Direct intragraft thrombectomy as a rescue strategy for early bypass occlusion: Case report and literature review

Early occlusion of a superficial temporal artery-middle cerebral artery (STA-MCA) bypass is an uncommon but critical complication. I report a case of postoperative day 1 graft occlusion with preserved recipient artery flow that was successfully salvaged approximately 35 hours after the index surgery. Direct intragraft thrombectomy through multiple longitudinal arteriotomies, combined with a new STA-MCA anastomosis and perioperative antithrombotic therapy, restored bypass patency. The patient was discharged without neurological deficit; early postoperative angiography confirmed patency, and long-term patency was confirmed by magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) and arterial spin labeling at 2 years. I additionally reviewed the literature on rescue strategies and related clinical courses for occluded or flow-compromised extracranial-intracranial (EC-IC) bypass grafts, including surgical revision, pharmacologic fibrinolysis, endovascular treatment, and observation. This case highlights that, when recipient arterial flow is preserved and thrombus is mainly located within the donor graft, direct intragraft thrombectomy may provide a practical salvage option for early bypass failure.