Interposition saphenous vein bypass graft between the common and intracranial internal carotid arteries

22 common carotid to intracranial internal carotid artery bypass grafts with interposition saphenous vein were performed in 20 patients over a four year period. The distal anastomosis was end-to-end on the internal carotid artery at a site between the ophthalmic and posterior communicating arteries. Early occlusion (rendered patent with Urokinase) occurred in one graft resulting in fatal infarction. Flow included all the anterior and middle cerebral arteries in 17 bypass procedures and middle cerebral artery only in five bypasses. Complications attributable to the bypass were seen following six procedures. These complications resulted in mortality in one case (early graft occlusion) and permanent morbidity (partial monocular visual loss) in two cases. Other complications resulting in no, or temporary, morbidity were cortical infarction due to division of collateral meningeal supply during opening (n=1), epidural haematoma (n=1), and intimal hyperplasia causing delayed graft stenosis (n=1). With the exception of the operative complications no patient subsequently experienced a hemispheric ischaemic episode. Minimising complications is possible with avoidance of proximal ligation of the internal carotid artery whenever possible, ligation of the ophthalmic artery when steal into a cavernous sinus fistula is a possibility, careful evaluation of existing collaterals from the middle meningeal artery (and their preservation) and attention to timing for the postoperative introduction of anticoagulants. Early graft occlusion (4.5%) is likely to remain the most feared complication of this procedure. Immediate intervention with intragraft Urokinase may re-establish graft patency.