• Jin Woo Bae, Won-Sang Cho, Hee Change Lee, Young Hoon Choi, Sung Ho Lee, Kang Min Kim, Hyun-Seung Kang, and Jeong Eun Kim.
• Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.
• World Neurosurg. 2021 Oct 1; 154: 83-90.

ObjectiveAlthough technically demanding, bypass surgery is a vital part of the neurosurgical armamentarium. The aim of this article was to present representative troublesome cases related to the manipulation of donor arteries (DAs) and recipient arteries during low-flow extracranial-intracranial bypass.MethodsIn the past 5 years, 507 low-flow bypass surgeries were performed in patients with cerebral aneurysms, moyamoya disease, and intracranial atherosclerotic stenosis. Frustrating perioperative situations were retrospectively reviewed, and 6 representative cases were described.ResultsCase 1 involved repeat microanastomosis owing to occlusion of the anastomotic segment by thrombus formation. Case 2 involved repair of the DA injured by thermal energy. Case 3 involved direct repair of the DA damaged by a sharp knife. Case 4 involved repeat microanastomosis owing to avulsion of the anastomotic segment. Case 5 involved lengthening of the short DA with a nearby interposition graft. Case 6 involved use of retrograde flow via the distal segment of the DA secondary to the injury of the proximal segment of the DA. In all patients, rescue procedures were successful, and bypass flow was patent with no relevant complications.ConclusionsThe intraoperative accidents reported here were frustrating; however, all patients were safely rescued without significant sequelae. It is hoped that our experiences will help young neurosurgeons handle troublesome situations.Copyright © 2021 Elsevier Inc. All rights reserved.

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