Subclavian-to-Extracranial Vertebral Artery Bypass in a Patient With Vertebrobasilar Insufficiency: 3-Dimensional Operative Video.

Abstract

Hemodynamic insufficiency from extracranial vertebral artery (VA) stenosis may be a primary cause for transient ischemic attacks in patients with vertebrobasilar insufficiency (VBI). Recent literature supports open or endovascular revascularization in selected patients. Although traditionally carotid-to-VA bypass was used to augment flow and alleviate symptoms of VBI, a subclavian artery (SA)-to-VA bypass avoids the risk of ischemic injury of the anterior intracranial circulation. We describe a SA-to-extracranial VA bypass in a 53-yr-old woman who presented with vertigo, dizziness, and syncope exacerbated by neck movements. An angiogram demonstrated complete bilateral proximal VA occlusions. The patient had collateral flow distally from muscular branches off the thyrocervical trunk and minimal flow through the anterior circulation. Neck movements appeared to reduce flow from the muscular branches, producing symptoms. Given the patient's symptoms, the radiographic findings, and the unsuitability of an endovascular procedure to augment flow, a left VA revascularization procedure was planned (either VA could have been the recipient for revascularization). Using an interposition saphenous vein (SV) graft (harvested by the cardiac surgical team), we augmented the posterior circulation with a left SA-to–VA (V3 segment) vascular bypass. The thyrocervical trunk was used as donor vessel because its caliber matches the SV graft and V3 segment. The horizontal part of the V3 segment was isolated in the J-groove of the C1 arch. Microsurgical end-to-end thyrocervical trunk-to-SV and end-to-side SV-to-VA anastomoses were performed, and flow was confirmed. Postoperative angiography showed patent flow through the graft and improved posterior circulation, with symptomatic improvement continuing at 6-mo follow-up. This report is exempt from informed consent. Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/opx130 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Subclavian-to-Extracranial Vertebral Artery Bypass in a Patient With Vertebrobasilar Insufficiency: 3-Dimensional Operative Video","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_r8guqjyl"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Disclosures Dr Taussky is a consultant for Covidien/ev3/Medtronic, unrelated to this work. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.