- The EC/IC bypass, pioneered by Donaghy and Yasargil in 1967, plummeted in popularity after publication of the international cooperative EC/IC bypass study in 1985.
- The EC/IC trial randomized 1377 patients with symptomatic ICA or MCA stenosis to either STA-MCA bypass or medical therapy with ASA.
- Despite a graft patency rate of 96%, surgical patients suffered more and earlier fatal and nonfatal strokes.
- Ischemia secondary to thromboembolic events would not be expected to improve with flow augmentation, and inclusion of such patients in the surgical arm could therefore artificially lower the apparent efficacy of the procedure.
- Patients with severe MCA stenosis and those with persistent symptoms following ICA occlusion fared especially worse with bypass.
- Critique:
- Inclusion criteria failed to distinguish between hemodynamic vs. thromboembolic causes of stroke.
- Only half of the patients received antiplatelet agents at entry into study
- No evaluation preop for cerebrovascular hemodynamic status..
- Randomization-to-treatment bias could have occurred
- No angiographic determinants for entry.
- A large percentage of patients had no symptoms between the angiographic demonstration of ICA occlusion and randomization.
- Large number of patients underwent surgery outside the study.
- A high percentage of patients had tandem lesions
Both the patient and the therapist were not blinded
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