Submandibular high-flow bypass in the treatment of skull base lesions: an analysis of long-term outcome

Background: Cerebral bypass surgery remains an integral part of the treatment of complex skull base tumors and unclippable aneurysms. Objective: The authors retrospectively analyzed a single-surgeon experience using a high-flow submandibular-infratemporal saphenous vein graft bypass technique after carotid artery sacrifice in the resection of complex skull base tumors and carotid isolation in unclippable aneurysms. Methods: Data on indications, surgical technique, bypass patency, complications, and outcome were collected for patients treated with adjunctive submandibular high-flow bypass for skull base lesions. Results: Eleven patients (age range: 13-77 years) were treated for various skull base lesions: 4 patients were treated for skull base tumors with resection of the ICA, 6 were treated for aneurysms not amenable to clipping, and one was treated for invasive Mucor infection. Using a saphenous vein graft, a high-flow bypass was created from the high cervical internal carotid artery (ICA) or external carotid artery to ICA or middle cerebral artery by means of a submandibular-infratemporal route. Postoperative computed tomography angiography indicated bypass patency in 10/11 patients. There was no operative mortality. Follow-up of up to 12 years (mean 57 months) was achieved. Conclusion: Direct high-flow submandibular-infratemporal interpositional saphenous vein bypass graft is an effective and durable technique for the treatment of complex skull base lesions where internal carotid artery revascularization is indicated.