Transposition Of Vertebral Artery Research Articles

Vertebral Artery Mobilization During Transcondylar Extreme Far Lateral Approach for Excision of Large Foramen Magnum Meningioma: 2-Dimensional Operative Video.

Foramen magnum meningiomas are challenging lesions owing to their proximity to the lower brainstem, vertebrobasilar system, and lower cranial nerves.1,2 Tumor size, origin, morphology, relationship to neurovascular structures, and bony anatomy determine the optimal surgical approach.2,3 Classically, far lateral approaches have been the workhorse approach to the foramen magnum. Variations of the far lateral including transcondylar and extended transcondylar (paracondylar), with or without transposition of the vertebral artery, are sometimes used for a more lateral approach to the brainstem and clivus. Here, we present a 60-year-old male patient presenting with a large foramen magnum meningioma. Preoperative workup includes computed tomography and MRI with angiography to assess for posterior circulation dominance, anatomic variants including posterior inferior cerebellar artery origin, venous, and bony anatomy.1,4 An extreme far lateral provides access anterior to the vertebral artery to extend exposure beyond the standard far lateral approach. This comprised transcondylar drilling, bony mobilization of the V3 Vertebral artery from C1 foramen transversarium, and dural mobilization of vertebral artery with a dural cuff at its site of dural entry. The patient tolerated the procedure, gross total resection was achieved, and the patient was discharged home. This video demonstrates in detail the steps of exposure, condylar drilling, vertebral artery transposition, and dural opening. These maneuvers can be difficult to conceptualize yet are key to successful extended transcondylar exposure. The patient gave informed consent for surgery and video recording. Institutional Review Board approval was deemed unnecessary.

Cervical Giant Cell Tumor Removal With an Anterolateral Approach With Vertebral Artery Transposition: 2-Dimensional Operative Video.

Cervical Giant Cell Tumor Removal With an Anterolateral Approach With Vertebral Artery Transposition: 2-Dimensional Operative Video.

Chyle leak after transposition of the aberrant left vertebral artery via 1-debranching thoracic endovascular aortic repair: a case report

BackgroundAlthough the transposition of the aberrant left vertebral artery (ALVA) in 1-debranching thoracic endovascular aortic repair requiring zone 2 coverage for thoracic aneurysm with ALVA is reported to be an effective option, there are few reports of complications associated with the transposition of the ALVA.Case presentationAn 87-year-old man underwent 1-debranching thoracic endovascular repair for a saccular thoracic aortic aneurysm with the aberrant left vertebral artery. Simultaneously, the transposition of the ALVA was performed to prevent cerebral complications because the left vertebral artery was dominant. Postoperative computed tomography revealed the reconstructed vertebral artery and no endoleak. However, a postoperative chyle leak occurred and was treated with lymphangiography.ConclusionAlthough the ALVA transposition is one of the better options, a chyle leak should be considered a serious complication of the procedure.

Vertebral Artery Transposition and Dural Ring Reconstruction: A New Treatment Modality for Cervical Spinal Cord Compression Resulting From Aberrant Vertebral Arteries.

Two of three patients who were consecutively treated within the past 7 years using traditional methods in our center presented with recurrence and even aggravation during follow-up. Therefore, a new approach was developed to treat a recent patient to provide for complete decompression of the spinal cord. To illustrate a new treatment modality for patients with cervical spinal cord compression resulting from aberrant vertebral arteries. The aberrant vertebral arteries were freed after substantial dissection of their dural rings. The compression was released after moving the aberrant vertebral arteries, which were sutured to the lateral mass to the extradural space. New dural rings above the atlas were created to allow the vertebral artery to enter the dura mater into a wider subdural space. The patient experienced full relief from her initial complaints except for mild numbness of the bilateral lower extremities immediately after surgery. Postoperative imaging studies indicated successful transposition of bilateral aberrant vertebral arteries and significant decompression of the spinal cord. Her symptoms did not recur over a 6-month follow-up period. Imaging studies at the 6-month follow-up showed stable vertebral artery transposition and spinal cord decompression. A patient with cervical spinal cord compression resulting from aberrant vertebral arteries was successfully treated by our new technique, which includes vertebral artery transposition, fixation, and dural ring reconstruction. Our approach could be an alternative for durable spinal cord decompression in such patients.

Foramen Magnum Meningioma-The Attainment of the Intra-Arachnoidal Dissection: 2-Dimensional Operative Video.

Ventral foramen magnum meningiomas are a forbidding lesion. The stake is so high with a risk of devastating paralysis and respiratory failure. Careful preoperative clinical and radiological evaluation is necessary to implement the best treatment plan. Successful surgical intervention depends on paying high attention to minute details throughout the case, from intratracheal intubation to extubation. The neural head-on-neck position is critical to avoid further medullary compression at intubation and positioning.1 Extensive neurophysiological monitoring, including somatosensory, motor, brainstem evoked potential, and cranial nerves, during the positioning and throughout the case, is extremely helpful to detect early signs of dysfunction.1 To expose and access ventral tumors, partial condyle resection and vertebral artery transposition are invaluable techniques.2,3 Preservation and minute manipulation of the vital neurovascular structures at this junction that includes the medullar, anterior spinal artery, posterior inferior cerebellar artery, vertebral junction perforators, and lower cranial nerves are essential for good outcomes. This is achieved by microsurgical intra-arachnoidal dissection under high magnification and after debulking the tumor to establish that plane.1,3,4 The demonstration of this technique is the purpose of this article. We demonstrate these surgical tenets applied to the resection of a large ventral foramen magnum meningioma extending from the midclivus to the C3 vertebral body level in a 54-yr-old female presenting with swallowing difficulties. The patient consented to the surgical intervention and the publication of her images. Image at 1:38 reprinted with permission from Al-Mefty O, Operative Atlas of Meningiomas. Vol 1, © LWW, 1998.

Letter to the Editor: The Trend of “Neurosurgery Interested” Among Omani Medical Students and Interns Despite the Absence of a Neurosurgery Residency Program: Does This Indicate It's Time to Change?

The extreme lateral infrajugular transcondylar-transtubercular exposure (ELITE) is a surgical approach developed in the late 1980s by Prof. T. Fukushima and represents the dorsolateral inferior skull base procedure of choice to approach lesion located ventrolaterally at the level of the craniocervical junction (CCJ). This approach consist in a suboccipital craniotomy/craniectomy with partial condylectomy and jugular tubercule drilling that can be extended providing for subtotal condylectomy and vertebral artery transposition. The “limited” variation of the ELITE approach consist in a lateral suboccipital craniectomy opening the foramen magnum and removal of at least half of the posterior arch of the atlas without condyle drilling. This surgical technique was recently demonstrated to be particularly suitable for the surgical management of spinal tumor located ventrolaterally in the upper cervical spine. This operative video illustrates step-by-step the surgical technique adopted for the microsurgical resection of a C1-C2 intradural schwannoma located antero-laterally (Video 1). ELITE approach offers a wide and adequate exposure and access to the CCJ, allowing direct visualization and access to the tumor with minimal neural manipulations, early detection of the vertebral artery and, for tumor located at C1-C2 level, without drilling the occipital condyle. In our experience, ELITE procedure is the preferred surgical approach for resection of tumors located ventrally or ventrolaterally to the first 2 cervical levels.

Left Vertebral to Carotid Artery Transposition

Our video demonstrates the technique of carotid to carotid and subclavian to carotid bypass with vertebral artery transposition. It also highlights the importance of transcranial Doppler monitoring during the procedure. Transcranial Doppler monitoring highlights the change in blood flow to the cerebral vasculature, in particular, that of the middle cerebral artery when the carotid artery was clamped.

Microvascular Decompression using Muscle Graft for Vertebral Artery Medullary Compression Syndrome


 It is well known that brainstem dysfunction may be caused by vascular compression of the medulla oblongata. However, only a limited number of reports have found microvascular decompression surgery to be an effective treatment for symptomatic patients with medulla oblongata dysfunction.
 This report describes a patient with vertebral artery compression of lateral medulla oblongata who presented with lateral medullary syndrome. Microvascular decompression surgery using the transcondylar fossa approach was effective in relieving patient symptoms.
 The transcondylar fossa approach and the transposition of vertebral artery along with autologous muscle graft interposition technique is appropriate in microvascular decompression surgery to relieve vertebral artery compression of medulla oblongata.
 

Far lateral approach without occipital condylar resection for intradural ventral/ventrolateral foramen magnum tumors and aneurysms of V4 segment of vertebral artery: Review of surgical results

BackgroundControversies exist regarding the need and extent of condylar resection for safe surgical management of intradural ventral/ventrolateral foramen magnum (VFM) tumors and aneurysms of V4 segment of vertebral artery (VA) by far lateral approach. This retrospective study was conducted to evaluate the results of basic far lateral approach(retrocondylar approach) without upfront occipital condylar resection. Methods and ResultsTwenty one patients underwent surgery via far lateral approach for intradural VFM tumors and aneurysms of V4 segment of VA at Sri Sathya Sai Institute of Higher Medical Sciences during 9 years(2008–2016) study period. Eight patients had VA aneurysms and 13 patients had intradural VFM tumors. After basic far lateral approach(retrocondylar approach), dura was opened and checked if the exposure was adequate for safe surgery. Retrocondylar approach provided adequate exposure for all these lesions and resection of occipital condyle/jugular tubercle was not required in any of these cases. Skeletonization or transposition of VA was not done in any of these cases. Gross total resection of the tumor could be done in 9 patients(9/13–69.2 %) and near total excision (>95 %) in 4 patients (4/13–30.8 %). Seven of the 8 VA aneurysms were successfully clipped. Outcome at a final follow up of 3 months or more was good(mRS<2) in 19 patients(19/21–90.5 %) and poor in 2 patients. Complications included lower cranial nerve deficits [transient-2/21(9.5 %), persisting-2/21(9.5 %)], motor deficits(2/21−9.5%), seventh nerve paresis(1/21−4.8%), sixth nerve paresis(2/21−9.5%) and pseudomeningocele(1/21−4.8%). ConclusionBasic far lateral (retrocondylar) approach provides excellent exposure for majority of VFM tumors and aneurysms of V4 segment of VA. Condylar resection(transcondylar approach), drilling of jugular tubercle (transtubercular approach), skeletonization/transposition of VA might not be required for safe surgical management of majority of these lesions.

Surgical Treatment of Vertebral Artery Stenosis: An Overlooked Surgery with Low Morbidity

Vertebral artery (VA) stenosis as a cause of ischemic events and its surgical treatment is an overlooked subject. After reporting our initial results, the results of VA stenosis operations and the follow-up studies are analyzed. This retrospective, single-center study includes 43 symptomatic proximal VA stenosis patients between September 2012 and March 2019. The demographics and clinical data were obtained from the hospital records. Doppler ultrasonography and computed tomography angiography were used to establish the diagnosis and for follow-up. The surgical procedures were as follows: VA transposition in 30 (69.8%), VA bypass 8 (18.6%), saphenous vein interposition in VA in 4 (9.3%), and decompression of kinking in 1 (2.3%) patient. Eleven patients (25.5%) had concomitant carotid surgery. The Kaplan-Meier method was used to calculate the survival and patency rates. Most common symptoms were vertigo and loss of balance in 38 (88.4%) and 14 (32.6%) patients, respectively. Twenty-five patients were males (58.1%), and the average age was 64.6±9.8 (50-90) years. The 30-day death, 30-day stroke, and 30-day death/stroke rates were 2.3%, 4.7%, and 7%, respectively. Ten patients (23.3%) had morbidities which were related to the intervention. Horner syndrome was found in 5 (11.6%) patients, and facial nerve injury was found in one (2.3%) patient. Three (7.1%) patients died during the follow-up period, and overall survival of the patients at 3years was 91.4%±5.8%. Two (4.7%) patients had cerebrovascular events (CVEs) occurred during the follow-up. One- and three-year CVE-free survivals were 97.1%±2.9% and 90.1%±7.2%, respectively. Two patients (5.4%) had restenosis. One- and three-year patency of VA after procedure was 89.1%±7.4%. Thirty-seven (86%) patients had complete recovery of symptoms after surgery; 5 patients (11.6%) kept their preoperative symptoms in different levels. Vertebral artery surgery can be performed with acceptable mortality and morbidity rates. Restenosis-free, CVE-free, and overall survival rates are satisfactory.

Applicability of a standardized thoracic endograft with a single branch for the left subclavian artery to treat aortic disease involving the distal arch

ObjectiveCoverage of the left subclavian artery (LSA) origin during thoracic endovascular aortic repair (TEVAR) is associated with increased neurologic complications. Our group is involved in the development of an off-the-shelf (OTS) thoracic endograft incorporating a left common carotid artery (LCCA) scallop and a retrograde inner branch for LSA perfusion. This study aimed to evaluate the arch morphology of patients treated by TEVAR and requiring LSA coverage to determine the applicability of this OTS device. MethodsThe preoperative anatomy of consecutive patients from three separate cohorts treated with TEVAR with LSA coverage was studied. High-quality preoperative computed tomography angiography images were analyzed on an imaging workstation. Location of the origin of the supra-aortic trunks and their anatomic relationship were depicted in all patients; the LCCA origin was set as reference point. We determined the proportion of arch morphology in our cohort of patients eligible for this OTS device configuration. ResultsThere were 196 patients included in this study, 132 in the dissection cohort and 64 in the aneurysm cohort. The median length from the lower margin of the LCCA to the proximal aspect of the pathologic process was 25.0 mm (18.2-35.2 mm), with 68.4% (n = 134) of our cohort presenting with a proximal sealing zone length >20 mm. The median LCCA-LSA distance was 20.8 mm (16.6-25.4 mm). The median clock position of the LSA from the LCCA was −10 minutes (−30 to 0 minutes). In total, 127 patients (64.8%) could have been treated with the current OTS branched TEVAR configuration; 59 were excluded for proximal neck length distal to the LCCA <20 mm and 10 because of the clock position of the LCCA, and 9 first required a vertebral artery transposition. ConclusionsThe low variability of LSA and LCCA locations in patients with distal aortic arch disease offers wide applicability of a new standardized thoracic branched endograft.

Resection of a Meningioma at Craniocervical Junction through Far Lateral Approach: Two-Dimensional Operative Video.

Tumors located in the craniocervical junction region are significantly challenging for surgical resection. We shared our experience of a meningioma at craniocervical junction resected through far lateral approach in a 68-year-old female. The patient presented with intermittent headache with discomfort in the neck and shoulders for 3 years without any positive signs. Magnetic resonance imaging (MRI) revealed a tumor of 3.6 cm × 3.0 cm × 2.5 cm lying at the ventral side of medulla oblongata, with T1 hypointensity, T2 hyperintensity, and a significant enhancement on T1-contrast image. The far lateral approach on the right side was planned to resect the tumor with a park-bench position. The patient underwent a standard craniotomy using a lazy S -shaped incision. The transposition of vertebral artery was performed carefully therein, followed by removal of part of the arches of atlas and axis. After exposure of the tumor, vertebral artery (VA) and posterior inferior cerebellar artery (PICA) adhesive to the lesion could be seen operatively. Truncating the supplying blood vessels of the tumor was taken as the first step, followed by resecting the tumor mass in a piecemeal manner. While preserving VA, PICA, posterior nerves, medulla oblongata, and cervical cord, gross-total resection was achieved under the careful operation. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as a meningioma (World Health Organization [WHO] grade I). Postoperative MRI scan depicted complete resection of the tumor. The patient remained symptom free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient. The link to the video can be found at: https://youtu.be/i9H-wS4fF10 .

Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch

ObjectivesThe aim of this study was to present our experience with the management of isolated left vertebral artery during hybrid aortic arch repairs with thoracic endovascular aortic repair completion. MethodsThis is a single-center, observational, cohort study. Between January 2007 and December 2018, 9 patients (4.5%) of 200 who underwent thoracic endovascular aortic repair were identified with isolated left vertebral artery. The isolated left vertebral artery was the dominant vertebral artery in 4 cases and entered the Circle of Willis to form the basilar artery in all cases. Isolated left vertebral artery transposition was performed in 2 patients during open ascending/arch repair before thoracic endovascular aortic repair completion. In 4 patients, isolated left vertebral artery transposition was performed concomitant with carotid-subclavian bypass during thoracic endovascular aortic repair completion (“zone 2” thoracic endovascular aortic repair). Primary outcomes were early (<30 days) and late survival, freedom from aortic-related mortality, and isolated left vertebral artery patency. ResultsPrimary technical success was achieved in all cases. Isolated left vertebral artery–related complication occurred in 1 patient (Horner syndrome). Immediate thrombosis, vagus/recurrent laryngeal nerve palsy, lymphocele, and chylothorax were never observed. Postoperative cerebrovascular accident or spinal cord injury was not observed. Median follow-up was 15 months (range, 3-72). We did not observe aortic-related mortality during the follow-up. Aortic-related intervention was never required. Both isolated left vertebral artery and carotid-subclavian bypass are still patent in all patients with no sign of anastomotic pseudoaneurysm or stenosis. ConclusionsAlthough isolated left vertebral artery is not a frequent occurrence, it is not so rare. It may pose additional difficulties during hybrid aortic arch surgical repairs, but isolated left vertebral artery transposition was feasible, safe, and a durable reconstruction.

Debranching TEVAR with Left Vertebral Artery Transposition for Aortic Arch Aneurysm with Metal Allergy

Debranching TEVAR with Left Vertebral Artery Transposition for Aortic Arch Aneurysm with Metal Allergy

Supraclavicular transposition of aberrant left vertebral artery for hybrid treatment of aortic arch aneurysm: a case report

BackgroundVertebral artery variations are common in thoracic aortic patients. If patients have the aberrant left vertebral artery, the more difficult to determine the treatment modality.Case presentationWe report the case of a 63-year-old man with an aberrant left vertebral artery originating from an aneurysmal aortic arch. The patient underwent a successful hybrid thoracic endovascular aortic repair after aortic arch debranching and transposition of the aberrant left vertebral artery to the left common carotid artery through a supraclavicular incision without sternotomy.ConclusionsThe aberrant left vertebral artery originating from the aortic arch can be safely transposed to the left common carotid artery through a supraclavicular approach.

Lower third clivus and foramen magnum intradural tumor removal: The plea for a simple posterolateral approach

BackgroundAnterior or anterolateral lesions of the lower third clivus and/or foramen magnum require a surgical exposure that provides a clear visualization of both pathological and normal anatomy without retraction of neural or vascular structures. The posterolateral approach permits access to the anterolateral intradural aspect of the brainstem. The aim of this study was to stress that there is no need for vertebral artery transposition, occipital condyle drilling, occipitocervical fixation or trans-oro-pharyngeal access to remove these lesions. MethodsAll five consecutive patients treated surgically for an intradural foramen magnum lesion in the Department of Neurosurgery at Angers University Hospital, between May 2012 and January 2015, were included in this retrospective study. In 4 cases, patients were referred to us for a second opinion after an initial surgical proposal at another institution. For all patients, the data collected were age at diagnosis, clinical signs, and quality of rostral and caudal exposure of the lesion, quality of resection, complications and postoperative neurological deficits. ResultsAll patients were operated on with a control of the rostrocaudal part of the lesion, without touching the vertebral artery, or the use of occipital condyle drilling. There was no need for occipitocervical fixation. Total resection was achieved in 4 cases, subtotal resection in one. All had watertight dural closure with no dural patch, or postoperative neurological deficits. No recurrence occurred between 6 and 30 months after surgery. ConclusionBased on these results, the posterolateral approach was a simple, effective and safe procedure for anterior and anterolateral intradural lesion of the foramen magnum.

Vertebral Artery Transposition Via an Extreme-Lateral Approach for Anterior Foramen Magnum Meningioma or Craniocervical Junction Tumors

Vertebral artery (VA) transposition in theextreme-lateral transcondylar approach can minimize the manipulation of the low cranial nerves and the brain stem. The authors describe the surgical technique of VA transposition. From March 2000 to December 2014, 28 of 48 patients underwent VA transposition for anterior foramen magnum meningioma (16 patients) and craniocervical junction (CCJ) tumors (12 patients). Tumor was resected via an extreme-lateral approach with partial condylectomy to expose the anterior portion of the brain stem. For intradural tumors, the VA was mobilized caudomedially after circumferential dural incision around the VA at the level of the foramen magnum. For extradural tumors involving the CCJ, VA was transposed medially from the transverse foramen of C1 without any dural incision. Gross total resection was achieved in 26 of 28 patients (92.9%) with VA transposition. Histologically, meningioma and schwannoma were most common. The origin of the tumors was foramen magnum (57.1%), C1 nerve root (17.9%), clivus (10.7%), jugular foramen (7.1%), posterior skull base (3.6%), and hypoglossal canal (3.6%). VA transposition was performed intradurally in 19 patients (67.9%) and extradurally in 9 patients (32.1%). Surgical morbidity was 17.9% including 4 patients with hypoglossal nerve palsy and 1 patient with quadriparesis. The mean follow-up duration after surgery was 4.2 years (range, 0.1-14.8 years). VA transposition can provide a wide surgical window for anterior foramen magnum meningioma or tumors involving the CCJ with the least manipulation of the neuraxis.

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

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. 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. 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 and angioplasty, resulting in a restenosis rate of 4.5%. Despite the optimization of medical therapies and lifestyle modifications, a select subset of patients with posterior vascular circulation insufficiency remains. In the authors' experience, vertebral artery-carotid artery transposition provides a surgical option with relatively low long-term complication and restenosis rates that are comparable or lower than those reported with endovascular treatment.

Hybrid Treatment of a Complex Aortic Arch Aneurysm with an Aberrant Left Vertebral Artery

We report a case of an elderly male with significant comorbidities and a dominant aberrant left vertebral artery originating on an aneurysmal aortic arch. The patient underwent a successful staged hybrid procedure with aortic arch debranching and left vertebral artery transposition onto the left common carotid artery, followed by endovascular aneurysmal repair.

椎骨動脈─総頚動脈転位術後に鎖骨下動脈stentingを施行した椎骨動脈起始部狭窄を伴う鎖骨下動脈狭窄症の1例

椎骨動脈─総頚動脈転位術後に鎖骨下動脈stentingを施行した椎骨動脈起始部狭窄を伴う鎖骨下動脈狭窄症の1例