Safe and Secure Bypass Surgery Based on Basic Strategy and Training

Background: Bypass surgery is a fundamental and essential technique used by neurosurgeons. The indication for extracranial-intracranial (EC-IC) bypass surgery for cerebral ischemia is limited due to the high rate of perioperative stroke, and it is necessary to conduct safe and secure surgery to reduce perioperative complications. Herein, we report our technique of conducting bypass surgery in a safe and secure manner. Methods: We performed EC-IC bypass surgeries for patients with symptomatic internal carotid artery or middle cerebral artery (MCA) steno-occlusive lesions. All surgeons trained with 10-0 nylon sutures and gauze or the artery of a chicken wing using a microscope before performing the operation. Antiplatelet treatment was continuously administered before and after the operation. The parietal and frontal branches of the superficial temporal artery (STA) were harvested under microscopic visualization and secure hemostasis was achieved. After a dry and acceptable operative field was obtained and established, STA-MCA bypass surgery was performed. During the anastomotic procedure, we focused on not taking a bite of the underside of the artery, and not injuring the intima of the arteries, by controlling the magnification of microscope appropriately. Results: Twenty-six patients underwent EC-IC bypass surgery between 2014 and 2016 (mean age 66.3 years). Postoperative complications were delayed wound healing and chronic subdural hematoma. During the perioperative period, bypass patency was confirmed in all cases, and there was no cerebral infarction or hemorrhage. Conclusions: EC-IC bypass surgery can be performed in a safe and secure manner by using a basic surgical strategy which recognizes pitfalls, and incorporating training which enables surgeons to conduct basic procedures with high precision.