Tag: Recipient artery

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Selective-Targeted Extra-Intracranial Bypass Surgery in Complex Middle Cerebral Artery Aneurysms: Correctly Identifying the Recipient Artery Using Indocyanine Green Videoangiography

Neurosurgery 71[ONS Suppl 2]:ons274–ons285, 2012

Treatment of complex middle cerebral artery (MCA) aneurysms often requires vessel sacrifice or prolonged temporary occlusion with extra- to intracranial (EC-IC) bypass to preserve perfusion. A crucial surgical step is the identification of the bypass recipient artery matching the distal territory of the involved vessel.

OBJECTIVE: To report about the feasibility and efficiency of an indocyanine green videoangiography (ICG-VA) assisted technique for identification of cortical recipient vessels to perform selective-targeted EC-IC bypass.

METHODS: The proposed technique is based on the analysis of differences in the timing of filling of M4 vessels seen on serial ICG-VAs. A delayed fluorescence can be visualized either primarily on a baseline ICG-VA or secondarily on an ICG-VA performed during temporary occlusion of the involved MCA branch. M4 branches presenting delayed fluorescence represent suitable bypass recipient arteries. We report 7 consecutive patients treated for complex MCA aneurysms with selective-targeted EC-IC bypass.

RESULTS: Application of the proposed technique permitted the correct identification of recipient arteries (cortical branches of the involved MCA segment) in all patients. The cortex distal to the occlusion filled concomitantly on ICG-VA at the end of surgery. All patients underwent successful treatment of the aneurysm, including a cortical bypass. There were no ischemic complications, and a favorable clinical outcome was achieved in all patients (modified Rankin Scale at follow-up # modified Rankin Scale preoperative).

CONCLUSION: The proposed ICG-VA-based technique enables reliable and accurate identification of the cortical recipient artery and eliminates the risk of erroneous revascularization of noninvolved territories.

Posted on

Selective-Targeted Extra-Intracranial Bypass Surgery in Complex Middle Cerebral Artery Aneurysms: Correctly Identifying the Recipient Artery Using Indocyanine Green Videoangiography

Neurosurgery 71[ONS Suppl 2]:ons274–ons285, 2012

Treatment of complex middle cerebral artery (MCA) aneurysms often requires vessel sacrifice or prolonged temporary occlusion with extra- to intracranial (EC-IC) bypass to preserve perfusion. A crucial surgical step is the identification of the bypass recipient artery matching the distal territory of the involved vessel.

OBJECTIVE: To report about the feasibility and efficiency of an indocyanine green videoangiography (ICG-VA) assisted technique for identification of cortical recipient vessels to perform selective-targeted EC-IC bypass.

METHODS: The proposed technique is based on the analysis of differences in the timing of filling of M4 vessels seen on serial ICG-VAs. A delayed fluorescence can be visualized either primarily on a baseline ICG-VA or secondarily on an ICG-VA performed during temporary occlusion of the involved MCA branch. M4 branches presenting delayed fluorescence represent suitable bypass recipient arteries. We report 7 consecutive patients treated for complex MCA aneurysms with selective-targeted EC-IC bypass.

RESULTS: Application of the proposed technique permitted the correct identification of recipient arteries (cortical branches of the involved MCA segment) in all patients. The cortex distal to the occlusion filled concomitantly on ICG-VA at the end of surgery. All patients underwent successful treatment of the aneurysm, including a cortical bypass. There were no ischemic complications, and a favorable clinical outcome was achieved in all patients (modified Rankin Scale at follow-up # modified Rankin Scale preoperative).

CONCLUSION: The proposed ICG-VA-based technique enables reliable and accurate identification of the cortical recipient artery and eliminates the risk of erroneous revascularization of noninvolved territories.

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Flash Fluorescence With Indocyanine Green Videoangiography to Identify the Recipient Artery for Bypass With Distal Middle Cerebral Artery Aneurysms

Neurosurgery 70[ONS Suppl 2]:ons209–ons220, 2012 DOI: 10.1227/NEU.0b013e31823158f3

Distal middle cerebral artery (MCA) aneurysms frequently have nonsaccular morphology that necessitates trapping and bypass. Bypasses can be difficult because efferent arteries lie deep in the opercular cleft and may not be easily identifiable.

OBJECTIVE: We introduce the “flash fluorescence” technique, which uses videoangiography with indocyanine green (ICG) dye to identify an appropriate recipient artery on the cortical surface for the bypass, enabling a more superficial and easier anastomosis.

METHODS: Flash fluorescence requires 3 steps: (1) temporary clip occlusion of the involved afferent artery; (2) videoangiography demonstrating fluorescence in uninvolved arteries on the cortical surface; and (3) removal of the temporary clip with flash fluorescence in the involved efferent arteries on the cortical surface, thereby identifying a recipient. Alternatively, temporary clips can occlude uninvolved arteries, and videoangiography will demonstrate initial fluorescence in efferent arteries during temporary occlusion and flash fluorescence in uninvolved arteries during reperfusion.

RESULTS: From a consecutive series of 604 MCA aneurysms treated microsurgically, 22 (3.6%) were distal aneurysms and 11 required a bypass. The flash fluorescence technique was used in 3 patients to select the recipient artery for 2 superficial temporal artery-to-MCA bypasses and 1 MCA-MCA bypass. The correct recipient was selected in all cases.

CONCLUSION: The flash fluorescence technique provides quick, reliable localization of an appropriate recipient artery for bypass when revascularization is needed for a distal MCA aneurysm. This technique eliminates the need for extensive dissection of the efferent artery and enables a superficial recipient site that makes the anastomosis safer, faster, and less demanding.

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