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Extra-intracranial standard bypass in the elderly: perioperative risk, bypass patency and outcome
Nora Sandow1, Paul von Weitzel-Mudersbach, Sverre Rosenbaum
1Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany.
Insights
Extra-intracranial (EC-IC) bypass surgery is safe and effective for elderly patients (≥70 years) with cerebrovascular disease. Careful patient selection ensures comparable outcomes to younger patients, demonstrating the procedure
Area of Science:
- Neurosurgery
- Vascular Surgery
- Neurology
- Geriatrics
Background:
- Chronic atherosclerotic vessel occlusion and cerebrovascular hemodynamic insufficiency may necessitate extra-intracranial (EC-IC) bypass surgery.
- An increasing elderly population presents with cerebrovascular hemodynamic insufficiency, yet data on EC-IC bypass in this demographic is limited.
- This study addresses the safety and efficacy of EC-IC bypass in patients aged 70 years and older with occlusive cerebrovascular disease.
Purpose of the Study:
- To evaluate the safety and efficiency of extra-intracranial (EC-IC) bypass surgery in elderly patients (≥70 years).
- To compare outcomes of EC-IC bypass in patients ≥70 years versus those <70 years.
- To assess perioperative complications, bypass patency, and short-term outcomes in different age groups.
Main Methods:
- Retrospective analysis of 50 patients undergoing standard EC-IC bypass surgery (superficial temporal artery to M2 segment of the medial cerebral artery).
- Patient selection criteria included symptomatic occlusive cerebrovascular disease and severely restricted hemodynamic reserve capacity, confirmed by advanced imaging.
- Outcomes analyzed included perioperative neurological and surgical complications, bypass patency, and short-term results, comparing patients ≥70 years (n=16) with those <70 years (n=34).
Main Results:
- No significant differences in gender, vascular pathology, comorbidities, or symptoms were observed between the age groups.
- The perioperative stroke rate was 0% in both groups; mild morbidity was comparable (18.8% vs. 14.7%).
- Initial bypass patency was high in both groups (93.8% in ≥70 years vs. 97.1% in <70 years), with low secondary occlusion rates.
Conclusions:
- Extra-intracranial (EC-IC) bypass surgery demonstrates comparable safety and efficiency in patients aged 70 years and older compared to younger patients.
- A careful preoperative work-up and strict adherence to indication criteria are crucial for successful EC-IC bypass outcomes in elderly individuals.
- The findings support EC-IC bypass as a viable treatment option for selected elderly patients with symptomatic occlusive cerebrovascular disease and hemodynamic insufficiency.
Background:
Patients with chronic atherosclerotic vessel occlusion and cerebrovascular hemodynamic insufficiency may benefit from extra-intracranial (EC-IC) bypass surgery. Due to demographic changes, an increasing number of elderly patients presents with cerebrovascular hemodynamic insufficiency. So far, little data for EC-IC bypass surgery in elderly patients suffering occlusive cerebrovascular disease are available. We therefore designed a retrospective study to address the question whether EC-IC bypass is a safe and efficient treatment in a patient cohort ≥70 years.
Methods:
50 patients underwent EC-IC standard bypass surgery with translocation of the superficial temporal artery to an M2 segment of the medial cerebral artery. Criteria for bypass surgery were presence of symptomatic occlusive cerebrovascular disease of the anterior circulation and proof of a severely restricted or abrogated reserve capacity (detected by H2O-photon emission tomography or single photon emission computer tomography - before and after forced vessel dilatation by diamox). The incidence of perioperative neurological and surgical complications, bypass patency, bypass function and short-term outcome were retrospectively analyzed.
Results:
The study cohort consisted of 16 patients ≥70 years (mean = 74.3 years, SE 1.3). It was compared to a cohort of 34 patients <70 years (mean = 61.2 years, SE 1.0). Both groups underwent EC-IC bypass surgery after careful preoperative work-up. Both patient groups did not differ significantly in gender, vascular pathology, previous history of diseases/comorbidity or clinical symptoms. The number of patients which underwent stenting or other endovascular treatments of the internal or common carotid artery prior to EC-IC bypass surgery was significantly higher in the group of patients ≥70 years (37.5 vs. 0%, p < 0.001). Perioperative stroke rate was 0% in both groups and mild morbidity occurred in 18.8 and 14.7%, respectively (p = 0.699). One 84-year-old female patient died due to perioperative endocarditis. Initial bypass patency was 93.8% in patients above the age of 70 years and 97.1% in the younger group (p = 0.542). Secondary occlusion rate was low in both groups (≥70 years: 0% vs. <70 years 3.7%). No new neurologic deficit occurred in patients with a patent bypass during the follow-up period (median 18 ± 13.1 months). Two patients with an initially occluded bypass and one with a secondary bypass occlusion suffered from new neurological symptoms.
Conclusions:
Our data show comparable safety and efficiency of EC-IC bypass surgery in patients under and above the age of 70 years due to a careful preoperative work-up and a strict indication for bypass surgery.
