Double Reimplantation Technique to Reconstruct Arterial Bifurcations with Giant Aneurysms

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Abstract
Objective: To introduce the double implantation technique, a variation of standard radial artery or saphenous vein bypass that can be used to reconstruct arterial bifurcations in the management of giant aneurysms with complex branch arteries. Methods: This technique was applied in two patients with giant aneurysms. A 74-year-old woman presented with a ruptured thrombotic middle cerebral artery aneurysm, and a 24-year-old man presented with an enlarging infectious aneurysm of the distal anterior cerebral artery (ACA). Results: In the first case, a saphenous vein graft was anastomosed end-to-end to the external carotid artery. The temporal M2 middle cerebral artery trunk was disconnected from the aneurysm and reimplanted onto the graft with an end-to-side anastomosis. The graft was anastomosed end-to-side to the frontal M2 middle cerebral artery trunk, and the aneurysm was trapped. Similarly, in the second case, a radial artery graft was connected to a proximal ACA branch (anterior internal frontal artery) and to the distal pericallosal artery, with reimplantation of the callosomarginal artery onto the graft. The aneurysm was occluded proximally with a clip. Conclusion: The combination of two arterial reimplantations onto a bypass graft connected to a proximal donor artery (3 anastomoses overall) reconstructs an arterial bifurcation and enables the exclusion of a giant aneurysm. Ischemia times are minimized by completing the proximal anastomosis first, successively reimplanting efferent arterial trunks distally, and restoring cerebral perfusion to reimplanted arteries while other anastomoses are performed. This technique may be indicated when critical efferent arteries require revascularization, conventional donor arteries are diminutive, the aneurysm has ruptured, or intraluminal thrombus requires debulking.