The tandem bypass: Subclavian artery-to-middle cerebral artery bypass withDacron and saphenous vein grafts. Technical case report.

BACKGROUND Fusiform. or dolichoectatic intracranial aneurysms often cannot be managed with conventional surgical or endovascular techniques, and inste ad require trapping and revascularization techniques. On rare occasions in elderly patients, extracranial sites used for anastomosing the bypass have been previously repaired with synthetic vascular prostheses. This circumsta nce in an elderly subarachnoid hemorrhage patient led to a novel bypass pro cedure, the tandem bypass: a long extracranial-to-intracranial bypass with two grafts of different materials assembled in series. CASE DESCRIPTION A 71-year-old man with carotid artery atherosclerotic dise ase and a previous vascular reconstruction (subclavian artery-to-internal c arotid artery Dacron interposition graft) presented with a subarachnoid hem orrhage from a dolichoectatic supraclinoid ICA aneurysm. The aneurysm was t reated with trapping and distal revascularization. The final construct was a subclavian artery-to-middle cerebral artery bypass, with the graft being the previous Dacron prosthesis and a long saphenous vein. The vein graft wa s anastomosed end-to-side to the Dacron graft proximally, and end-to side t o the middle cerebral artery distally Subsequently, inflow to the aneurysm was occluded with clips on the Dacron graft beyond the proximal anastomosis of the vein graft, and outflow from the aneurysm was occluded with clips o n the supraclinoid ICA. CONCLUSIONS The tandem bypass, which uses prosthetic craft material and sap henous vein in succession, is a technically straightforward technique in pa tients who need extracranial-to-intracranial bypasses and who also have pre existing carotid reconstructions or lack sufficient saphenous vein to compl ete a long bypass. (C) 2001 by Elsevier Science Inc.