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The Transperiosteal “Inside-Out” Occipital Artery Harvesting Technique

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The Transperiosteal “Inside-Out” Occipital Artery Harvesting Technique LABORATORY INVESTIGATION J Neurosurg 130:207–212, 2019 The transperiosteal “inside-out” occipital artery harvesting technique *Arnau Benet, MD,1,2 Halima Tabani, MD,1,2 Xinmin Ding, MD, PhD,1,2 Jan-Karl Burkhardt, MD,1,2 Roberto Rodriguez Rubio, MD,1,2 Ali Tayebi Meybodi, MD,1,2 Peyton Nisson, BS,2 Olivia Kola,2 Sirin Gandhi, MD,1,2 Sonia Yousef, BS,2 and Michael T. Lawton, MD1,2 1Department of Neurological Surgery, and 2Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California OBJECTIVE The occipital artery (OA) is a frequently used donor vessel for posterior circulation bypass procedures due to its proximity to the recipient vessels and its optimal caliber, length, and flow rate. However, its tortuous course through multiple layers of suboccipital muscles necessitates layer-by-layer dissection. The authors of this cadaveric study aimed to describe a landmark-based novel anterograde approach to harvest OA in a proximal-to-distal “inside-out” fashion, which avoids multilayer dissection. METHODS Sixteen cadaveric specimens were prepared for surgical simulation, and the OA was harvested using the classic (n = 2) and novel (n = 14) techniques. The specimens were positioned three-quarters prone, with 45° contralater- al head rotation. An inverted hockey-stick incision was made from the spinous process of C-2 to the mastoid tip, and the distal part of the OA was divided to lift up a myocutaneous flap, including the nuchal muscles. The OA was identified us- ing the occipital groove (OG), the digastric muscle (DM) and its groove (DG), and the superior oblique muscle (SOM) as key landmarks. The OA was harvested anterogradely from the OG and within the flap until the skin incision was reached (proximal-to-distal technique). In addition, 35 dry skulls were assessed bilaterally (n = 70) to study additional craniometric landmarks to infer the course of the OA in the OG. RESULTS The OA was consistently found running in the OG, which was found between the posterior belly of the DM and the SOM. The mean total length of the mobilized OA was 12.8 ± 1.2 cm, with a diameter of 1.3 ± 0.1 mm at the suboccipital segment and 1.1 ± 0.1 mm at the skin incision. On dry skulls, the occipitomastoid suture (OMS) was found to be medial to the OG in the majority of the cases (68.6%), making it a useful landmark to locate the OG and thus the proximal OA. CONCLUSIONS The anterograde transperiosteal inside-out approach for harvesting the OA is a fast and easy tech- nique. It requires only superficial dissection because the OA is found directly under the periosteum throughout its course, obviating tedious layer-by-layer muscle dissection. This approach avoids critical neurovascular structures like the vertebral artery. The key landmarks needed to localize the OA using this technique include the OMS, OG, DM and DG, and SOM. https://thejns.org/doi/abs/10.3171/2017.6.JNS17518 KEY WORDS aneurysms; bypass; occipital artery; occipital groove; revascularization; posterior circulation; far-lateral approach; surgical technique HE occipital artery (OA) is a frequently used donor ported early experience with posterior circulation revas- vessel for extracranial-intracranial bypass proce- cularization achieved using the OA,13 the OA has been dures to the posterior circulation, by virtue of its widely used as a donor vessel in treating posterior circula- Tproximity to the recipient vessels and its optimal caliber, tion aneurysms, ischemic neurological disorders, and rees- length, and flow rate.3 After Sundt and Piepgras first re- tablishing blood flow after resection of skull base tumors, ABBREVIATIONS AICA = anterior inferior cerebellar artery; DG = digastric groove; DM = digastric muscle; OA = occipital artery; OG = occipital groove; OMS = occipito- mastoid suture; PICA = posterior inferior cerebellar artery; SOM = superior oblique muscle; VA = vertebral artery. SUBMITTED February 26, 2017. ACCEPTED June 13, 2017. INCLUDE WHEN CITING Published online January 26, 2018; DOI: 10.3171/2017.6.JNS17518. * Drs. Benet and Tabani contributed equally to this work. ©AANS 2019, except where prohibited by US copyright law J Neurosurg Volume 130 • January 2019 207 Unauthenticated | Downloaded 10/05/21 10:15 AM UTC A. Benet et al. particularly those involving the vertebral artery (VA) or distal) approach for harvesting the OA was performed in posterior inferior cerebellar artery (PICA).3,13 the rest of the specimens (n = 14) to test the feasibility Although the OA has sufficient length and caliber to of the technique and to define the surgical landmarks for effectively redirect blood flow to the posterior circula- identification of the OA (Video 1). tion,10 it has a tortuous course in which it passes through VIDEO 1. Clip showing anterograde inside-out OA harvest. The 3D multiple layers of suboccipital muscles, necessitating lay- video depicts stepwise dissection of the OA aided by the antero- er-by-layer dissection for exposure. Therefore, harvesting grade inside-out technique. Copyright Arnau Benet. Published with the OA has been regarded as time consuming and more permission. Click here to view. challenging than harvest of the superficial temporal ar- The specimens were positioned in a three-quarter tery. 2,7 The conventional method used to harvest the OA prone position with the head turned 45° toward the contra- entails removing it from its distal to its proximal segment, lateral side by using the 3-pin head clamp (Mizuho Amer- using layer-by-layer muscle dissection through the nuchal ica), and the neck was slightly flexed, allowing flattening and suboccipital musculature.6,8 The transitional segment of the suboccipital musculature. This position allowed of the OA, which runs between the superior edge of the exposure of the mastoid process as well as easy access splenius capitis muscle and the superior nuchal line, has to the inion and the spinous process of C-2. The classic been deemed the most challenging segment of the OA to inverted hockey-stick incision was performed, connecting harvest because it is known to traverse vertically through the spinous process of C-2 to the tip of the mastoid process several layers, including the tendon of the splenius capitis (Fig. 1A). The incision began along the avascular midline muscle and the galea aponeurotica.7 Recently, Fukuda et through the nuchal ligament and was extended superiorly al. proposed 3 variations of the conventional OA harvest- 3 cm above the superior nuchal line. At this point, it was ing technique, all of which directed the dissection toward turned laterally in a horizontal fashion until reaching the the transitional segment of the OA, using 3 different skin asterion region and then continued inferiorly to end 1 cm incisions.7 The authors concluded that the most critical below the mastoid tip. While performing the incision, care step during OA harvest is the dissection of the transitional was taken to keep the cut shallow near the lateral third of segment, and that layer-by-layer dissection of muscles is the superior nuchal line to prevent inadvertent damage to required to safely and effectively harvest this segment. the distal segment of the OA, which runs subcutaneously. Several studies have described the microanatomy of the The subcutaneous segment of the OA was then iden- OA in detail for its use in posterior circulation bypass.2,3 tified, ligated, and transected. In 2 cases, longer grafts However, an efficient, technically less challenging, and were obtained by dissecting distally (superiorly) into the minimally invasive technique for harvesting the OA is scalp as proof of concept, but measurements were taken still lacking. only to the skin incision for statistical consistency. Blunt In this cadaveric surgical simulation study, we propose dissection was then continued in the avascular plane in a novel technique for harvesting the OA via an antero- the midline until the occipital bone was exposed. The nu- grade (from proximal to distal) approach performed using chal muscles were then elevated from medial to lateral a myocutaneous flap. Our objective was to describe the into the flap, keeping the periosteal sheath intact within approach in a stepwise manner and define key landmarks the flap (Fig. 1B). Dissection then continued through the to safely and efficiently harvest the OA by using the pro- suboccipital space, and the C-1 and C-2 vertebrae were posed technique. exposed between the posterior rectus capitis major and minor muscles. The suboccipital muscles were elevated Methods subperiosteally along the inferior nuchal line into a single Craniometric Study myocutaneous flap. As dissection continued inferiorly, the longissimus capitis was freed from its insertion at the Thirty-five dry skulls were assessed bilaterally (n = 70) posterior margin of the mastoid process and the poste- to study the bony landmarks that can be used to identify rior belly of digastric muscle (DM) was detached from its and locate the proximal segment of the OA. The occipi- attachment at the digastric groove (DG), and both were tal groove (OG) was bilaterally identified in each skull. included in the flap. The shape of the OG was classified into canal, groove, or The OA was then identified in the OG, which was found impression. Next, the asterion was located and the origin medial to the DG (Fig. 1C). It was bound medially by the of the occipitomastoid suture (OMS) was identified. The superior oblique muscle (SOM) and laterally by the poste- OMS was then followed inferiorly to assess its relationship rior belly of DM. Once the OA was identified, it was dis- with the course of the OA: medial to the OA, lateral to the sected proximally by using sharp microdissection under OA, or crossing the OA. the microscope, freeing it from its surrounding connective and periosteal tissue. Dissection was then continued dis- Development and Feasibility Assessment of the Proposed tally with 45° Pott scissors, following the course of the OA Technique under the periosteum.
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