Technique for Direct Bypass Surgery:
- Map out STA anterior to zygomatic arch for 8-9cm, using Doppler.
- Dissect STA and vascular cuff under microscope.
- Open dura wide over Sylvian fissure, under high magnification, identify M4 recipient artery.
- Cut distal STA at 45 degrees, place temporary clips on recipient artery.
- Make an elliptical arteriotomy over M4 branch.
- Perform end-to-side anastomosis using 10 to 0 interrupted suture under high magnification.
- Remove temporary clips from recipient and proximal STA once bypass completed.
- Place STA and vascularized cuff in close apposition to cortical surface to facilitate delayed collateralization
Liu, Jonathan J., and Gary K. Steinberg. “Direct Versus Indirect Bypass For Moyamoya Disease”. Neurosurgery Clinics of North America 28.3 (2017): 361-374.