Abstract
Moyamoya disease is a progressive steno-occlusive vasculopathy affecting the intracranial internal carotid arteries and posing significant perioperative challenges during cardiac surgery. We present a 54-year-old male with bilateral carotid artery occlusion who had previously undergone left-sided encephaloduroarteriosynangiosis (EDAS), with angiography confirming robust collateral formation from the superficial temporal to middle cerebral artery territory. Three years later, he developed severe multivessel coronary artery disease requiring surgical revascularization. Coronary artery bypass grafting (CABG) was performed using a pump-assisted beating-heart technique without aortic cross-clamping due to heavy ascending aortic calcification. Intraoperative neuroprotection included near-infrared spectroscopy monitoring, controlled PaCO2, hematocrit and blood pressure maintenance, mild hypothermia, and avoidance of vasoconstrictors. The patient recovered uneventfully and was discharged without neurological deficits on postoperative day 10. Importantly, unlike previous Moyamoya cases undergoing CABG, this report describes one of the very few documented instances performed after EDAS. The presence of established indirect collaterals likely contributed to a favourable neurological outcome, underscoring that staged revascularization may confer significant neuroprotection and should be considered in preoperative planning for selected Moyamoya patients.