A Multidisciplinary Approach To Combined Direct And Indirect Cerebral Revascularization Utilizing The Temporoparietal Fascia Flap
Idean Roohani, BS1, David A. Daar, MD1, Shivani D. Rangwala, MD2, Jonathan J. Russin, MD2, Joseph N. Carey, MD1.
1Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA, USA, 2Department of Neurosurgery, Keck School of Medicine, Los Angeles, CA, USA.
PURPOSE: The pedicled temporoparietal fascial flap (TPFF) is a novel approach using combined revascularization for treating cerebral ischemic disease, such as Moyamoya angiopathy (MMA). This study evaluates complications and outcomes using the pedicled TPFF for combined cerebral revascularization.
METHODS: A retrospective review was performed on combined plastic surgery and neurosurgery patients with underlying MMA who underwent extracranial-to-intracranial cerebrovascular bypass surgery with a pedicled TPFF from 2016-2022. Clinical and radiographic data were recorded. Primary outcomes included bypass patency and postoperative complications.
RESULTS: Thirty-five pedicled TPFFs were performed. Average age at surgery was 41.9±15.4years. There were no intraoperative complications, perioperative mortality, or flap loss. Postoperative complications included seven (20.0%) wound complications, five (14.3%) ischemic events, three (8.6%) intracerebral hemorrhages, two (5.7%) superficial surgical site infections, and one (2.9%) patient required shunt placement due to residual low-pressure hydrocephalus following ruptured aneurysm repair. Patients with longer temporary clip times suffered ischemic complications (38.8±5.2 vs. 29.6±4.5minutes; p=0.001). Three patients suffered from iatrogenic strokes, one of which used the M4 segment of the middle cerebral artery (MCA) as the recipient vessel as opposed to more proximal MCA anastomosis at M2 segment (n=34, 97.1%). Immediate postoperative imaging demonstrated a 100.0% (35/35) patency rate. Among the 21 patients with longer-term follow-up imaging (13.8±9.7months postoperatively), 100.0% demonstrated continued bypass patency. Overall follow-up time was 10.2±10.6months.
CONCLUSIONS: Use of the TPFF for combined cerebral revascularization surgery highlights the value of a collaborative neurosurgery and plastic surgery approach, demonstrating good outcomes, minimal donor site morbidity, and a high graft patency rate.
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