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OBJECTIVE: The effectiveness of revascularization for complex aneurysms is well-established. This study aimed to describe the technical characteristics and clinical efficacy of intracranial-to-intracranial (IC-IC) bypass for the treatment of complex intracranial aneurysms. METHODS: We retrospectively reviewed all patients with aneurysms who underwent a preplanned combination of surgical or endovascular treatment and IC-IC bypass at our institution between January 2006 and September 2023. IC-IC bypass techniques included four strategies: type A (end-to-end reanastomosis), type B (end-to-side reimplantation), type C (in situ side-to-side anastomosis), and type D (IC-IC bypass with a graft vessel). RESULTS: During the study period, ten patients with aneurysms each underwent IC-IC bypass surgery. Aneurysms were located in the middle cerebral artery (60.0%), anterior temporal artery (10.0%), anterior cerebral artery (20.0%), and vertebral artery (10.0%). There were three saccular aneurysms (30.0%), two fusiform aneurysms (20.0%), one dissecting aneurysm (10.0%), and four pseudoaneurysms (40.0%). We performed the type A strategy on five patients (50.0%), type B on one (10.0%), type C on one (10.0%), and type D on three (30.0%). During a mean period of 68.3 months, good clinical outcomes (modified Rankin Scale score, 0-2) were observed in all patients. Follow-up angiography demonstrated complete aneurysmal obliteration in all patients and good bypass patency in nine of ten patients (90.0%). CONCLUSION: The treatment of complex aneurysms remains a challenge with conventional surgical or endovascular treatments. IC-IC bypass surgery is a useful technique, associated with favorable clinical outcomes, for treating complex aneurysms.

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PURPOSE: Ruptured mycotic pararenal aortic aneurysms are rare and serious condition that requires prompt treatment. Open surgery with aortic resection and in-situ or extra-anatomic reconstruction is the standard treatment. The aim of this technical note is to report urgent endovascular treatment using a readily available custom-made device (created for another patient), with a back-table modification using pericardium patch and a new fenestration. TECHNIQUE: In preoperative measurements on centerline-based workstation, aortic diameter in proximal and distal landing zone and target vessel position matched the measurements of graft plan of custom-made device (CMD) besides left renal artery. To address current patient`s anatomy, closure of the nonsuitable fenestration with pericardial patch and creation of new fenestration (1 cm above and 1:15 hours posterior to original fenestration) for the respective target vessel have been performed. Postoperative computed tomography angiography (CTA) scan showed complete exclusion of aneurysm, perfused target vessels, and no endoleak. Under resistance-based antibiotic therapy, the patient was asymptomatic and showed normal infection parameters in blood samples postoperatively. CONCLUSION: In the hands of an experienced endovascular aortic surgeon modification of a custom-made device is a quick and feasible technique in this emergency situation. Long-term follow-up must confirm the durability and reliability of this new technique. CLINICAL IMPACT: The described technique of modification of a custom-made endograft can provide an alternative endovascular treatment option for urgent complex abdominal aortic pathologies. Compared to the current available treatment modalities, like physician modified endografts, off-the-shelf branched devices, parallel grafts and in-situ fenestration, it can save considerable time and provides reasonable sealing in ruptured cases. The technique offers a valuable add-on to the armamentarium of experienced endovascular physicians.

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OBJECTIVE/BACKGROUND: Endovascular thoracoabdominal and pararenal aortic aneurysm repair is more complex and requires more devices than infrarenal aneurysm repair. It is unclear if current reimbursement covers the cost of delivering this more advanced form of vascular care. The objective of this study was to evaluate the economics of fenestrated-branched (FB-EVAR) physician-modified endograft (PMEG) repairs. METHODS: We obtained technical and professional cost and revenue data for four consecutive fiscal years (July 1, 2017, to June 30, 2021) at our quaternary referral institution. Inclusion criteria were patients who underwent PMEG FB-EVAR in a uniform fashion by a single surgeon for thoracoabdominal/pararenal aortic aneurysms. Patients in industry-sponsored clinical trials or receiving Cook Zenith Fenestrated grafts were excluded. Financial data were analyzed for the index operation. Technical costs were divided into direct costs that included devices and billable supplies and indirect costs including overhead. RESULTS: 62 patients (79% male, mean age: 74 years, 66% thoracoabdominal aneurysms) met inclusion criteria. The mean aneurysm size was 6.0 cm, the mean total operating time was 219 minutes, and the median hospital length of stay was 2 days. PMEGs were created with a mean number of 3.7 fenestrations, using a mean of 8.6 implantable devices per case. The average technical cost per case was $71,198, and the average technical reimbursement was $57,642, providing a net negative technical margin of $13,556 per case. Of this cohort, 31 patients (50%) were insured by Medicare remunerated under diagnosis-related group code 268/269. Their respective average technical reimbursement was $41,293, with a mean negative margin of $22,989 per case, with similar findings for professional costs. The primary driver of technical cost was implantable devices, accounting for 77% of total technical cost per case over the study period. The total operating margin, including technical and professional cost and revenue, for the cohort during the study period was negative $1,560,422. CONCLUSIONS: PMEG FB-EVAR for pararenal/thoracoabdominal aortic aneurysms produces a substantially negative operating margin for the index operation driven largely by device costs. Device cost alone already exceeds total technical revenue and presents an opportunity for cost reduction. In addition, increased reimbursement for FB-EVAR, especially among Medicare beneficiaries, will be important to facilitate patient access to such innovative technology.

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OBJECTIVE: Complex anterior cerebral artery (ACA) aneurysms are still technically challenging to treat. Bypass surgery is needed to achieve aneurysm obliteration and ACA territory revascularization. Severe atherosclerosis of aneurysm walls can cause clip slippage, intraoperative rupture, postoperative ischemic events. How to assess the atherosclerotic changes in vascular walls by high-resolution vessel wall magnitude resonance imaging (VWI) is the key question in complex ACA aneurysm surgical management. METHODS: This retrospective single-center study included eight patients diagnosed with complex anterior cerebral arteries admitted to our hospital for bypass surgery from January 2019 to April 2022. We discussed the application of VWI in aneurysms treated with in situ bypass and reviewed previous experience of revascularization strategies for complex ACA aneurysms. RESULTS: In this study, we treated 8 cases of complex ACA aneurysms (3 communicating aneurysms/5 postcommunicating aneurysms) over the prior one year. In situ side-to-side anastomosis (1 A2-to-A2/6 A3-to-A3) was performed in seven cases, and trapping combined with excision was performed in another case. Following bypass, complete trapping was performed in 4 cases, and proximal clipping was performed in 3 cases. No surgery-related neurological dysfunctions were observed. The final modified Rankin scale was 0 in seven of the eight cases and 2 in one case. CONCLUSION: High-resolution VWI, as a favorable preoperative assessment tool, provides insight into patient-specific anatomy and microsurgical options before operations, which can help neurosurgeons develop individualized and valuable surgical plans.

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PURPOSE: To demonstrate that occipital artery (OA)-p1 posterior inferior cerebellar artery (PICA) bypass can be an alternative for complex posterior circulation aneurysms. METHODS: A far-lateral approach to craniotomy was performed on 20 cadaveric specimens, and the OA was obtained 'in-line.' Its length, diameter, and the number of p1/p2 and p3 segmental perforators were determined, and the relationship between the caudal loop and cerebellar tonsil position was also assessed. The distance between the PICA's origin and the cranial nerve XI (CN XI), the buffer length above the CN XI after dissection, the OA length required to complete the OA-p1/p3 PICA bypass, and the p1 and p3 segment diameters were all measured. A bypass training practical scale (TSIO) was used to evaluate the quality of the anastomosis. RESULTS: All specimens underwent OA-p1 PICA end-to-end bypass and had favorable results for the TSIO score, 15 sides underwent OA-p3 PICA end-to-side bypass, and the other bypass protocols were less common. The buffer length above the CN XI after dissection, the distance between the PICA's origin and the CN XI, and the first perforator were all of sufficient length. The direct length of the OA needed to complete the OA-p1 PICA end-to-end bypass was significantly less than the available length and the OA-p3 PICA end-to-side bypass, with the OA matching the p1 segment diameter. The number of p1 perforators was less than that of p3, and the OA diameter was equal to that of the p1 segment. CONCLUSION: OA-p1 PICA end-to-end bypass is a feasible alternative in cases in which p3 segment has high caudal loops or anatomic anomalies.

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Cerebral revascularization is the ultimate treatment for a subset of complex middle cerebral artery (MCA) aneurysms. The decision for the revascularization strategy should be made during the treatment process. This study aimed to summarize the revascularization strategies for different types of complex MCA aneurysms and their outcomes. The clinical data of patients with complex MCA aneurysms who underwent cerebral revascularization since 2015 were analyzed retrospectively. The aneurysms were classified according to the location and other main characteristics that affect the selection of surgical modalities. The corresponding surgical modalities and treatment outcomes were summarized. A total of 29 patients with 29 complex MCA aneurysms were treated with cerebral revascularization from 2015 to 2022. Treated aneurysms were located at the prebifurcation segment in 7 patients, bifurcation segment in 12 patients, and postbifurcation segment in 10 patients. Surgical modalities in the prebifurcation segment included four high-flow extracranial-to-intracranial (EC-IC) bypasses with aneurysm trapping or proximal occlusion, two IC-IC bypasses with aneurysm excision, and one combination bypass with aneurysm excision. In the bifurcation segment, surgical modalities included two low-flow EC-IC bypasses with aneurysm excision or trapping, six IC-IC bypasses with aneurysm excision, three combination bypasses with aneurysm excision, and one constructive clipping with IC-IC bypass. In the postbifurcation segment, surgical modalities included nine IC-IC bypasses with aneurysm excision and low-flow EC-IC bypass with aneurysm trapping. The revascularization strategy for prebifurcation aneurysms was determined based on the involvement of lenticulostriate arteries, whereas the strategy for bifurcation aneurysms was determined based on the number of distal bifurcations and the shape of the aneurysm. The location of the aneurysm determined the revascularization strategy for aneurysms in the postbifurcation segments. Angiography demonstrated that aneurysms were completely obliterated in 26 cases and shrank in 3 cases, and all bypasses except one were patent. The mean follow-up period was 47.5 months. Three patients developed hemiplegic paralysis, and one developed transient aphasia postoperatively due to cerebral ischemia. No new neurological dysfunction occurred in the other 25 patients with no recurrence or enlargement of aneurysms during the follow-up. Prebifurcation aneurysms involving the lenticulostriate arteries require proximal occlusion with high-flow bypass. Most of the other aneurysms can be safely excised or trapped by appropriate revascularization strategies according to their location and orientation.

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OBJECTIVE: Stent-assisted coiling (SAC) using the jailing technique is a well-established treatment for wide-neck intracranial aneurysms. However, low-volume packing, which is a key factor for aneurysm recanalization, can occur in patients with irregularly shaped aneurysms. We have devised a real-time monitoring system for aneurysm catheterization that allows the intentional placement of the jailed coil-delivery microcatheter and deployed stent, referred to as the "scope" technique. Herein, we present a case of irregularly shaped anterior communicating artery (ACoA) aneurysm successfully treated with SAC using this technique. METHODS: A 72-year-old woman diagnosed with an unruptured wide-neck ACoA aneurysm that was eccentric to the parent ACoA and overhanging posteriorly underwent SAC using this technique. Bilateral transradial quadraxial systems (6-Fr Simmons guiding sheath/6-Fr intermediate catheter/3.2-Fr intermediate catheter/microcatheter) were established via right and left internal carotid artery. The stent-delivery microcatheter was advanced into the left A2 via the right A1, leaving a 0.014″ microguidewire for visualization under fluoroscopic guidance. To place the coil-delivery microcatheter in the middle of the aneurysm after stent deployment, the coil-delivery microcatheter was cannulated into the aneurysm via the left A1, intendedly through the posterior side of the stent-delivery microcatheter in the down-the-barrel view of the parent ACoA (the scope technique). RESULTS: After stent deployment, SAC of the aneurysm was successfully achieved. CONCLUSIONS: Using this technique, the coil-delivery microcatheter was cannulated into the aneurysm, while monitoring its positional relationship with the stent-delivery microcatheter in real time. This technique is a useful treatment option for irregularly shaped and wide-neck aneurysms.

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BACKGROUND: Internal maxillary artery (IMA) bypass has become popularized due to its medium-to-high blood flow, short graft length, and well-matched arterial caliber between donor and recipient vessels. METHOD: We described an open surgery of a NEW "workhorse," the IMA bypass, to treat a giant, thrombosed cerebral aneurysm. The extracranial middle infratemporal fossa (EMITF) approach was used to unveil the pterygoid segment of the IMA for cerebral revascularization. CONCLUSION: Although this technique is technically challenging, the variations in IMA can be effectively identified and sufficiently exposed in this technique to achieve favorable clinical outcomes with a high bypass patency rate.

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Fusiform or near-fusiform aneurysms that involve the long segment of the supraclinoid internal carotid artery (ICA) pose significant challenges to neurovascular surgeons. Involvement of the origin of vital branching arteries in this segment may preclude safe treatment with flow diverting stents. In addition, clip reconstruction may also not be possible in this region due to entire or near-entire involvement of the circumference of the ICA ( Fig. 1 ). In this video article, we present a case of a complex and previously leaked, (visualized with hemosiderin) aneurysm of the posterior communicating segment of the ICA, in a 60-year-old female. Multiple complexities made this aneurysm challenging to treat. These included (1) a 270-degree encirclement of the ICA with multiple lobulations that left only a small section of nondiseased vessel wall, (2) a relatively short segment of the supraclinoidal ICA that made proximal control challenging thus requiring an extradural anterior clinoidectomy, (3) a fetal posterior communicating artery that originated immediately proximal to the beginning of the aneurysm, and lastly, (4) an anterior choroidal artery that was firmly adherent over the aneurysm dome. In this video, we present the microsurgical steps for dealing with this complex aneurysm, including extradural clinoidectomy and clip reconstruction ( Fig. 2 ). Postoperatively, the patient woke up without any deficits. Angiography showed complete obliteration of the aneurysm. The link to the video can be found at: https://youtu.be/3Zz-ecvlDIc .

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As technology and surgeon experience evolve, endovascular repair of complex abdominal aortic aneurysms is often preferred in appropriately selected patients. However, the presence of pedunculated aortic thrombus represents a relative contraindication for endoluminal therapy due embolization risks. Here, we present a 68-year-old woman with a 5.8-cm pararenal aortic aneurysm associated with pedunculated aortic thrombus. She was treated with a modified Cook-Zenith aortic cuff to first entrap the aortic thrombus, followed by treatment of the aneurysm with a modified Z-FEN graft. This cuff modification provides a novel approach to deal with such luminal thrombus.

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BACKGROUND: Cerebral revascularization strategies through extracranial to intracranial bypass have been adopted in the management of complex intracranial aneurysms. The internal maxillary artery used as a donor in a bypass is an effective method. At present, there are few quantitative analyses of cerebral blood flow perfusion. The main focus of this study was to evaluate the effectiveness of blood perfusion after bypass grafting. METHODS: From April 2015 to December 2017, 19 patients who underwent internal maxillary artery radial artery middle cerebral artery bypass surgery with unobstructed bypass vessels were selected. Cerebral blood flow perfusion before and after bypass surgery was quantitatively evaluated by computed tomography perfusion imaging. The cerebral blood perfusion in the region of interest was measured by computed tomography perfusion. RESULTS: The aneurysms were excised after trapping in 2 cases with mass effects and neural compression. Proximal occlusion of the parent artery was performed in 9 cases of fusiform or giant dissecting aneurysms. Trapping was performed after bypass surgery in 8 cases. Within 3 months after surgery, 17 patients had good outcomes. After the hypothesis test, there was a significant difference between the preoperative △cerebral blood volume and postoperative △cerebral blood volume in the anterior area of the semioval center cross section (P = 0.001 < 0.05). CONCLUSIONS: The internal maxillary artery as a bypass donor is an effective method that can provide sufficient intracranial blood perfusion, and there is usually no cerebral ischemia in the surrounding area.

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OBJECTIVE: Recent guidelines recognize the role of chimney endovascular aneurysm repair (ChEVAR) in the treatment of complex aortic disorders. The optimal configuration and number of visceral vessels that can be incorporated is still controversial. We aim to review outcomes from a multi-institutional decade-long experience with ChEVAR. METHODS: Patients undergoing ChEVAR with multiple (≥2) chimney branches were selected from a prospectively maintained database at the two academic university hospitals. All patients were poorly suited for fenestrated or branched endograft repair (F/BEVAR) and deemed poor-risk for open surgery. RESULTS: Forty-nine multiple ChEVAR were performed in 44 men and 5 women, with complete outcome data at a mean follow-up of 18 months. Overall, 2 patients died during follow-up (4%) with no aneurysm-related mortality and two ruptures after ChEVAR (4.1%) due to a type Ib endoleak from iliac limb pullout and persistent gutter-flow, both repaired with endovascular means. No stroke or spinal cord ischemia was noted during the follow-up period. Reintervention was undertaken in eight patients (16.3%) with five reinterventions for persistent gutter-flow and four chimney graft-associated. Three-vessel ChEVAR was performed in 16 patients, with two-vessel ChEVAR in 33 patients for a total of 114 chimney branches (mean 2.3 chimneys per patient). There were 21 superior mesenteric artery (SMA), 45 right renal, 46 left renal artery (LRA), and two accessory LRA chimneys placed. Antegrade configuration of chimney branches was chosen in 43 patients (88%). There were no significant differences between three-vessel and two-vessel ChEVAR upon univariate analysis in aneurysm size (65.6 vs 60.5 mm; p = 0.059), iliac diameter (7.3 vs 7.1 mm; p = 0.85), or endograft oversizing (30 vs 32.5%; p = 0.43). Three-vessel ChEVAR was associated with a larger aneurysm neck diameter (28.4 vs 25.0 mm; p = 0.021), shorter native infrarenal neck (0.5 vs 3.37 mm; p = 0.002) as well as longer seal zone (36.33 vs 22.67 mm; p = 0.005) compared with two-vessel ChEVAR. At follow-up, there were no significant differences in gutter area between three-vessel and two-vessel ChEVAR (18.9 vs 15.7 mm3; p = 0.73) nor the rate of persistent gutter-flow (12.5 vs 9.1%; p = 0.71). CONCLUSION: Reintervention to multiple chimney grafts and for persistent gutter-flow is higher compared to single chimneys and demands close surveillance. However, based upon this combined transantlantic experience, we believe multiple ChEVAR provides a reasonable and safe option for complex aortic aneurysm repair when open or custom endografts are not available or indicated based on their Instructions For use, even when triple chimney grafts are required. The optimal configuration for multiple ChEVAR still warrants further study, although theoretical preliminary advantages may exist for a combination of antegrade and retrograde chimneys.

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BACKGROUND: Posterior cerebral artery (PCA) aneurysms are rare, and most are giant, dissecting, or fusiform in morphology. Proximal occlusion of the PCA without revascularization causes high risk of ischemic complications. This study aimed to evaluate the safety and validity of using superficial temporal artery (STA)-PCA bypass through zygomatic anterior temporal approach in complex PCA aneurysms. METHODS: Trapping or resecting of aneurysms and reconstruction of distal PCA through a zygomatic anterior temporal approach were performed in 6 patients from June 2017 to August 2020. Postoperative angiography confirmed obliteration of aneurysms and patency of bypass artery. Neurological function was assessed by the modified Rankin Scale (mRS). RESULTS: Patients were 4 men and 2 women with a mean age of 43.8 years (range, 21-58 years). Subarachnoid hemorrhage occurred in 5 patients. Hunt and Hess grade was IV in 3 patients, III in 2 patients, and I in 1 patient. All PCA aneurysms were treated with trapping or resection of the aneurysms and revascularization of distal PCA. Postoperatively, all aneurysms were eliminated, and no new permanent neurological deficit was found. During follow-up, mRS score of all patients improved: 2 patients had mRS score 0, 1 patient had mRS score 1, 1 patient had mRS score 3, and 2 patients had mRS score 4. Long-term graft patency rate was 100%. CONCLUSIONS: STA-PCA bypass appears to be safe and effective for the treatment of complex PCA aneurysms requiring supplementation of blood flow in the area of the PCA. We established a surgical route, allowing the procedure to be done through the zygomatic anterior temporal approach. This approach provides adequate operative field exposure and reduces retraction of temporal lobe.

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OBJECTIVE: To present a retrospective review of a single-institute experience with bypass surgery of complex anterior cerebral artery aneurysm. METHODS: Eight patients (5 females and 3 males; mean age, 34.2 years) with complex anterior cerebral artery aneurysms were treated with bypass. There were 3 precommunicating aneurysms, 1 communicating artery aneurysm, and 4 postcommunicating aneurysms (2 in A2 and 2 in A3). A3-A3 side-to-side in situ bypass was performed in 6 cases. A3-radial artery-A3 interpositional bypass was performed in 1 case with A3 segments located far apart, and A3-A3 transplantation was performed in 1 case with nonparallel aligned A3 segments. Of the 8 aneurysms, 3 were secured with proximal clipping, 1 was secured with distal clipping, 1 was secured with direct clipping, 1 was secured with isolation, and 2 were secured with embolization. RESULTS: Aneurysm obliteration was achieved in all cases. Only 1 in situ bypass from a smaller donor artery to a larger recipient artery failed with minor postoperative infarction. Intraoperative bleeding from the site of anastomosis occurred in 1 case during embolization. All patients had complete recovery with normal neurological function during follow-up at outpatient clinics. CONCLUSIONS: We established a simplified surgical algorithm for complex anterior cerebral artery aneurysms based on the geometrical and spatial relationship between efferent arteries. The reasons for bypass failure and hemorrhagic complication were also discussed.

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Background: Few reports have shown the therapeutic outcomes of flow diversion (FD) for intracranial aneurysms beyond the circle of Willis, and the efficacy of this technique remains unclear. Materials and methods: A retrospective study was performed on 22 consecutive patients, diagnosed with intracranial aneurysms beyond the circle of Willis, and treated with pipeline embolization device (PED) (Medtronic, Irvine, California, USA) between January 2015 and December 2019. Result: The 22 patients were between 16 and 66 years old (mean 44.5 ± 12.7 years), and six patients were male (27.3%, 6/22). Twenty-two patients had 23 aneurysms. The 23 aneurysms were 3-25 mm in diameter (12.2 ± 7.1 mm on average). The diameter of the parent artery was 1.3-3.0 mm (2.0 ± 0.6 mm on average). The 23 aneurysms were located as follows: 17 (73.9%, 17/23) were in the anterior circulation, and 6 (26.1%, 6/23) were in the posterior circulation. PED deployment was technically successful in all cases. Two overlapping PEDs were used to cover the aneurysm neck in 3 cases. One PED was used to overlap the two tandem P1 and P2 aneurysms. Other cases were treated with single PED. Coil assistance was used to treat 7 aneurysms, including 4 recurrent aneurysms and 3 new cases requiring coiling assistance during PED deployment. There were no cases of complications during PED deployment. All patients were available at the follow-up (mean, 10.9 ± 11.4 months). All patients presented with a modified Rankin Score (mRS) of 0. During angiographic follow-up, complete embolization was observed in 22 aneurysms in 21 patients, and one patient had subtotal embolization with the prolongation of stasis in the arterial phase. Conclusion: PED deployment for intracranial aneurysms beyond the circle of Willis is feasible and effective, with high rates of aneurysm occlusion.

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A 57-year-old man who had previously suffered a transient episode of retrograde amnesia was admitted to the vascular department of the Burdenko Neurosurgical Center. Computed tomography angiography revealed a complex trifurcation aneurysm of the right middle cerebral artery (MCA) bifurcation. There were no clear focal symptoms after the neurologic examination. The patient underwent a right-sided craniotomy to approach the Sylvian fissure and MCA branches. The MCA aneurysm with 2 lobes had been exposed. One of the M2 branches densely adhered to the aneurysm dome. Attempts of the M2 separation along the dome stopped because there was a high risk of injury to the M2, the aneurysm, or both. To cutoff M2 without bleeding from the aneurysm, a curved clip was used, which we called an insulating clip. After this manipulation, it was already possible to try the neck closing with additional clips, however, according to manual sensations, we were not sure that the insulating clip would not shift and there would be no bleeding. The insulating clip interfered with the final clipping and should have been removed. Temporal aneurysmorrhaphy was used to ensure that the surgeon's manipulations were not complicated by bleeding. This also acted as a guarantee that, in the event of bleeding, the rupture would not spread to the neck of the aneurysm. Thus the M2 cutting-off with an insulating clip and temporal aneurysmorrhaphy were options that allowed for adequate final clipping. There were no intraoperative or postoperative complications. The patient remained neurologically intact and was discharged 7 days after surgery (Figure 1).

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BACKGROUND: Children's complex middle cerebral artery (MCA) aneurysm is a relatively rare occurrence. When the huge aneurysm is located in the MCA bifurcation with an inconspicuous neck and involving numerous arteries, intravascular interventional surgery or aneurysm clipping are often difficult treatment options. At this point, high flow bypass revascularization is necessary as a treatment to preserve cerebral blood flow. In recent years, the internal maxillary artery (IMA) has gradually become the mainstream donor artery of thw high flow bypass. We performed internal maxillary artery -radial artery-middle cerebral artery (IMA-RA-MCA) and superficial temporal artery-middle cerebral artery (STA-MCA) bypass as the treatment of a complex MCA bifurcation aneurysm in consideration of the patient's condition and the advantage of the IMA. According to the author, this case is the youngest reported case of IMA-RA-MCA bypass at present. CASE DESCRIPTION: A male child, 7 years and 8 months, was admitted to the hospital due to "recurrent headache for more than 9 months," DSA indicated that there was a large wide-necked aneurysm at the bifurcation of the right MCA M1 segment, with a size of about 1.16*1.58*1.32 cm. The inflow path of the aneurysm was in front of M1 bifurcation, and one outflow path originated from the aneurysm body, and another small outflow path attached to the aneurysm body. After completing the preoperative evaluation, an extended pterional approach with zygomatic osteotomy was performed to fully expose the aneurysm and IMA, harvesting the left radial artery at the same time, then a STA-MCA bypass, IMA-RA-MCA bypass, and aneurysm trapping were performed. postoperative re-examination showed that bypass vessels and the distal middle artery vessels were patent and the aneurysm disappeared, the child has no neurological dysfunction. CONCLUSIONS: IMA-RA-MCA bypass is an effective high-flow cerebral blood reconstruct scheme in the treatment of complex middle cerebral artery bifurcation aneurysms. This case can provide a reference for the surgical treatment of complex middle cerebral artery bifurcation aneurysms in children.

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OBJECTIVES: To report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). METHODS: A retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates. RESULTS: Twenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up. CONCLUSIONS: Inner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.

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OBJECTIVE: In the present study, we reviewed the 30-day and 1-year clinical results of the use of the investigational unitary manifold (UM) stent graft system (Sanford Health, Sioux Falls SDak) for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm). METHODS: The present study was a single-center, multiarm, prospective review of the first 44 patients who had undergone repair of Crawford type IV, pararenal, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) using the physician-modified UM under a physician-sponsored investigational device exemption. The primary end point was freedom from major adverse events at 30 days, including all-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, and renal failure. RESULTS: Technical success was achieved in all 44 patients (100%), with a large number of these patients having undergone previous aortic repair (20 of 44; 45.5%). All the intended 170 visceral vessels (100%) had been successfully cannulated and stent grafted. No episodes of paraplegia or in-hospital deaths were recorded. One patient had died of aneurysm-related ischemic stroke (2.3%). The rate of transient nonclinically significant spinal cord ischemia was 4.5%. At the last follow-up, one reintervention had been required owing to branch patency from a thrombotic event. Of the 170 bridging stent grafts, 169 have remained patent through a mean follow-up of 8.8 months (range, 0-36 months). No type I or III endoleaks, migration, or component separation in the investigational device has occurred. CONCLUSIONS: The early and midterm results with the use of the UM suggest it could be a viable option for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) without exposing patients to the increased risk of permanent spinal cord ischemia, renal failure, visceral vessel ischemia, or aneurysm-related mortality that results from open thoracoabdominal aortic aneurysm repair. The high technical success rate, in native and previous repairs, supports the utility of this device as a bail-out technique for failed endovascular aneurysm repair or proximal extension of disease after previous aortic repair. However, experience is limited, and this approach requires further study before widespread adoption.

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