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  • Title: Direct Bypass Surgery for Moyamoya and Steno-occlusive Vasculopathy: Clinical Outcomes, Intraoperative Blood Flow Analysis, Long-term Follow-up, and Long-term Bypass Patency in a Single Surgeon Case Series of 162 Procedures.
    Author: Khan NR, Elarjani T, Jamshidi AM, Lu VM, Silva MA, Richardson A, Harrington T, Valdes T, Campo N, Krementz N, Asdaghi N, Sur N, Londono EM, Malik AM, Koch S, Romano J, Morcos JJ.
    Journal: World Neurosurg; 2022 Dec; 168():e500-e517. PubMed ID: 36216248.
    Abstract:
    BACKGROUND: Cerebral extracranial-intracranial (EC-IC) direct bypass is a commonly used procedure for the treatment of cerebral hypoperfusion secondary to chronic steno-occlusive vasculopathy. We sought to determine clinical outcomes, intraoperative blood flow analysis, long term follow up, and long term patency rates from a single surgeon's series of direct cerebral bypass for moyamoya disease, moyamoya syndrome, and steno-occlusive disease. METHODS: We reviewed clinical, demographic, operative and neuroimaging records for all patients who underwent a direct EC-IC bypass by the senior author between August 1999 and November 2020. Primary outcomes analyzed were functional long-term outcomes (by modified Rankin score [mRS]), surgical complications, and short-term and long-term bypass patency. RESULTS: A total of 162 revascularization procedures in 124 patients were performed. Mean clinical follow up time was 2 years 11 months. The combined immediate and long term postoperative stroke and/or intracerebral hemorrhage rate was 6.2%. There were 17 bypasses (10%) that were found to be occluded at long-term follow-up, all but one were asymptomatic. Long-term graft occlusion was correlated with presence of complete collateralization on preoperative angiography but not cut flow index (CFI). Overall, patients had a significant clinical improvement with a mean mRS score 1.8 preoperatively and 1.2 postoperatively. CONCLUSIONS: In our consecutive series of patients treated with direct EC-IC cerebral bypass, there was significant improvement in functional outcome as measured by the mRS. The long term patency rate was 90%. There was a statistically significant correlation between complete or incomplete angiographic collateralization patterns and long-term bypass occlusion. There was no correlation between bypass type, clinical syndrome, or CFI and long-term occlusions. The role of bypass surgery and the need for surgical expertise remain strong in the treatment of moyamoya variants and a select group of atherosclerotic steno-occlusive patients.
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