great saphenous vein graft.

BACKGROUND: Extracranial-to-intracranial bypass is used for flow replacement and diversion that prevent the serious complications associated with sudden ligation of the middle cerebral artery for treatment of complex tumors or aneurysms. Extracranial-to-intracranial bypass is a demanding procedure that requires experience in advanced microsurgical techniques. In this article, the authors review the first report of an extracranial-to-intracranial bypass performed by a plastic surgeon with emphasis on indications for microsurgical involvement in neurosurgical practice and on description of the surgical technique.

METHODS: Between April of 2004 and October of 2006, three extracranial-to-intracranial bypass cases were performed including one for a complex aneurysm rupture and two for resections of cranial base tumors. In every case, the intracranial approach was used by the neurosurgeon. The bypass was performed by interposing a reverse great saphenous vein graft between the superficial temporal artery, in end-to-end anastomosis, and the second segment of the middle cerebral artery, in end-to-side anastomosis.

RESULTS: In each case, postoperative cerebral angiography demonstrated complete patency of the extracranial-to-intracranial bypass. Neither of the two surviving patients at a mean follow-up of 13 months had deterioration of neurologic function, postoperative stroke, or surgery-related death. One of the patients was dead before the 6-month follow-up.

CONCLUSIONS: The reverse great saphenous vein graft is a good option for extracranial-to-intracranial bypass, with the advantages of high-flow graft, wide lumen, adequate length, easy harvest, and minimal donor-site morbidity. The plastic surgery/neurosurgery alliance allows scope for improved outcomes in complex neurosurgical cases and continues to push the frontiers of reconstructive microsurgery.