LAUSR

BACKGROUND Cerebral bypass procedures are complex, require substantial experience and skills, and thorough preoperative planning. Cerebrovascular surgeons face increasingly complex bypass cases because most routine cases are managed by endovascular means, and because increasing numbers of patients have complex medical problems which affect available and suitable bypass conduit options. We present herein several cerebral bypass cases with limited bypass conduit alternatives, and where there were unexpected intraoperative difficulties requiring complex solutions. METHODS The Neurological Surgery department database was reviewed to identify patients that had undergone cerebral bypass procedures during a 13-year period where there were limited available bypass conduits, and where unexpected intraoperative difficulties were encountered whilst performing cerebral bypasses. RESULTS Patient outcomes and graft patency were evaluated for 13 cases including six ischemia cases, three giant aneurysms, two mycotic aneurysms, one dissecting aneurysm, and one gunshot-induced pseudoaneurysm. Median duration of follow-up was 43 months. In 12 of 13 cases, bypass graft/grafts were patent on the last computed tomography angiogram. In one case, a prophylactic bypass procedure, the graft was not filling, probably due to lack of demand. Two patients died during follow-up due to unrelated causes. CONCLUSIONS Cerebrovascular surgeons should be versatile in dealing with complex bypass cases. When there are limited available conduit options, we find that collaboration with other surgical specialties, such as plastics and vascular, is helpful. In cases where extreme intraoperative difficulties are expected, thorough preoperative planning with multiple back-up plans should be exercised, as demonstrated in this report.