Revascularizing the upper basilar circulation with saphenous vein grafts: operative technique and lessons learned

The purpose of this study was to report our operative technique and lessons learned using saphenous vein conduits to revascularize the rostral basilar circulation (ie, bypass to the posterior cerebral or superior cerebellar arteries). We also review the evolution of this technique for the treatment of vertebrobasilar insufficiency (VBI) and complex posterior fossa aneurysms.

Data were collected retrospectively for 8 consecutive patients undergoing rostral basilar circulation saphenous vein bypass grafts at our institution between 1989 and 2004 for the treatment of VBI or in conjunction with Hunterian ligation of complex posterior circulation aneurysms. The indications for treatment, pre- and postoperative neurologic status, angiographic results, operative complications, and long-term clinical outcomes were analyzed for each patient.

With clinical and angiographic follow-up ranging from 3 months to 15 years, 7 of 8 bypasses remained patent, 3 of 3 aneurysms remained obliterated, and 4 of 5 patients with VBI experienced resolution of their preoperative symptoms. There were no surgery-related deaths, but 2 patients did experience major neurologic morbidity. The outcomes for the 217 total patients reported in the literature were as follows: 135 excellent (62%), 26 good (12%), 30 poor (14%), and 26 dead (12%).

Despite the risk of serious neurologic complications with this procedure, when one considers the natural history of untreated patients, saphenous vein revascularization of the rostral basilar circulation remains an acceptable option. Although surgical technique has varied, patient selection criteria, graft patency, and patient outcomes have been relatively constant over the past 25 years.