SURGICAL VIDEO Subclavian-to-Extracranial Vertebral Artery Bypass in a Patient With Vertebrobasilar Insufficiency: 3-Dimensional Operative Video ∗ ∗ Amol Raheja, MBBS , Philipp Taussky, MD ,GaneshS.Kumpati, ‡ ∗ MD , William T. Couldwell, MD, PhD Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah; Department of Cardiothoracic Surgery, University of Utah, Salt Lake Watch now at https://academic.oup.com/ons/article-lookup/doi/10.1093/ons/ City, Utah opx130 Hemodynamic insufficiency from extracranial vertebral artery COMMENTS (VA) stenosis may be a primary cause for transient ischemic attacks in patients with vertebrobasilar insufficiency (VBI). n the age where steno-occlusive carotid disease is dominated by the Recent literature supports open or endovascular revascular- I routine practices of carotid endarterectomy and stenting, one almost ization in selected patients. Although traditionally carotid-to- forgets the wide range of potential flow problems that can develop in the VA bypass was used to augment flow and alleviate symptoms extracranial circulation. Clinical trials can still not encompass or antic- ipate every situation that can arise. This unusual case of bilateral vertebral of VBI, a subclavian artery (SA)-to-VA bypass avoids the risk occlusion with thyrocervical reconstitution presents a ripe opportunity of ischemic injury of the anterior intracranial circulation. We for surgical creativity. The rationale for use of the subclavian artery is describe a SA-to-extracranial VA bypass in a 53-yr-old woman very sound – we are also reminded that this is an artery that is not out who presented with vertigo, dizziness, and syncope exacerbated by of bounds to cerebrovascular neurosurgeons. This video admirably illus- neck movements. An angiogram demonstrated complete bilateral trates how the procedure is done and will be welcomed by any neuro- proximal VA occlusions. The patient had collateral flow distally surgeon who finds him or herself confronted by the same or similar from muscular branches off the thyrocervical trunk and minimal problem. 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 Peter Nakaji unsuitability of an endovascular procedure to augment flow, a Phoenix, Arizona left VA revascularization procedure was planned (either VA could have been the recipient for revascularization). Using an interpo- he authors have provided us with an educational and immersive 3- sition saphenous vein (SV) graft (harvested by the cardiac surgical dimensional video of a subclavian to extracranial V3 vertebral artery team), we augmented the posterior circulation with a left SA-to– bypass in a 53-year-old woman who presented with vertigo, dizziness, VA (V3 segment) vascular bypass. The thyrocervical trunk was and syncope exacerbated by neck movements. On imaging, she was used as donor vessel because its caliber matches the SV graft and documented to have complete bilateral proximal VA occlusions with V3 segment. The horizontal part of the V3 segment was isolated distal collateral flow from the thyrocervical trunk, which was compro- in the J-groove of the C1 arch. Microsurgical end-to-end thyro- mised by neck movements resulting in her symptoms. She additionally had minimal flow through the anterior circulation. Post-bypass angiog- cervical trunk-to-SV and end-to-side SV-to-VA anastomoses were raphy documents improved brain perfusion. performed, and flow was confirmed. Postoperative angiography The video is not only informative but proceeds in a manner that showed patent flow through the graft and improved posterior facilitates its educational impact. The only negative is that it makes the circulation, with symptomatic improvement continuing at 6-mo procedure look simple. follow-up. This report is exempt from informed consent. Disclosures Mark Calayag Dr Taussky is a consultant for Covidien/ev3/Medtronic, unrelated to this work. Michael L. Levy The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. San Diego, California 312 | VOLUME 14 | NUMBER 3 | MARCH 2018 www.operativeneurosurgery-online.com Downloaded from https://academic.oup.com/ons/article-abstract/14/3/312/3980195 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Operative Neurosurgery – Oxford University Press
Published: Mar 1, 2018
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