{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T14:27:31Z","timestamp":1791469651493,"version":"4.3.4"},"reference-count":27,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,2,1]]},"abstract":"<jats:sec>\n<jats:title>OBJECTIVE<\/jats:title>\n<jats:p>Direct cerebral revascularization is considered as one of the most technically challenging operations in neurosurgery. Technical errors are often not identified during the case, but only after the recirculation stage, making management crucial at that time of the procedure. In this study, the authors sought to describe troubleshooting of the technical errors encountered in initially failed bypass cases.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>METHODS<\/jats:title>\n<jats:p>A retrospective analysis describing a single-surgeon, single-institution experience between 2014 and 2021 was performed, based on operative reports and videos, including a 30-day follow-up period. Initially failed bypass was defined if the bypass was not patent or had a significant leak after recirculation, irrespective of the final result.<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>RESULTS<\/jats:title>\n<jats:p>One hundred thirty-eight bypass cases were reviewed for complex aneurysms (n = 49), moyamoya disease (n = 59), and atherosclerosis (n = 30). Fifty-one initially failed anastomoses were identified; 43 of these were the result of a technical error. Etiologies of these failed anastomoses included a clot (n = 14), vessel kinking (n = 4), spasm (n = 5), suture-related cause (n = 5), inappropriate donor or recipient (n = 3), or lack of demand (n = 8). A major leak was attributed to an uncoagulated side branch (n = 4), vessel injury due to suture\/clip placement (n = 1), or inadequate suture line coverage (n = 7). Thirty-seven (86%) of 43 cases were troubleshot successfully, as salvage maneuvers included papaverine vessel massage, donor repositioning, re-anastomosis for occlusion in select cases, local hemostatic agents, and suturing or coagulating side branches in a leak. Thirty-day follow-up revealed similar rates of patency between successfully troubleshot patients (35\/37) and the rest of the cases (80\/87, p = 0.6).<\/jats:p>\n<\/jats:sec>\n<jats:sec>\n<jats:title>CONCLUSIONS<\/jats:title>\n<jats:p>Three major patterns of a noncompatible bypass were found: a major leak, an acute occlusion, or a delayed occlusion. Based on the authors\u2019 experience, salvage strategies proved successful, showing an eventual high patency rate. The authors suggest a gradual, structured algorithm to address this stage in surgery that may contribute specifically to cerebrovascular neurosurgeons at the beginning of their careers.<\/jats:p>\n<\/jats:sec>","DOI":"10.3171\/2023.6.jns2356","type":"journal-article","created":{"date-parts":[[2023,8,26]],"date-time":"2023-08-26T03:47:05Z","timestamp":1693021625000},"page":"450-462","source":"Crossref","is-referenced-by-count":2,"title":["Troubleshooting the bypass: intraoperative management of initially failed anastomosis in direct cerebral revascularization surgery"],"prefix":"10.3171","volume":"140","author":[{"given":"Omer","family":"Doron","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"},{"name":"Department of Biomedical Engineering, The Aldar and Iby Fleischman Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Devon B.","family":"O\u2019Donnell","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Colin","family":"Dallimore","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hamza","family":"Khilji","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob D.","family":"Greisman","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michelle","family":"Villagran","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rafael A.","family":"Ortiz","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erez","family":"Nossek","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, NYU Langone Medical Center, New York University, New York, New York"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jason A.","family":"Ellis","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David J.","family":"Langer","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra\/Northwell Health, New York, New York;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"2","key":"b1","series-title":"Neurosurg Rev","first-page":"389","article-title":"Bypass in neurosurgery\u2014indications and techniques","volume":"42","author":"Wessels L","year":"2019","unstructured":"Wessels L, Hecht N, Vajkoczy P. 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