Vertebral artery transposition for revascularization of the posterior circulation: a critical assessment of temporary and permanent complications and outcomes

Abstract

P osterior circulation infarction accounts for 25%-30% of all ischemic infarcts.3 After the carotid bifurcation, the proximal vertebral artery (VA) is the most common site of stenosis of the feeding vessels to the brain. 15 Unlike the carotid bifurcation, stenosis of the proximal VA that exceeds 30% is significantly associated with infarction in the posterior circulation 21 and large-vessel occlusive disease is implicated in 14%-32% of infarctions in the posterior circulation. 3,4 Unlike the carotid circulation, for which the natural history of stenosis is well understood, the natural history of vertebrobasilar insufficiency is less well known. Furthermore, the effect of novel agents, including antiplatelet agents and statins, on altering the natural history of these lesions is less well studied. Recent attempts at the use of stenting and/or angioplasty for these lesions has produced mixed results 1,8,26,27 and significant rates of restenosis, ranging from 11% for drug-eluting stents to more than 30% for bare-metal stents.Microsurgical revascularization of the proximal VA has been well described, but the majority of published series included small patient populations and short follow-up ObJect Despite advances in medical management and endovascular therapies, including the introduction of statins, antiplatelet agents, and drug-eluting stents, some patients experience medically refractory vertebrobasilar insufficiency and may benefit from robust surgical revascularization. The aim of this study was to evaluate such patients after surgical revascularization, emphasizing long-term outcomes and rates of complications. MethODS The authors retrospectively identified 22 patients (5 women and 17 men) whose mean age was 69.1 years (range 48-81 years) who underwent revascularization of the posterior circulation via a proximal vertebral artery-carotid artery transposition between 2005 and 2013. The patients' conditions before surgery were clinically summarized, and long-term outcomes and complication rates after surgery were evaluated. reSultS All the patients were symptomatic before surgery although they received the best medical therapy as defined by their primary care physician. Presenting symptoms consisted of stroke, transient ischemic attacks (TIAs), and/or findings attributable to posterior circulation hypoperfusion. There were no deaths associated with revascularization surgery. The postoperative complication rate was 45.5%, which included 3 cases of recurrent laryngeal nerve palsy, 1 case of thoracic duct injury, 2 cases of TIA, and 4 cases of Horner's syndrome. The thoracic duct injury was identified intraoperatively and ligated without sequelae, all the TIAs resolved within 24 hours of surgery, all 4 sympathetic plexus injuries resolved, and all but 1 of the recurrent laryngeal nerve palsies resolved, resulting in a 4.5% complication rate in a mean follow-up period of 8.8 months. All the patients had resolution of their presenting symptoms, and a single patient had symptomatic restenosis that required stenting a...

Simultaneous reconstruction of the carotid and vertebral arteries using a temporary intraluminal shunt (a clinical case)

“…[6], подключично-сонное шунтирование у больных с мультифокальным атеросклерозом в 18% случаев дополнялось одномоментной КЭА на той же стороне. Случаи одномоментной транспозиции ПА в ОСА и КЭА на ипсилатеральной стороне также встречались в публикациях, однако во всех случаях они выполнялись без использования временного внутрипросветного шунта [7]. Причиной был тщательный предоперационный отбор пациентов для подобных вмешательств, при котором наличие разомкнутого артериального круга большого мозга являлось противопоказанием к транспозиции в ОСА.…”

“…Причиной был тщательный предоперационный отбор пациентов для подобных вмешательств, при котором наличие разомкнутого артериального круга большого мозга являлось противопоказанием к транспозиции в ОСА. У таких пациентов предпочтение отдавалось анатомическим реконструкциям ПА в виде эндартерэктомии из ее устья, а также транспозиции ПА в подключичную артерию или щитошейный ствол, что позволяло избежать временного пережатия ОСА и связанных с этим ишемических осложнений [7].…”

Experience with vertebral artery origin stenting and ostium dilatation: results of treatment and clinical outcomes

“…In patients with a posterior circulation stroke/TIA, the risk of recurrent stroke is about 30.5% in patients with stenosis of at least 50% in comparison with individuals without stenosis (8.9%) 16. Even though there are still some indications for VA to common carotid artery transposition,2 9 most patients with VAO stenosis are treated with endovascular approaches. At our center, these patients are offered endovascular treatment with VA origin angioplasty and stenting.…”

“…Unlike stenosis of the carotid bifurcation, stenosis of the proximal vertebral artery (VA) that is >30% is significantly associated with infarction in the posterior circulation 1 2. Approximately 20% of patients with vertebrobasilar ischemia may have severely occlusive lesions (≥50% stenosis) at or near the origin of the VAs 3–6.…”

“…Even though some indications exist for open vascular management of VAO stenosis (eg, VA to common carotid artery transposition), the majority of patients with symptomatic VAO stenosis are treated with endovascular technology to prevent secondary strokes 2 9. Endovascular stenting and/or angioplasty procedures for these lesions have produced mixed results with different rates of restenosis, ranging from 11% for drug-eluting stents (DES) to >30% for bare-metal stents (BMS) 10–13.…”