Rcvascularization of cerebral ischemia
after previous bilateral
extracranial-intracranial bypass procedures
V. S. Sottiurai, MD, PhD, L. Herbert, MD, and D. Hatter, MD, New Orleans, La.
Extracranial-intracranial (EC-IC) bypass grafting procedures were specially designed for
treatment of bilateral internal carotid artery occlusion. When performed in an expeditious manner, EC-IC bypass procedures have produced effective and durable results,
despite the recent disfavor given to this procedure. This communication reports a
68-year-old white man who developed generalized cerebral ischemia manifested as confusion, incoherence, disorientation, ataxia, and numerous episodes of syncope daily. A
cerebral angiogram revealed bilateral external carotid arteries and left solitary vertebral
artery critical stenosis. Transcranial Doppler study demonstrated reduction of cerebral
and vertebral-basilar perfusion. Howerer, the patient's EC-IC bypass graft had remained
patent since 1985. The patient's recurrent symptoms of global ischemia and syncope
resolved after carotid endarterectomy, vein patch external carotid artery, and vertebralto-common carotid artery transposition. This report reiterates the value of the EC-IC
bypass procedure and presents the surgical management of symptomatic external carotid
and vertebral artery stenosis in patients after EC-IC bypass procedures. (J Vasc Surg
1997;26:160-3.)

Extracranial-intracranial (EC-IC) bypass grafting
procedures were designed by YasargiF and later elaborated by Shields and Donaghy. 2 We describe a patient who has done well after undergoing EC-IC
bypass grafting procedures without symptoms o f
global ischemia fore April 1985 to December 1994.
H e was seen in consultation for daily ataxia, syncope,
and progressive development o f incoherence, dizziness, and memory impairment. A cerebral angiogram
revealed that bilateral external carotid and left solitary vertebral arteries had critical stenosis. Carotid
endarterectomy, vein patch angioplasty o f the external carotid artery, and v e r t e b r a l - t o - c o m m o n carotid
artery transposition resulted in resolution of these
symptoms.
CASE R E P O R T
A 68-year-old man who had global cerebral
ischemia and daily episodes o f syncope showed
From the Department of Surgery, Section of Vascular Surgery,
Louisiana State UniversitySchool of Medicine.
Reprint requests: V. S. Sottiurai, Department of Surgery, Section
of Vascular Surgery,LouisianaState UniversitySchoolof Medicine, 1542 Tulane Ave., New Orleans, LA 70112-2822.
Copyright© 1997 by The Societyfor VascularSurgeryand International Society for Cardiovascular Surgery, North American
Chapter.
0741-5214/97/$5.00 + 0 24/4/78862
160

>80% bilateral external carotid stenosis on duplex
scan. Only 18 to 29 m l / s e c o f flow was documented in the anterior, middle, and posterior cerebral arteries. The patient did not have cardiac
arrhythmia or seizure disorders, whereas the resuits o f electronystagmography was consistent
with brain stem ischemia. A cerebral angiogram
revealed patent EC-IC bypasses and critical stenosis o f bilateral external carotid and solitary left
vertebral arteries (Fig. 1).
With the patient under general anesthesia, the
common, internal, and external carotid arteries and
the vertebral artery were exposed through an oblique
incision placed along the anterior border o f the
sternocleidomastoid muscle. Sympathetic nervous
plexus and vertebral ganglion were preserved, and
cranial nerves (XII, X, and its associated branches)
were protected. The thoracic duct was transected
after ligation.
After systemic heparin (5000 U) was administered, the c o m m o n and external carotid arteries
were occluded with vascular clamps. A carotid arteriotomy was made, and an Argyle shunt (8F) was
placed in the external and c o m m o n carotid arteries
to maintain cerebral blood flow. Ulcerative
plaques with necrotic debris were found in the
internal carotid cul de sac and in several areas
along the c o m m o n carotid arteries (Fig. 1, C and

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Sottiurai, Herbert, and Hatter 161

Fig. 1. Preoperative cerebral angiograms. A, Left EC-iC anastomosis at middle cerebral artery
(arrow). B, Right EC-IC anastomosis at middle cerebral artery (arrow). C, Left external carotid
stenosis (arrow) at cul de sac of occluded left internal carotid artery (arrow). D, Stenosis of right
external carotid artery (arrow). E, Critical stenosis of left solitary, vertebral artery (arrow). F,
Postoperative magnetic resonance angiogram depicts transposition of vertebral artery to the side
of common carotid artery (lower arrow). Upper arrow indicates branching of external carotid
artery.

Fig. 2). The c o m m o n and external carotid arteries
were endarterectomized, and the internal carotid
cul de sac was resected. The vertebral artery was
transected at its origin and was transposed to the
endarterectomized c o m m o n carotid artery after
spatulation. Saphenous vein patch angioplasty o f
the external carotid artery and carotid bifurcation
was performed with running 6-0 prolene (Fig. 3).
The preoperative global ischemia and syncope resolved after the operation.
DISCUSSION
EC-IC bypass procedures, when properly performed in an expeditious manner, have produced
effective and durable results, a-6 Despite the recent
disfavor given the procedure, 7 new information continues to support certain values o f this operation. 8
This patient's case is a good testimony o f the procedure. Progression o f atherosclerosis remains a threat
to the patency and function o f the external carotid
and vertebral arteries. Therefore, frequent surveil-

lance (every 6 to 12 months) with physical examination is needed. Duplex scan with transcranial Doppler is useful in interrogating cerebral and vertebral
ischemic symptoms. Correction o f external carotid
stenosis and vertebral revascularization should be
considered when reduction o f territorial arterial perfusion can be established by transcranial Doppler or
xenon washout studies. Resolution of global ischemia and vertebrobasilar insufficiency symptoms in
this patient is a reflection of improved cerebral and
brain stem perfusion. Postoperative transcranial
Doppler analysis supported this conclusion (cerebral
flow, 28 to 33 ml/sec; vertebral arterial flow, 29
ml/sec). A postoperative magnetic resonance angiogram showed widely patent vertebral-carotid transposition (Fig. 1, F).
Despite the fact that EC-IC bypass is often considered an end-stage procedure, surgical correction
of extracranial carotid and vertebral artery stenosis is
still indicated when a discrete anatomical lesion can
be identified.

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Sottiurai, Herbert, and Hatter

[OURNALOF VASCULARSURGERY
July 1997

Fig. 2. Intraoperative specimen demonstrates necronc
thrombi in internal carotid cul de sac.

Fig. 3. Intraoperative photograph of long arteriotomy of common carotid artery (small
arrows). Open arrows point to vein patch angioplasty of the external carotid artery. Solid arrow
points to end-to-side vertebral carotid transposition.

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Volume 26, Number 1

REFERENCES

1. Yasargil MG. Microsurgery applied to neurosurgery. Stuttgart: Verlag, 1969:95-119.
2. Shields CB, Donaghy RM. Arterial venous grafts for cerebral
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3. Chater N, Popp J. Microsurgical vascular bypass for occlusive
cerebrovascular disease: review of 100 cases. Surg Neurol
1976;6:115-8.
4. Yasargil MG, Yonekawa YL. Results of microsurgical extraintracranial arterial bypass in the treatment of cerebral ischemia. Neurosurgery 1977;1:224.
5. Reichman OH. Extracranial-intracranial arterial anastomosis
In: Whisnant IP, Sandok BA, editors. Cerebral vascular diseases. New York: Grune and Stratton, 1975:175-85.

Sottiurai, Herbert, and Hatter 1 6 3

6. Gratzl O, Schmiedek P, Spetzler R, SteinhoffH, Margurth F.
Clinical experience with extra-intracranial arterial anastomo~
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7. Holohan TV. Extracranial-intracranial bypass to reduce the
risk ofischemic stroke. Can Med Assoc J 1991;144:1457-65.
8. Ishikawa T, Houkin K, Abe H, Isobe M, Kamiyama H.
Cerebral hemodynamics and long-term prognosis after extracraniai-intracranial bypass surgery. J Neurol Neurosurg
Psychiatry 1995;59:625-8.

Submitted Oct. 21, 1996; accepted Oct. 27, 1996.