| Objective: Current studies have shown that direct or combined bypass can be used in the treatment of moyamoya disease and improve the prognosis of patients with hemorrhagic(Recommendation Grade B,Level of Evidence: middle)or ischemic moyamoya disease(Recommendation Grade B,Level of Evidence: low).Sequential double anastomosis(SDA)and Double barrel anastomosis(DBA)are two variants of direct bypass technology.DBA needs to perform end-to-side anastomosis between two donor arteries and two recipient arteries respectively,while SDA only uses one donor artery and two recipient arteries for side-side and end-side anastomosis successively.It can be considered that the length of the vascular branch of side-to-side anastomosis is 0 in SDA.According to Poiseuille’s law,when the pressure is constant,the total branch length of SDA decreases,the total blood flow resistance decreases,and the total blood flow of SDA bypass vessel increases compared with DBA.Therefore,we proposed a hypothesis: the blood flow of SDA bypass is higher than DBA,but it is still a low-flow bypass,and the effect of SDA in the treatment of Moyamoya disease is better than DBA.This paper intends to confirm the validity of this hypothesis through retrospective control study.Methods: After obtaining approval of Ethical Review Committee,we retrospectively analyzed the clinical data of 74 operations in 54 patients with moyamoya disease treated by SDA or DBA combined EMS in the First Hospital of China Medical University in 10 years.A total of 20 SDA combined EMS were performed from July 2019 to November2022,and 54 DBA combined EMS were completed from August 2014 to November 2022.A total of 20 patients underwent bilateral operations,and the interval of bilateral operation was [3.39(2.40,4.97)] months,11 patients underwent bilateral DBA combined EMS,3patients underwent bilateral SDA combined EMS,6 patients underwent SDA combined EMS on one side and DBA combined EMS on the opposite side.1.Baseline data of the two groups were collected: including preoperative hemorrhagic or ischemic strokes history,symptoms,the time between the first symptom and the operation,gender,age,hypertension,dyslipidemia,smoking,drinking,preoperative modified Rankin Scale(m RS),Digital subtraction angiography(DSA),Suzuki staging and computed tomography perfusion(CTP)results before surgery.2.Intraoperative ultrasound or indocyanine green(ICG)angiography were used to confirm the patency of the two anastomoses.3.The follow-up time in SDA combined EMS group was 19.30±12.93 months,12 cases(60.00%)were followed more than one year,and 8 cases(40%)were followed by 3～11months.The follow-up time in DBA combined EMS group was 41.94±21.63 months,51cases(94.4%)were followed more than one year,and 3 cases(5.6%)were followed by3～7 months.Data of 1 week after surgeries,medium and long-term follow-up of the two groups were collected:(1)m RS Scores by telephone follow-up;(2)New cerebral ischemic strokes,cerebral hemorrhage,and death events;(3)Bypass patency was assessed by DSA and/or computed tomographic angiography(CTA);(4)Bypass blood flow data were measured by ultrasound in 1 week after surgery;(5)The results of CTP in 1week after surgery and the healing of surgical incision in 1 week and 3 months after surgery.Chisquare test,continuous correction formula or Fisher’s exact probability method were used to analyze the counting data.For measurement data:(1)Independent-samples t test was conducted when normal distribution and homogeneity of variance;(2)Skewed distribution data were described by median and quartile spacing [M(P25,P75)];(3)Ranked data were statistically analyzed by Mann-Whitney U test or Kruskal-Wallis test.Results: 1.There was no significant difference in baseline data between the two groups:1)In the 54 patients,29 were females and 25 were males(female/male =1.16).2)The age of SDA combined EMS was [34.5(32.0,44.5)] years old,2 of them were younger than 18 years old(9 years,12 years).The age of DBA combined EMS was [37.5(28.0,48.3)] years old,4 patients were younger than 18 years old(6 years,7 years,9 years,12 years).There was no significant difference in the number of cases under 18 years old between the two groups.3)Preoperative Suzuki staging: SDA combined EMS,1 case of stage II,11 cases of stage III,7 cases of stage IV,1 case of Stage V,DBA combined EMS,1 case of stage II,29 cases of stage III,20 cases of stage IV,4 cases of stage V;4)Symptomatic moyamoya disease(TIA,hemorrhagic or ischemic strokes within 6 months before surgery): 15 cases(75.0%)in SDA combined EMS group and 37 cases(68.5%)in DBA combined EMS group.Hemorrhagic moyamoya disease: 2 cases(10%)in SDA combined EMS and 10 cases(18.5%)in DBA combined EMS.5)Preoperative m RS Score: SDA combined with EMS group [1(1,2)];DBA combined with EMS Group [1(1,2)](P=0.895>0.05).2.Intraoperative patency of both anastomoses was confirmed in 74 operations by ICG angiography or ultrasound.3.Postoperative(1 week)m RS: SDA combined EMS group was [1(0.25,2)] and DBA combined EMS group was [1(1,2)](P=0.632>0.05).The m RS at follow-up: SDA combined EMS group was [1(0,1)] and DBA combined EMS group was [0.5(0,1)].The difference was not statistically significant(P=0.906>0.05).The number of cases with m RS 0-1 in the DBA combined EMS at the last follow-up was higher than pre-operation(P=0.005<0.05)and 1 week after surgery(P=0.024<0.05).The number of cases with m RS 0-1 in the SDA combined EMS at the last follow-up was also higher than pre-operation(P=0.034<0.05)and 1 week after surgery(P=0.034<0.05),and the difference was statistically significant.4.Cases occurred ischemic strokes within 1 week after surgery: 2 cases(10.0%)in SDA combined EMS group and 8 cases(14.8%)in DBA combined EMS group(P=0.828>0.05).Cases occurred cerebral hemorrhage or subarachnoid hemorrhage within 1 week after surgery: 1 case(5.0%)in SDA combined EMS group and 4 cases(7.4%)in DBA combined EMS group(P=1.000>0.05),the difference was not statistically significant.There was no mortality in the two groups.Cases occurred cerebral strokes in medium and long-term follow-up: SDA combined EMS group had 0 cases(0.0%),DBA combined EMS group had 2(3.7%)cerebral hemorrhage,the difference was not statistically significant(P=1.000>0.05).The annual incidence density of cerebral hemorrhage and ischemia events was 0.00% in the SDA combined EMS group and 1.09% in the DBA combined EMS group during follow-up,the difference was not statistically significant(P > 0.05).There was no mortality in follow-up in the two groups.5.The patency of bypass was evaluated by DSA and/or CTA.10 cases(50.0%)completed the follow-up examination in SDA combined EMS group at [4.7(3.3,15.5)] months and the patency was 100.0%(10/10).26 cases(48.1%)completed the follow-up examination in DBA combined EMS group at [5.4(3.1,14.4)] months and the patency was 88.5%(23/26),the difference was not statistically significant(P=0.545>0.05).6.Superficial temporal arterial blood flow in 1 week after surgery: 17 cases(85.0%)in SDA combined EMS group completed the examination,and the blood flow was [82.0(49.0,111.0)] ml/min.32 cases(59.3%)in DBA combined EMS group completed the examination,and the blood flow was [82.5(69.5,96.80)] ml/min,the difference was not statistically significant(P=0.721>0.05).7.CTP: 15 cases(75.0%)in the SDA combined EMS and 31 cases(57.4%)in the DBA combined EMS completed the examination.The CTP stage difference was not statistically significant in the two groups in one month before surgery(P=0.627>0.05)and in one week after surgery(P=0.422>0.05).No overperfusion occurred in the two groups.8.Incisions in 20 patients treated by SDA combined EMS healed well,and 2 patients(3.7%)in the DBA combined EMS had local black scalp and returned to normal after three months.The difference had no statistical significance(P =1.000>0.05).Conclusion:1.The incidence of perioperative complications in SDA combined EMS and DBA combined EMS was basically same.2.The medium and long-term follow-up effect of SDA combined EMS and DBA combined EMS was basically same.3.The blood flow of STA was basically same in SDA and DBA combined EMS in postoperative.The bypass vascular patency was basically same in postoperative follow-up. |
PDF Full Text Request