Techniques and application in anterior cerebral artery-radial artery-middle cerebral artery bypass for complex middle cerebral artery aneurysms: donor selection, anastomosis technique, and clinical outcomes.

OBJECTIVE

The aim of this study was to evaluate the feasibility, surgical techniques, and clinical outcomes of anterior cerebral artery (ACA) to middle cerebral artery (MCA) bypass using a radial artery (RA) graft in the treatment of complex MCA aneurysms.

METHODS

A retrospective review was conducted on 11 patients with complex MCA aneurysms who underwent ACA-RA-MCA bypass between 2019 and 2025. Surgical details, intraoperative monitoring data, perioperative complications, and long-term graft patency and neurological outcomes were analyzed. Computational flow simulations were performed in selected cases to assess bypass flow rate.

RESULTS

All patients (mean age 46.7 [SD 18.6] years) underwent ACA-RA-MCA bypass in a hybrid operating room setting. The A1 segment of the ACA was selected as the donor in 10 cases and the A2 segment in 1 case. Superficial temporal artery-MCA bypass was used as a supplementary or salvage treatment in 2 patients. Immediate graft patency was achieved in 9 patients. Two aneurysms required revision for intraoperative occlusion. No surgical deaths occurred. Infarction related to M1 perforator involvement was observed in 5 patients, whereas no infarctions occurred in ACA territories. At final follow-up (range 3-30 months), 9 patients had a modified Rankin Scale (mRS) score of 0-2 and 2 patients had an mRS score of 4. Long-term graft patency was 100%, and complete aneurysm obliteration was achieved in all cases.

CONCLUSIONS

ACA-RA-MCA bypass is a safe and durable revascularization option for selected complex MCA aneurysms, especially those unsuitable for direct clipping or flow diversion. The use of the ACA as a donor provides favorable hemodynamic and intraoperative flexibility, particularly when performed in a hybrid operating room. Despite risks of perforator-related ischemia, mastering and understanding this surgical technique still remains critically important and necessary in the treatment of complex MCA aneurysms.