Introduction Previous trials rejected a role of extracranial-to-intracranial bypass surgery for managing symptomatic atheromatous disease. However, haemodynamic insufficiency may still be a rationale for surgery, provided it can be performed with low morbidity and that patency is robust.
Methods Consecutive patients undergoing bypass surgery for non-moyamoya symptomatic intracranial arterial stenosis and occlusion were retrospectively identified. The clinical course and surgical outcomes of the cohort were evaluated at six-weeks, six-months, and annually thereafter.
Results Between 1992 and 2017, 112 patients underwent 127 bypasses. The angiographic abnormality was arterial occlusion in 80% and stenosis in 20%. Procedures were to prevent future stroke (76%) and stroke reversal (24%), with revascularisation using an arterial pedicle graft in 80% and venous interposition graft (VIG) in 20%. A poor outcome (bypass occlusion, new stroke, new neurological deficit, or worsening neurologic deficit) occurred in 8.9% of patients. The risk of poor outcome was significantly lower with arterial pedicle grafts (Odds ratio=0.15), bypass for prophylaxis against future stroke (Odds ratio=0.11), or anterior circulation bypass (Odds ratio=0.17). Over the first eight years following surgery there were no poor outcomes in the 66 cases exhibiting all three of these characteristics.
Conclusion Prophylactic arterial pedicle bypass surgery for anterior circulation ischemia is associated with high graft patency and low stroke and surgical complication rates. Higher risks are associated with acute procedures, typically for posterior circulation pathology and requiring VIGs. A carefully selected subset of individuals with haemodynamic insufficiency and ischaemic symptoms are likely to benefit from cerebral revascularisation surgery.
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