Left Vertebral Artery to Common Carotid Artery Transposition in a Patient With Bilateral Vertebral Insufficiency: 3-Dimensional Operative Video

Sirin Gandhi, Claudio Cavallo, Justin R Mascitelli, Michael J Nanaszko, Xiaochun Zhao, Michael T Lawton
Operative Neurosurgery (Hagerstown, Md.) 2020 January 24
Extracranial vertebral artery (VA) atherosclerosis is responsible for 14% to 32% of posterior circulation infarctions.1 In the posterior circulation, narrowing of the VA > 30% is significantly associated with strokes. Subclavian artery (SCA) atherosclerosis can produce subclavian steal. Retrograde VA flow around an occluded SCA decreases blood flow to the posterior circulation and causes vertebrobasilar insufficiency (VBI). Flow augmentation to the posterior circulation can be achieved by VA endarterectomy, arterial stenting, VA-common carotid artery (CCA) transposition, or bypass using an interposition graft.2,3 This video illustrates microsurgical revascularization of the proximal VA with VA-CCA transposition. A 58-yr-old man with a prior stroke and chronic right VA occlusion presented with dysarthria and gait instability. Angiographic evaluation confirmed complete midcervical right VA occlusion and left SCA occlusion proximal to VA origin, with subclavian steal. After obtaining patient consent and a failed attempt at endovascular recanalization of the left SCA, a left VA-CCA end-to-side transposition was performed. Neck dissection exposed the left CCA. The thyrocervical trunk served as a landmark to identify the SCA, which was traced proximally to the VA origin. After proximal occlusion, the VA was transected and "fish-mouthed" for end-to-side anastomosis to CCA. An intraluminal, continuous suture technique was used to sew the back walls of this anastomosis. Postoperative computed tomography angiography confirmed bypass patency. Collateral circulation through the thyrocervical and costocervical trunks likely supplied the left arm, and no cerebral, or limb, ischemic symptoms were noted on follow-up. VA-CCA transposition is an uncommon technique for safe and effective revascularization of symptomatic, medically refractory VBI caused by VA occlusion or, as in this case, SCA occlusion with secondary subclavian steal. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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