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"Choosing" the right type of surgery (Read 36167 times)
Emily
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"Choosing" the right type of surgery
Oct 19th, 2005 at 7:44pm
 
how do you know?

so far the gist i've got is this:

STA-MCA - direct bypass from outside skull to inside

EDAS - indirect bypass -> arteries are laid on the surface of the brain and left to grow

EMS - indirect bypass -> muscle (and it's bloody supply) is laid down on the surface of the brain and left to grow

i can't remember the names but i've got one (left) completely closed, one on the right almost completely closed and a third (where?) not doing too well.....
people say make sure you have the right surgery for your case but how do you know?
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Shan
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Re: "Choosing" the right type of surgery
Reply #1 - Oct 19th, 2005 at 8:06pm
 
Hi Emily,

I know it may be difficult to remember and understand the options available to you.  My suggestion, which I'm sure you've heard or read many times before, is to seek the advice from a MM specialist who can offer their advice on which surgery is best suited for your needs.  I, personally, had a double direct STA-MCA bypass, as well as an indirect on my right side.  So therefore, you may even have the need to have more than one type of surgery done.  I think as with any type of procedure, even though they may go in with a gameplan, things may change once they start the operation and plans may be subject to change depending on what they see, or what happens during surgery.

My best advice would be for you to seek the advice of MM specialists (even if they are located in the U.S.) and ask them for their opinion of your situation and what type of surgery(s) they would recommend.  Then, after receiving all of their responses, you can base your decision on what to do/where to go from there.   Smiley  I know I probably didn't offer you any solid answers to your question, but I hope this helps... Smiley

Take care,
Shan
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« Last Edit: Oct 19th, 2005 at 8:33pm by Shan »  

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kotipup
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Re: "Choosing" the right type of surgery
Reply #2 - Oct 19th, 2005 at 8:14pm
 
Emily,

An experienced MM surgeon should be able to tell you which procedure is best for you.

I think for many adults, STA-MCA is usually the ideal, because it delivers immediate blood flow, and adults may not grow in new vessells as quickly as children do.  However, not all adults are good candidates for the STA-MCA surgery, and one of the indirect bypass procedures may be a better fit.

If your neurosurgeon isn't giving you good answers about why you aren't doing well after surgery, you might look into getting a second opinion.  At the very least, if a second neurosurgeon with MM experience agrees with what the first is doing, you would know you were doing all you can; however you might end up getting some other treatment options from the second neurosurgeon --- you have nothing to lose  Wink

I'm not sure where you live, but my daughter had surgery with Dr. Steinberg in Stanford, CA, and I would recommend him very highly.  He saved our daughter's life.  Daphne'd had two strokes before her MM diagnosis, when she was 16 months old, and her doctors in Philadelphia did not expect her to live beyond two weeks.   Thanks to her surgeries back in March (and her incredible will), she celebrated her second birthday on October 7th.   ;Grin

Jenny

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DJ
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Re: "Choosing" the right type of surgery
Reply #3 - Oct 19th, 2005 at 8:29pm
 
Hi Emily,

I understand how overwhelming all of the information can be when you're first diagnosed, but hang in there!

Choosing which surgery to have is a personal decision based on your research and your individual case.

Basically, the direct bypass (STA-MCA) provides immediate bloodflow around the occlusion and is generally the option prefered for adults.  Generally, adults have arteries large enough for the surgeon to graft together.

Indirect type bypasses (EDAS, EMS) take time to "grow" and provide relief.  Time varies from patient to patient but it could take anywhere from a month to 6 months to a year to see the benefit.  Indirect is generally the option preferred for children because generally, children don't have arteries large enough for the surgeon to work with.  Also, children are able to grow new networks of arteries much faster than adults.

Another important factor to take into consideration is... because of the way the temporal (donor) artery is utilized in the different types of surgeries, additional surgeries may (or may not) not be possible if the initial procedure doesn't work for some reason.

Example: Generally, if an in direct type surgery doesn't work, there is a very good chance you will not be able to go back and have a direct type surgery performed afterwards.  This factor is especially important for adults.


You'll notice I italicized generally in the statements above because every case is different.  As Shan suggested, it's best to get an opinion from someone who deals with MM on a regular basis to help you decide which option is best for your individual case.

This probably doesn't answer any questions for you either, but I hope it give you more information to help you make a decision for your case.

Hang in there!  If there is anything else or any other questions we can give you some opinions on, please don't hesitate to let us know!

Smiley

DJ

[Nov 5, 2005 edit in blue]
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« Last Edit: Nov 5th, 2005 at 2:11am by DJ »  

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Emily
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Re: "Choosing" the right type of surgery
Reply #4 - Oct 19th, 2005 at 9:52pm
 
thanks for your replies....
there's two surgeons at my hospital with MM experience, i have an appointment tomorrow so i guess i'll just wait and see what they say.
i think they're a bit unsure what to do with me as i'm an adult - 23, but i'm the size of a child (4 foot 8" ) - and seem to have the symptoms of a child rather than an adult (they described me as extraordinary, hehe, wicked)....
i'll let you know what they say.
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« Last Edit: Oct 19th, 2005 at 9:54pm by Emily »  
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Shan
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Re: "Choosing" the right type of surgery
Reply #5 - Oct 20th, 2005 at 12:01am
 
Hi Emily,

Great to hear that you have 2 MM specialists near you!  I wish you the best at your appointment tomorrow... Smiley

Take care,
Shan  Cheesy
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Sara
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Re: "Choosing" the right type of surgery
Reply #6 - Oct 20th, 2005 at 9:20am
 
Emily:

Good Luck at your appointment. I just wanted to offer one more piece of advice. First of all, I am glad to hear there are doctors in your area that have some MM experience. Secondly, I wanted to ask if you thought those doctors would "consult" with Dr. Scott or Dr. Steinberg about your case. When I had my surgery in 1989, my doctor consulted with Dr. Scott. He was wonderful, and while he wasn't actually my doctor, and didn't actually DO the surgery, he helped my doctor figure out what was best for me since I was "one of the first children diagnosed" in the States.

I aws the first surgery for MM performed in Houston, Texas, which has a HUGE Med. Center. And everything turned out great!

Please keep us all up to date!

Smiley Sara
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Emily
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Re: "Choosing" the right type of surgery
Reply #7 - Oct 21st, 2005 at 2:04am
 
First meeting with Dr John Laidlaw today and I really liked him. Very comfortable and straight-forward. He's got quite a lot of experience, has decided I first need an STA-MCA of my left side. It seems to be pretty urgent that I get immediate blood supply to that side so that's what we're going to start with.
Then we'll take it from there, my right side also needs to be done, but as I'm experiencing no symptoms yet, we may be able to do an EDMS. And then..... further down the track some sort of bypass on one of the ones (forgot the name already) up the back along the vertebrae.
Kinda sucks that I need so much work but hey i'm never one to do things halfway!!!
My initial surgery will be in about 5 weeks, and i'm currently on plavix (and aspirin) so will be stopping that (plavix) 3 weeks before surgery and having to give myself daily injections (clavicrol?? or something) leading up to the surgery.. (seems my risk of stroke right now is kinda nasty).
so yeah....
feeling good, happy with him and his experience... speaking to the aneasthetist soon and having some SPECT scans and seems to be all under control.

oh and i have to lose my hair  Cry  - because i'll have to eventually have 3 operations i might as well go it all at once than leave it in messy clumps...  combine that to a summer of not being able to drive (i am truly madly deeply in love with my kombi and that's devastating) or spend the festival season with my friends (i WAS moving back to queensland before christmas)..... so basically it's tough times ahead!
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« Last Edit: Oct 21st, 2005 at 2:36am by Emily »  
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Shan
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Re: "Choosing" the right type of surgery
Reply #8 - Oct 21st, 2005 at 4:09am
 
Hi Emily,

I'm glad that you're not putting this off and have gone to see your doctor, Dr. Laidlaw today.  I'm also pleased to hear that he is experienced.  Wink

Looks like his current plan is for you to have 3 surgeries?  An STA-MCA on your left side, then an EDMS on your right, then another bypass along your vertebrae?  I'm just wondering if he gave any time frame for your second surgery?  My MRI/MRA on my other side (left) showed multiple TIA's, and I too am not having symptoms, but the option for surgery is still not up for discussion by my neuro at this time.  Smiley

I too was on Plavix but am now on Aggrenox..but I wanted to ask you more about the injections you mentioned you will have to give yourself leading up to your surgery.  I tried googling it, but I couldn't find it.  It really caught my interest.  Is it like a fast acting/short-term blood thinning medication?  Smiley Also, I know you mentioned stopping Plavix 3 weeks pre-op, but do you have to also stop taking aspirin prior to your surgery?  I hope you don't mind me asking so many questions...I'm just very interested.

About your hair...don't worry.  I looked quite funny with 1/3 of my head shaved off.  I planned to shave my entire head once I woke up and realized how much was gone...but I chickened out at the last minute.  I personally took a liking for bandanas and probably have one in close to every color ever made.  Wink  By the way, I agree with your decision to shave everything off at once. I was told it's better so your hair can grow back evenly...

Last but not least, your post sounds so positive and filled with confidence, which makes me so happy for you!  A positive attitude will definitely help with morale, and I believe very important with the whole healing process!  Keep the positive attitude, Emily!  Keep up that great spirit!  You'll do just fine!  Smiley

Take care,
Shan
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« Last Edit: Oct 21st, 2005 at 4:37am by Shan »  

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Re: "Choosing" the right type of surgery
Reply #9 - Oct 21st, 2005 at 4:52am
 
Hi Emily...enjoyed reading your post.  Cara was six when she had her surgeries...she had both the STA-MCA and EMS done on both sides.  Dr. Meyer didn't think the STA-MCA would hold up because her arteries were VERY SMALL - less than 1mm - and it was like "toilet paper thin" (imagine wetting toilet paper..just falls apart)...but he managed to do the bypass and they kept checking over next few days with the doppler (listening for the blood flow)..it never closed up.  A year later  her MRI/MRA shows good blood flow from the bypass...but they couldn't tell about the EMS as really would need the cerebral angiogram to see that and they didn't feel the need to do that yet unless she was getting worse, with problems..etc.      We look forward to hearing your progress up to surgery, pre-op and post op....sending lots of prayers your way.

Tight HUGS,

Carol
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Emily
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Re: "Choosing" the right type of surgery
Reply #10 - Oct 21st, 2005 at 5:07am
 
hey shan. no prob about the questions, i'll try my best to answer them...

No time frame for my second surgery yet, i think that's entirely dependant on the patient, how they recover from the first one and how urgent the second one is. ideally he'd like to give me a STA-MCA for the second one also as that gives the most immediate improvement in blood flow; however, if for example, i don't recover too well from (or my vessels don't "cooperate" well during) the first op, then he'll go for an EDMS for the second one. I may easily recover from a stroke the first time, but a second major stroke could result in permanent damage, etc... That's just an example... Also, right now I need help asap, hence the STA-MCA... if it wasn't so urgent he's probably do the EDMS as it's a less risky procedure.

i was on hepron in hopsital, then switched to asprin and plavix upon discharge. the injections will be because dr laidlaw wants me off plavix asap but with my track record i'll have a stroke pretty darn quickly and it may not be pretty. so (sorry i forget the name) [this drug] must allow my blood to be thin enough to avoid strokes but thick enough to not complicate surgery. i'll get all the details in the next few days so i'll get back to you.

i have to admit i'm quite devastated about my hair.. i have long dreadlocks... which i have been growing to some time and i'm very proud of Sad oh well.. i'll cut them, shave it off and eventually, when this is all over - sew them back on! hehe...

anyway bring on the questions, makes me think about things and keeps me positive also!
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Re: "Choosing" the right type of surgery
Reply #11 - Oct 21st, 2005 at 5:29am
 
Emily....

...the hair part may be hard.  While just line of hair was taken from both of Cara's head...you couldn't tell she had brain surgery 5 days.  But I understand it depends on the types of surgery involved and everyone is different, different arterial network.  You may find you enjoy short hair for change.  Hang in there. Wink..carol
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Shan
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Re: "Choosing" the right type of surgery
Reply #12 - Oct 21st, 2005 at 11:30am
 
Hi Emily,

Thanks for your post.  I too was on heparin pre and post op, then when I was discharged, I was on Plavix and 325 aspirin.  I had a one time 4 1/2 hr nose bleed once, so my neuro switched me to 81 mg aspirin and Aggrenox and stopped the Persantine, but it looks like my current bleeding time is "disturbingly" normal.  As soon as I do my breast biopsy next week Wednesday and pray that surgery is not needed...then my neuro will change my meds to thin my blood further which is definitely needed!  He, as well as my internist are puzzled as to why regular aspirin combined with Aggrenox (also contains aspirin and persantine) isn't thinning my blood the way it should be.  I've also been referred to a hematologist/oncologist which I will be seeing next week Thursday.  If you can, please let me know the name of the shot you'll be giving yourself.  I'd like to ask about it; although, I am a BIG baby when it comes to needles.  Embarrassed

You have long hair? Okay, I'm jealous. Wink  But like I said earlier, don't worry...we know you're just as beautiful on the inside as out!  Smiley

Take care,
Shan
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Re: "Choosing" the right type of surgery
Reply #13 - Oct 31st, 2005 at 1:11am
 
I'm wondering if anyone out there has ever had an indirect bypass that didn't work well -- and then followed it with a direct bypass.  If so, how did things go?  Thanks.
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Re: "Choosing" the right type of surgery
Reply #14 - Oct 31st, 2005 at 1:20pm
 
Hi Patti,

Nice to see you on the board again!  It was great meeting your husband and son in Las Vegas, and we were sorry you couldn't be there.

I'm hoping your post doesn't mean that Michael is having difficulties, but thought I should post some of what I understand about direct and indirect bypasses.

Indirect surgery most likely prohibits a future direct bypass because it sacrifices the superficial temporal artery needed to do a direct bypass.  I've also heard that by virtue of doing the direct bypass, the patient benefits from getting an indirect bypass at the same time.

Keep in mind that I'm just a layperson, and my education about the different types of surgery continues to evolve.  This information should be confirmed by a MM specialist.

Please keep us posted on how things are going with all of you.  You will be in my thoughts and prayers.

Warmly,
Jill

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Emily
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Re: "Choosing" the right type of surgery
Reply #15 - Oct 31st, 2005 at 9:17pm
 
hey shan, the injection is subcutaneous Clexane, got an appointment on thursday to 'learn' how to do it.
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Re: "Choosing" the right type of surgery
Reply #16 - Nov 2nd, 2005 at 7:53am
 
I wonder what their reasoning is for taking you off one anticoagulant "as it is close to surgery" and putting you on another.  Is the Clexane somehow safer for surgery?
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Re: "Choosing" the right type of surgery
Reply #17 - Nov 2nd, 2005 at 8:44am
 
Hi Emily,

Thanks!  

Anyway, to answer pomem's question, I looked up Clexane, and it sounds like you were prescribed since this since "abnormal surgeries may produce a risk of thrombosis" (blood clots).  Your doctor is probably doing this as a precautionary measure, which I think is great.  Smiley I was on heparin about 24 hrs prior to my surgery via IV since I was already admitted to the NICU, I believe for the same reason as you.

"Enoxaparin is given by injection under the skin, and is used to prevent clots forming in the blood. This can occur in various conditions where the normal blood circulation is disturbed. Surgery, particularly abdominal surgery, produces a risk of thrombosis, as does a heart attack and poorly controlled angina (unstable angina). Clots can also occur when people are bed-ridden for long periods of time. Enoxaparin is given to prevent thrombosis in these groups of people."


I give you credit, Emily, for being able to give yourself these injections.  I am just getting use to poking my finger daily to check my glucose levels.  Undecided You would think that after having to have lab tests now once a month, I would be used to it...but I'm a big baby when it comes to needles.  Embarrassed  I know that when it comes down to it, we have to do what we have to do.  Wink

Please know that we're thinking of you.  You've got the right spirit, determination and attitude!....and I have no doubt that you'll do fine.  ;Grin  You also have such a great support system, including us, that is going to be right there with you! Smiley

Take care,
Shan
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Emily
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Re: "Choosing" the right type of surgery
Reply #18 - Nov 2nd, 2005 at 6:22pm
 
thanks shan Smiley
have my app today, still not sure if they're intra-venous or intra-muscular.. i assume the former...

and yeah em i figured it's because it's not actually a blood thinner, just something that prevents clotting.. are they different? is that what your medical-paragraph meant shan?
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Re: "Choosing" the right type of surgery
Reply #19 - Nov 3rd, 2005 at 1:22am
 
Hi Emily,

Actually, I thought that blood thinners were anticoagulants, but now I'm second guessing myself.  Smiley  I know that aspirin has an anticoagulant effect, which means it helps with thinning your blood.  Hmm...I'm pretty sure that anticoagulants and blood thinners were the same thing, but hopefully somebody can let us both know what the correct answer is.  Anybody?  Smiley  I think the difference lies between anticoagulants and antiplatelet therapy/medication.

Take care,
Shan




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Re: "Choosing" the right type of surgery
Reply #20 - Nov 3rd, 2005 at 1:24am
 
Hi Emily,

I couldn't go to bed without trying to find out more info on this subject...so to Google I went...and found this:

What is an anticoagulant?

An anticoagulant is a substance that prevents coagulation; that is, it stops blood from clotting.

What is an anticoagulant medication?

A drug that is used as a "blood-thinner" to prevent the formation of blood clots and to maintain open blood vessels. Anticoagulants have various uses. Some are used for the prophylaxis (prevention) or the treatment of thromboembolic disorders. Thrombi are clots. Emboli are clots that break free, travel through the bloodstream, and lodge therein.

What are antiplatelet agents?

Antiplatelet agents are medications that block the formation of blood clots by preventing the clumping of platelets. There are three types of antiplatelet agents: aspirin, the thienopyridines, and the glycoprotein IIb/IIIa inhibitors. These agents differ in four ways: the way in which they prevent platelets from clumping, their potency (how strongly they prevent clumping), how rapidly they work, and their cost.

How do antiplatelet agents work?

Aspirin

Aspirin prevents blood from clotting by blocking the production of thromboxane A-2, a chemical that platelets produce that causes them to clump. Aspirin’s antiplatelet effect lasts for days while the other NSAIDs’ antiplatelet effects last for only hours.

Thienopyridines

In addition to thromboxane A-2, platelets also produce adenosine diphosphate (ADP). When ADP attaches to receptors on the surface of platelets, the platelets clump. The thienopyridines, for example, ticlopidine (Ticlid) and clopidogrel (Plavix), block the ADP receptor. Blocking the ADP receptor prevents ADP from attaching to the receptor and the platelets from clumping.

Glycoprotein IIB/IIa Inhibitors

The glycoprotein IIb/IIIa inhibitors such as abciximab (Reopro) and eptifibatide (Integrilin) prevent clumping of platelets by inhibiting a different receptor on the surface of platelets, the receptor for glycoprotein IIb/IIIa. The glycoprotein IIb/IIIa inhibitors that are approved by the FDA must be given intravenously.


I found a list of blood thinning medications, and Enoxaparin is included:
http://www.umm.edu/altmed/ConsDrugs/DrugCats/BloodthinningMedications.html[/colo...

So...My guess is that blood thinners and anticoagulants are basically the same thing.  Antiplatelet therapy/medication may have an anticoagulant effect, but aren't necessarily considered anticoagulants.  I could be wrong, as I am not a doctor, but that is what I gathered from what I read.  I will be sure to ask my neuro at my next appt this Saturday...

I hope I didn't confuse you..
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Re: "Choosing" the right type of surgery
Reply #21 - Nov 3rd, 2005 at 1:55am
 
edit: oops forgot to log pomem out and me in (Emily)
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Emily
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Re: "Choosing" the right type of surgery
Reply #22 - Nov 3rd, 2005 at 1:58am
 
[try again!]

yep i'm confused Smiley hehe
but i did have my appointment with the hospital today and found out the following...

both are blood thinners

plavix takes a long time to get out of your system (i am stopping today and it will be out of my system in 2 weeks) - my op is on nov 17 (yes!!! i have a date!!)

clexane moves through your system very quickly, basically within a day. so i have daily injections and on my last day, (wed 16th) it will be out of my system by the time they start operating.

the injections will be done by hospital staff (coming round to my house every day) in my tummy (subcutaneous = fatty bits..... pffff what are they saying! hehe)

there we go.... make some sense?
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Re: "Choosing" the right type of surgery
Reply #23 - Nov 3rd, 2005 at 8:59am
 
Hi Emily,

Sorry for confusing you... You did the best thing...ask your doctor. Wink

Wow! The hospital will be coming to your house to give you the blood thinning injections? Woooo....how convenient!

Wishing you all the best,
Shan
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DJ
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Been there, done that...

Posts: 721
Wichita, KS
Gender: male
Re: "Choosing" the right type of surgery
Reply #24 - Nov 5th, 2005 at 8:41am
 
I've edited my original post in this thread and wanted to make sure the information was seen...

DJ wrote on Oct 19th, 2005 at 8:29pm:
Hi Emily,

I understand how overwhelming all of the information can be when you're first diagnosed, but hang in there!

Choosing which surgery to have is a personal decision based on your research and your individual case.

Basically, the direct bypass (STA-MCA) provides immediate bloodflow around the occlusion and is generally the option prefered for adults.  Generally, adults have arteries large enough for the surgeon to graft together.

Indirect type bypasses (EDAS, EMS) take time to "grow" and provide relief.  Time varies from patient to patient but it could take anywhere from a month to 6 months to a year to see the benefit.  Indirect is generally the option preferred for children because generally, children don't have arteries large enough for the surgeon to work with.  Also, children are able to grow new networks of arteries much faster than adults.

Another important factor to take into consideration is... because of the way the temporal (donor) artery is utilized in the different types of surgeries, additional surgeries may (or may not) not be possible if the initial procedure doesn't work for some reason.

Example: Generally, if an in direct type surgery doesn't work, there is a very good chance you will not be able to go back and have a direct type surgery performed afterwards.  This factor is especially important for adults.


You'll notice I italicized generally in the statements above because every case is different.  As Shan suggested, it's best to get an opinion from someone who deals with MM on a regular basis to help you decide which option is best for your individual case.

This probably doesn't answer any questions for you either, but I hope it give you more information to help you make a decision for your case.

Hang in there!  If there is anything else or any other questions we can give you some opinions on, please don't hesitate to let us know!

Smiley

DJ

[Nov 5, 2005 edit in blue]

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Adversity does not build character... it reveals it...  I help my neighbor and my neighbor helps someone else. Life is a wonderful circle!
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