Internal maxillary artery (IMax) – middle cerebral artery bypass in a patient with bilateral atherosclerotic carotid occlusion: A technical case report

• Published in: Journal of cerebrovascular and endovascular neurosurgery Vol. 26; no. 1; pp. 51 - 57
• Main Authors: Degollado-García, Javier, Casas-Martínez, Martin R., Mejia, Bill Roy Ferrufino, Balcázar-Padrón, Juan C., Rodríguez-Rubio, Héctor A., Nathal, Edgar
• Format: Journal Article
• Language: English
• Published: Korea (South) 대한뇌혈관외과학회 01.03.2024
• Subjects: 신경외과학; Brain ischemia; Carotid artery stenoses; Cerebral revascularization; Maxillary artery; Carotid atherosclerosis; IMax bypass
• ISSN: 2234-8565; 2287-3139
• DOI: 10.7461/jcen.2023.E2022.11.003

Since the first description of the possible utilization of the internal maxillary artery for bypass surgery, there are some reports of its use in aneurysm cases; however, there is no information about the possible advantages of this type of bypass for cerebral ischemic disease.We present a 77-year-old man with a history of diabetes, hypertension, systemic atherosclerosis, and two acute myocardial infarctions with left hemiparesis. Imaging studies reported total occlusion of the right internal carotid artery and 75% occlusion on the left side, with an old opercular infarction and repeated transient ischemic attacks in the right middle cerebral artery territory despite medical treatment. After a consensus, we decided to perform a bypass from the internal maxillary artery to the M2 segment of the middle cerebral artery using a radial artery graft. After performing the proximal anastomosis, the calculated graft’s free flow was 216 ml/min. Subsequently, after completing the bypass, the patency was confirmed with fluorescein videoangiography and intraoperative Doppler. Postoperatively, imaging studies showed improvement in the perfusion values and the hemiparesis from 3/5 to 4+/5. The patient was discharged one week after the operation, with a modified Rankin scale of 1, without added deficits.The use of revascularization techniques in steno-occlusive disease indicates a select group of patients that may benefit from this procedure. In addition, internal maxillary artery bypass has provided a safe option for large areas of ischemia that cannot be supplied with a superficial temporal artery - middle cerebral artery bypass.