Cervical Vertebral Artery Rerouting

Abstract

The endovascular treatment of intracranial aneurysms can be hampered by the tortuosity of extracranial vessels. Percutaneous or surgical vessel puncture can resolve the problem of inaccessibility. We describe rerouting of a kinked vertebral artery (VA) to restore transfemoral endovascular access to an aneurysm. A 63-year-old woman presented with progressive hemiparesis. Magnetic resonance imaging demonstrated a left fusiform vertebrobasilar aneurysm with mass effect on the brainstem. The patient was found to have a dominant left VA on angiography with a severe kink in its V1 segment. Tight loops of this segment prevented catheter progression past V1 during endovascular treatment. The left VA was rerouted from its subclavian origin to the C5 transverse foramen through a combined lateral and supraclavicular approach. Release of the VA off the C6 transverse process and C6 and C7 cranial nerve roots permitted unfolding of the VA. The excess length of the VA, initially present between the subclavian artery and the C6 transverse process, was spread over a longer distance. The tight angles present preoperatively were converted into a harmonious curvature. The rerouted VA was attached to surrounding soft tissue to maintain its position. The patient's postoperative course was uneventful. Endovascular treatment of the aneurysm was performed 15 days later. The VA rerouting technique can be used successfully in patients in whom tight loops in the VA prevent endovascular access to intracranial vessels.