Reassessing EC-IC bypass for symptomatic ICA and MCA occlusion: a single-centre study highlighting low perioperative risk and surgical expertise.

PURPOSE Extracranial-intracranial (EC-IC) bypass surgery remains controversial due to high complication rates reported in major trials. This study evaluates whether optimised perioperative protocols and surgical expertise can achieve substantially improved safety profiles in patients with symptomatic chronic internal carotid artery occlusion (CICAO) and chronic middle cerebral artery occlusion (CMCAO), addressing the critical gap between theoretical benefit and clinical reality.

MATERIALS AND METHODS This retrospective single-centre study analysed 256 consecutive patients with symptomatic CICAO (n = 162) or CMCAO (n = 94) who underwent superficial temporal artery-middle cerebral artery bypass between October 2006 and February 2021. All procedures were performed by a single experienced surgeon using standardised protocols, including continuation of antiplatelet therapy throughout the perioperative period, maintaining baseline blood pressure levels, and strict postoperative blood pressure control below 140 mmHg. Patients underwent comprehensive evaluation with magnetic resonance imaging, digital subtraction angiography, and computed tomography perfusion. Primary outcomes included 30-day stroke or death and recurrent stroke during 24-month follow-up.

RESULTS The mean temporary intraoperative occlusion time was 23.5 minutes. Remarkably, the 30-day haemorrhagic stroke rate was 0.8% (2/256) with no ischaemic strokes, representing a dramatic improvement over historical controls. During 24-month follow-up, recurrent stroke occurred in 1.5% (4/256) of patients. Patients with CMCAO demonstrated superior outcomes compared to CICAO patients, with total stroke rates of 1.0% versus 3.1%, respectively.

CONCLUSIONS Under expert surgical technique with optimised perioperative protocols, EC-IC bypass achieves exceptional safety profiles with complication rates substantially lower than previous major trials. The dramatic reduction from the historical 15% to 0.8% perioperative stroke rates demonstrates that surgical excellence and protocol optimisation can transform outcomes in cerebral revascularisation. These findings suggest that the poor results in previous trials may reflect technical and management factors rather than fundamental procedure limitations, warranting reconsideration of EC-IC bypass for carefully selected patients, particularly those with CMCAO.