title: Endovascular management of symptomatic spasm of radial artery bypass graft: technical case report.
abstract: OBJECTIVE
  To describe the technique of endovascular access for treatment of vasospasm of a radial artery bypass graft from the occipital artery to the M3 branch of the middle cerebral artery (MCA) in a patient with moyamoya disease.
  
  
  METHODS
  A 32-year-old woman presented with recurrent right-sided ischemic symptoms in the territory of a previous stroke. Angiographic findings were consistent with moyamoya disease, and a perfusion deficit was identified on computed tomography (CT) perfusion imaging.
  
  
  METHODS
  The patient underwent a left MCA bypass graft for flow augmentation. She returned with an occluded bypass graft, collateralization of the anterior MCA territory through a spontaneous synangiosis, and a severe perfusion deficit in the posterior MCA territory. She underwent a revision bypass graft procedure with the radial artery from the occipital artery stump to the MCA-M3 branch. She developed repeated symptomatic vasospasm of the radial artery graft postoperatively. After systemic anticoagulation, the graft was accessed through the occipital artery, and intra-arterial verapamil was injected. When this failed to resolve the graft spasm, the radial artery graft was accessed with a 0.14-inch Synchro-2 microwire (Boston Scientific, Natick Massachusetts), and sequential angioplasties were performed using over-the-wire balloons from the proximal to distal anastomosis and in the occipital artery stump. A nitroglycerin patch was applied cutaneously over the graft to relieve the vasospasm.
  
  
  RESULTS
  No complications occurred. Graft patency with robust flow was observed on the 5-month follow-up angiogram.
  
  
  CONCLUSIONS
  Endovascular techniques can be safely used for salvage of spastic extracranial-intracranial grafts.
authors.affiliation: Department of Neurosurgery, Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, 14209, USA.
authors.forename: Sabareesh K
authors.initials: SK
authors.lastname: Natarajan
authors.forename: Erik F
authors.initials: EF
authors.lastname: Hauck
authors.forename: L Nelson
authors.initials: LN
authors.lastname: Hopkins
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
mesh_terms: D000328:Adult; D000800:Angioplasty, Balloon / Q000379:methods*; D002548:Cerebral Revascularization / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D017534:Radial Artery / Q000637:transplantation*; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000628:therapy*