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Management of Severe Craniofacial Vascular Malformation Operated under Bypass; Evolution from a “No-flow” to a “Low-flow” - 10 Surgical Procedure Series
Lucie Lessard, MD, FRCSC, FACS1, Ali Izadpanah, MD,CM2, H Bruce Williams, MD, FRCSC, FACS1.
1McGill University, Montreal, QC, Canada, 2McGill University, Westmount, QC, Canada.
Introduction
Cardiopulmonary bypass (CBP) and circulatory arrest as an assist in the surgical excision of a severe facial vascular malformation was first described by Mulliken and Murray in 1979. Later on, its use had expanded for resection of intracranial vascular malformations. However, up-to-date, there have not been any published series of these procedures being used in the resection of craniofacial vascular malformations.
Purpose
We sought to review the first 10 surgical procedures performed at McGill University Health Centre (MUHC) for large vascular malformations resection using hypothermic CBP with or without circulatory arrest.
Methods
All consecutive patients at the MUHC who had a craniofacial vascular malformation resected with the aid of CBP were reviewed. A comparison of the classic midline sternotomy with cardiac arrest to percutaneous femoral bypass with hypothermic “low-flow” was performed. Charts were reviewed for the operative intervention including bypass parameters, and short-term and long-term complications of the procedure.
Results
Cardiopulmonary bypass was used in nine patients for ten surgical procedures for the resection of a variety of craniofacial vascular malformations from 1987-2001. All lesions had sclerotherapy and embolization of the feeding vessels 72-96 hours preoperatively. The average age of our patients was 21 ± 13.4 years (2 to 37 years). Procedures were conducted via either an open bypass or a closed femoral approach. There were no mortalities. There were two major cardiac intraoperative complications and one major postoperative complication, which were managed with no sequelae. The average length of postoperative hospital stay was 10 days. All patients went on to full recovery. The blood transfusions varied from 10 units to zero for our last patient.
Conclusions
The assistance and adjunct of CBP is a useful procedure in the resection of very large vascular malformations, in selected cases. There were no major long-term complications in this series. With the evolution of our approach, the use of complete circulatory arrest was not required in the majority of cases, and an adequate resection was usually possible with the “low-flow” state alone as we developed this technique with more experience through the process.
Figure 1. Scatter plot of total blood products and PRBC. Evolution from midline sternotomy and total circulatory arrest to femoral cannulation with hypothermic cardiac bypass with “low-flow” 
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