Occipital artery to extracranial vertebral artery anastomosis for bilateral vertebral artery stenosis at the origin: A case report
- Department of Neurosurgery, Suwa Red Cross Hospital, Kogandori, Suwa, Nagano, Japan
Department of Neurosurgery, Suwa Red Cross Hospital, Kogandori, Suwa, Nagano, Japan
DOI:10.4103/sni.sni_20_18Copyright: © 2018 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Masahito Katsuki, Yasunaga Yamamoto, Naomichi Wada, Yukinari Kakizawa. Occipital artery to extracranial vertebral artery anastomosis for bilateral vertebral artery stenosis at the origin: A case report. 16-Apr-2018;9:82
How to cite this URL: Masahito Katsuki, Yasunaga Yamamoto, Naomichi Wada, Yukinari Kakizawa. Occipital artery to extracranial vertebral artery anastomosis for bilateral vertebral artery stenosis at the origin: A case report. 16-Apr-2018;9:82. Available from: http://surgicalneurologyint.com/?post_type=surgicalint_articles&p=8846
Background:Revascularization of posterior circulation is essential in patients with severe bilateral vertebral artery (VA) stenosis despite administering maximal medical treatment, due to the high mortality of posterior circulation stroke.
Case Description:We present a 69-year-old man with bilateral severe VA stenosis at the origins, treated with occipital artery (OA)-distal VA anastomosis.
Conclusion:Endovascular treatment and other surgical treatments, such as bypass grafting, are effective, but OA-VA anastomosis is a safe and effective procedure for revascularization of the posterior circulation.
Keywords: Arterial reconstruction, occipital artery-vertebral artery transposition, vertebral artery stenosis, vertebrobasilar insufficiency
Bilateral vertebral artery (VA) stenosis can cause posterior circulatory insufficiency when the posterior communicating artery or other collaterals are poorly developed. The proximal portion, especially the origin, of the VA is the most common location (92%) of atherosclerotic occlusive disease in VA.[
A 69-year-old man was admitted to our hospital because of bilateral ataxia and dizziness. He had not been taking any medications and had been smoking 40 cigarettes per day for 49 years. Laboratory tests revealed mild dyslipidemia and impaired glucose tolerance. Blood pressure on admission was 188/92 mmHg. Magnetic resonance imaging (MRI) showed acute brain infarction at the bilateral cerebellar hemispheres and the right thalamus. The lesions in the cerebellum were not perfectly consistent with vessel-dominant regions supplied by the anterior inferior cerebellar artery or posterior inferior cerebellar artery. Head magnetic resonance angiography (MRA) showed bilateral VAs but posterior communicating arteries were not observed bilaterally. Neck MRA indicated right VA but did not show left VA [
Diffusion weighted magnetic resonance imaging showed acute brain infarction at the bilateral cerebellar hemispheres and the right thalamus (a). Head MRA showed the bilateral VAs but posterior communicating arteries were not observed bilaterally (b). Neck MRA indicated the right VA but not the left VA (c)
Posterior view of contrast-enhanced 3D-CTA before the operation (left) showed right VA severe stenosis at the origin (asterisk) and did not show the left VA from the ostia to the lower edge of the second cervical vertebra (white arrowheads). Whereas, 3D-CTA just after the operation (right) showed that the anastomosis was patent (white arrow) and the left VA was shown from the ostia to the union (black arrowheads)
We planned surgical reconstruction of posterior circulation in order to avoid fatal brain infarction due to posterior circulatory insufficiency, which is related to high morbidity and mortality. In terms of preoperative neurological symptoms, the muscle tones of extremities were intact. The gait on a flat surface was normal without assistance, but the tandem gait was unsteady when attempting to touch the heel of the right foot to the toe of the left foot. Mild dysmetria was seen when finger–nose–finger test was performed with the left forearm. He felt a difficulty to use his left hand as a subjective symptom. Dysarthria was mild to moderate with some slurring of speech so that we asked the patient to repeat sometimes.
We performed left OA to left distal extracranial VA anastomosis 3 months after the first admission avoiding hemorrhagic infarction [
Intraoperative findings of left OA to left extracranial VA anastomosis. After dissecting the OA and the VA (a), the OA was mobilized and anastomosed end-to-side to the VA (b). The VA was observed in the occipito-atlantal (C0-C1) level within the suboccipital triangle bounded by the rectus capitis posterior major muscle, obliquus capitis superior muscle, and obliquus capitis inferior muscle [
On the day following the operation, the patient walked without assistance but watching and the bilateral ataxia improved. 3D-CTA just after the operation showed that the anastomosis was patent, and the left VA was observed from the ostia to the union [
Posterior circulatory insufficiency carries risks of severe morbidity and mortality. Up to 25% of transient ischemic attacks (TIAs) and strokes are associated with posterior circulation, and patients with symptomatic VA stenosis have a 30–35% risk of stroke over 5 years and a 5–11% combined risk of stroke and death at 1 year.[
Open surgery and/or endovascular treatment are planned to revascularize VA. In terms of endovascular treatment, previous randomized controlled trials (RCTs), such as The Vertebral Artery Stenting Trial (VAST)[
In addition, the rates of perioperative stroke and death are comparable for open versus endovascular approaches. The main difference between surgical and endovascular treatment is durability. The perioperative stroke rates of open surgery and endovascular treatment are almost the same (0–4%). However, the patency rate and stroke-free rate of open surgery are both 90% at 10 years.[
Furthermore, in particular cases with severe VA stenosis, it has been reported that hybrid operations combining surgical manipulation of the proximal VA and endovascular techniques can be safe and effective.[
On the contrary, open surgery largely consists of two procedures: bypass grafting and transposition. Bypass grafting involves carotid bypass to the VA from the ostia to the transverse foramen of C6 (V1) or V3, or subclavian bypass to the V1, with vein grafting. Transposition involves anastomosing VA to ICA, the external carotid artery (ECA), or OA to VA, or VA to the subclavian artery.[
To our knowledge, there have been only 19 previous case reports of OA-VA transposition, as performed in our case. These previous reports indicated good patency and no complications of OA-VA transposition [
In our case, we chose OA-VA anastomosis instead of bypass grafting, VA-subclavian transposition, or endovascular treatment. Bypass grafting requires temporary occlusion of the ICA or common carotid artery (CCA), which markedly reduces cerebral blood flow, and therefore the operation must be performed quickly. Although blood flow in the ICA or CCA can be maintained using an internal shunt tube or partial vessel occlusion with a curved clip, the possibility of blood flow decrease is not zero. Furthermore, bypass grafting requires invasive and complicated procedures, such as wide skin incision, harvesting of the venous graft, two anastomoses, and multiple temporary clipping and occlusion procedures.
VA-subclavian transposition can improve the VA stenosis and was recommended by Ogawa[
Endovascular treatment also requires transient occlusion, so endovascular angioplasty for the right VA is unsafe for the same reason, and angioplasty itself can cause strokes due to embolization of debris despite using an embolic protection device, such as a filter. Endovascular angioplasty for the left VA is also difficult because insertion of the guidewire cannot be performed easily due to near occlusion of the left VA.
Based on the points discussed earlier, we performed left OA-VA anastomosis. Of course, it required temporary occlusion of the left VA. However, the left VA was almost occluded prior to surgery and the right VA could maintain its flow during temporary left VA occlusion. Therefore, OA-VA anastomosis was a safe procedure in this case [
The surgical strategy in this case. Schema of arteries in this case (a). The VA is divided into four segments: V1, origin to transverse foramen of C6; V2, from the transverse foramen of C6 to the transverse foramen of C2; V3, from C2 to the dura; V4, from the dura to their union to form the basilar artery. In our case, the right VA was the solitary feeding artery for the brainstem, so it was difficult to perform procedures requiring temporary occlusion of the right VA, such as anastomosing the right VA to the subclavian artery and endovascular angioplasty for the right VA. In addition, the left VA showed severe stenosis, so anastomosing the left VA to the subclavian artery and endovascular angioplasty for the left VA had no guarantee of success (b). On the contrary, left occipital artery-VA anastomosis was safe. Of course, it required temporary occlusion of the left VA. However, the left VA was almost occluded prior to surgery and the right VA was able to maintain its flow during temporary left VA occlusion (c)
Furthermore, when transposition of V1 to the subclavian artery is needed as a radical operation or two-stage operation, OA-VA anastomosis before V1-subclavian transposition can maintain flow of the VA for the brainstem via anastomosis at V3 during V1-subclavian transposition with temporary occlusion of the proximal VA. Therefore, OA-VA anastomosis can be a safe procedure and lead to radical operation.
OA to distal extracranial VA anastomosis is a good candidate for symptomatic bilateral severe VA stenosis at the origin and can be performed more safely and more easily than bypass grafting and endovascular treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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