319 A Case Series of Direct Multi-territory Cerebral Revascularizations Using a Three-Vessel Anastomosis

INTRODUCTION: The ability to perform simultaneous, multi-territory cerebral bypass using a single interposition graft has significant utility for the revascularization of multiple cerebral territories that would otherwise require multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. METHODS: Peri-operative data and outcomes were collected retrospectively for patients undergoing multi-territory cerebral revascularization using a three-vessel anastomosis over a 4-year period (2019-2023). RESULTS: Five patients underwent triple vessel bypass (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery (MCA) aneurysms (one ruptured) were treated multi-territory external carotid artery (ECA)-M2-M2 revascularization using a saphenous vein interposition graft, followed by either proximal ligation or partial/complete aneurysm clip trapping. Two patients with predominately bilateral anterior cerebral artery (ACA) territory moyamoya disease were treated with proximal superficial temporal artery (STA)-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap (RAFF) graft. Bypass patency was 100% and zero patients experienced surgery-related ischemia. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for a post-operative hematoma and RAFF debridement that did not affect bypass patency or neurologic outcome. Median Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores on discharge were 4 (range 3-5) and 2 (range 0-5), respectively. GOS and mRS scores were stable or improved on follow up in 4/5 patients; one patient died from medical complications of their original stroke. CONCLUSIONS: In experienced hands, three-vessel anastomosis can be a viable option for the safe, simultaneous revascularization of multiple ACA and MCA territories.