- Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
- Department of Neurosurgery, Aichi Rehabilitation Hospital, Nishio, Japan
- Department of Neurosurgery, Nagoya University Hospital, Nagoya, Japan
Correspondence Address:
Yusuke Sakamoto, Department of Neurosurgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan.
DOI:10.25259/SNI_528_2024
Copyright: © 2024 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Yusuke Sakamoto1, Sho Okamoto2, Ryuta Saito3. Less invasive bonnet bypass with subcutaneous tunneling method for common carotid artery occlusion – A technical note. 23-Aug-2024;15:300
How to cite this URL: Yusuke Sakamoto1, Sho Okamoto2, Ryuta Saito3. Less invasive bonnet bypass with subcutaneous tunneling method for common carotid artery occlusion – A technical note. 23-Aug-2024;15:300. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=13054
Abstract
Background: Common carotid artery occlusion (CCAO) sometimes requires vascular reconstruction. Ipsilateral superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is unsuitable due to insufficient blood flow to the external carotid artery. The bonnet bypass, one treatment option for CCAO, requires a long coronal incision and bone groove to prevent malposition and collapse of an interposition graft. However, this long incision might lead to skin complications and reduced collateral blood flow.
Methods: A 60-year-old man who experienced recurrent ischemic stroke presented with the right internal carotid artery occlusion and left CCAO. The left STA was unavailable; however, both branches of his right STA were well-developed. Minimizing skin invasion was a priority because the patient had diabetes mellitus. We performed a right STA parietal branch – right MCA anastomosis, followed by a right STA frontal branch – left radial artery graft (RAG) – left MCA bonnet bypass using small intermittent skin incisions.
Results: We drilled a bone groove extending across the entire length of the interposition graft through the small intermittent skin incisions. Furthermore, we applied a right STA-RAG end-to-side anastomosis instead of an endto-end anastomosis to preserve collateral skin anastomosis. Postoperatively, the bypass remained patent, and the patient was discharged without complications.
Conclusion: The bonnet bypass is a potential treatment for CCAO, but the procedure is invasive. Our modified bonnet bypass method enables less invasive management, preventing collapse and malposition of the interposition graft and minimizing skin complications.
Keywords: Common carotid artery occlusion, Intermittent skin incision, Interposition graft, Modified bonnet bypass, Subcutaneous tunnel
INTRODUCTION
Common carotid artery occlusion (CCAO) can cause cerebral ischemic stroke and requires vascular reconstruction.[
CASE REPORT
A 60-year-old man with bilateral carotid artery occlusion was admitted to our hospital for surgical treatment. He had experienced recurrent minor ischemic stroke and had undergone dual platelet drug therapy. Head-and-neck three-dimensional computed tomography angiography (3DCTA) showed right internal carotid artery occlusion and left CCAO [
Figure 1:
(a) Three-dimensional computed tomography angiography showed right internal carotid artery occlusion (arrow) and left common carotid artery occlusion (arrowheads). (b) Spectroscopy showed a general decrease in bilateral cerebral blood flow. The colored bar on the right side indicated the degree of cerebral blood flow.
Operation
First, a right STA frontal branch to the right MCA M4 branch anastomosis was performed. We created a short linear skin incision directly over the parietal branch distal to the junction of the frontal and parietal branches to prevent frontal branch injury. The first operation was performed without any complications. The clamp time for the MCA was 15 min. During outpatient follow-up, the patient developed bilateral chronic subdural hematomas. We performed burr-hole irrigation surgery twice, with maximum attention to preserve the STA frontal branch. Nine months after the first STA-MCA bypass surgery, we finally operated the right STA frontal branch – RAG – left MCA bonnet bypass.
The head was fixed in a neutral position with the Sugita multipurpose head frame (Mizuho Medical Co. Ltd, Tokyo, Japan). This device enabled us to rotate the head approximately 30° in clockwise and counterclockwise directions [
Figure 2:
(a) The head is fixed with a rotatable head frame. The red arrow shows the planned skin incision line for the left frontotemporal craniotomy (arrows). The intermittent short skin incisions for creating the subcutaneous bone groove are visible on the median forehead (arrowheads). (b) The superficial temporal artery frontal branch on the right forehead was harvested through an approximately 3 cm linear skin incision. The planned harvest site is marked with a red line (arrows). The surgical wound from a previous burr-hole irrigation surgery for chronic subdural hematoma is visible in the center of the picture (arrowheads). (c) The procedure of bone groove drilling. The subcutaneous bone groove was drilled through intermittent short skin incisions. A spatula was used to elevate the skin during the drilling of the bone groove. (d) Magnified horizontal view of the subcutaneous bone groove. The bone groove extended over almost the entire length of the interposition graft, preventing graft collapse and malposition. (e) The radial artery graft (RAG) was pulled through the bone groove, fitting perfectly into the RAG.
After completing the subcutaneous bone groove, we pulled the RAG through it. The bone groove seemed to fit perfectly to the RAG [
The postoperative course was uneventful, with 3DCTA showing excellent bypass patency [
Figure 4:
(a) Postoperative three-dimensional computed tomography angiography (3DCTA) right oblique view. The right superficial temporal artery (STA) parietal branch-M4 bypass of the first operation was patent (red arrows). The right STA frontal branch – radial artery interposition graft end-to-side anastomosis was also patent (arrowheads). The distal part of the right STA frontal branch was preserved due to the end-to-side anastomosis (blue arrow). (b) The left anterior oblique view of the postoperative 3DCTA. Residual skin staples on the medial forehead show the intermittent small skin incision for the reentry point (arrows). Residual skin staples on the left frontotemporal head show the skin incision for the left frontotemporal craniotomy (arrowheads). The bonnet bypass is perfectly patent (blue arrows).
Figure 5:
Schematic representation of our modified bonnet bypass. The red left-right arrow shows the left frontotemporal craniotomy and radial artery graft (RAG)-left M4 anastomosed part. The blue left-right arrow shows the intermittent skin incision for the reentry point. The black left-right arrow shows the right superficial temporal artery frontal branch-RAG end-to-side anastomosed part. Red arrows show the subcutaneous tunnel part.
DISCUSSION
CCAO is relatively rare, and standard revascularization is not applicable due to STA unavailability.[
Utilizing intermittent short skin incisions as reentry points enabled the drilling of the entire length of the bone groove without resorting to a long coronal skin incision. Our method, which aids in fixing and protecting the interposition graft, is less invasive than conventional bonnet bypass procedures. Moreover, we opted for end-to-side anastomosis between the donor STA and RAG to preserve blood flow to the skin flap instead of end-to-end anastomosis. Our method enables the preservation of collateral blood flow from the donor STA to the orbit or skin flap, potentially reducing skin complications and ischemic oculopathy.[
The bonnet bypass procedure is complicated. The previous studies have described the position of the patient as supine lateral, with the head fixed on the horse-shoe headrest and rotated in the opposite direction during the operation.[
CONCLUSION
The conventional bonnet bypass is a potential treatment for CCAO, but the procedure is complicated and invasive. Our modified bonnet bypass procedure, utilizing an intermittent tunneling method, allows for a less invasive approach while preventing the collapse and malposition of the interposition graft. Furthermore, this approach preserves collateral anastomosis in the skin.
Ethical approval
The Institutional Review Board approval is not required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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Jose Edison Cavalcante
Posted September 4, 2024, 3:01 pm
A very nice procedure and my doubts it’s the time to make this and chance to AVC … thanks