* Shower using antibacterial soap. Dress in freshly washed, loose-fitting clothing.
* Wear flat-heeled shoes with closed backs.
* If you have instructions to take regular medication the morning of surgery, do so with small sips of water.
* You should take 325mg of aspirin to thin the blood.
* Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
* Leave all valuables and jewelry at home (including wedding bands).
* Bring a list of medications (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken.
* Bring a list of allergies to medication or foods.
Arrive at the hospital 2 hours before your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups. An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line and an arterial line will be placed in your arm.
What happens during surgery?
What happens during surgery varies depending on the type of bypass procedure. Described below is the commonly performed STA-MCA bypass. There are 7 steps to the procedure, which generally takes 3 hours.
Step 1. prepare the patient
You will lie on your back on the operative table and be given anesthesia. Once asleep, your head is placed in a 3-pin, skull-fixation device, which attaches to the table and holds your head in position during the procedure. The hair near the incision area is shaved and the scalp is prepped with an antiseptic.
Step 2. make a skin incision
The surgeon uses Doppler ultrasound to locate and mark the course of the superficial temporal artery (STA) on the scalp with a pen. A skin incision is made along the artery.
Step 3. prepare the donor artery
A branch of the STA is carefully dissected from the underlying muscle. After the STA is freed, the muscle is cut and folded back to expose the bone.
Step 4. perform a craniotomy
Next, small burr holes are made in the skull with a drill. The burr holes allow entrance of a special saw similar to a jigsaw. The surgeon cuts an outline of a bone window. The bone flap is lifted and removed to expose the protective covering of the brain, called the dura. The dura is opened and folded back to expose the brain.
Step 5: prepare the recipient artery
Working under an operating microscope, the surgeon carefully locates a branch of the middle cerebral artery (MCA) suitable for bypass. The size of the recipient vessel must be a good match for the diameter of the donor vessel.
Step 6. attach donor and recipient arteries
Temporary clips are placed across the donor and recipient vessels to stop the blood flow. The distal STA is cut and the end prepared for anastomosis. The surgeon then makes an opening in the side of the MCA vessel and sutures the two blood vessels together.
Step 6. verify blood flow through the bypass
After the vessels are attached, the surgeon releases the temporary clips and verifies there are no leaks. Using a Doppler ultrasound or special fluorescent dye, good blood flow through the bypass is verified.
Step 7. close the craniotomy
The dura is closed with sutures. The bone flap is replaced, but a hole is enlarged to allow passage of the bypass vessel without kinking or pressure. The bone flap is secured to the skull with titanium plates and screws (Fig. 2). The muscles and skin are sutured back together. A dressing is placed over the incision.
What happens after surgery?
You will wake up in the recovery area called the post-anesthesia care unit (PACU). You may have a sore throat from the tube used during surgery to assist your breathing. The breathing tube (ventilator) usually remains in place until you fully recover from the anesthesia. Once awake you will be moved to the neuroscience unit for observation. You will frequently be asked to move your arms, fingers, toes, and legs as part of the neurological exam. You may experience some nausea and headache after surgery; medication can control these symptoms. Patients are encouraged to get out of bed and walk several times a day and are encouraged to eat and drink as tolerated.
The nurse will use a device called a Doppler ultrasound every few hours to check the pulse at your incision site to ensure the new connection between your arteries is working correctly. A CT scan will be performed at some stage after surgery to confirm that no complications have occurred (especially postoperative bleeding). In 1 to 2 days you'll be released from the hospital and given discharge instructions.
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