VERTEBRAL ARTERY SURGERY

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During the past two decades, improved understanding of vertebrobasilar insufficiency and posterior circulation infarction has increased awareness of the contribution of the vertebral arteries to the posterior cerebral circulation. With improved diagnostic abilities and vascular surgical techniques, reconstruction of the vertebral arteries provides safe and consistent long-term results.

Early vertebral artery operations usually involved trauma and resulted in packing or ligation of the vertebral artery. In 1959, thromboendarterectomy of the proximal vertebral artery was first reported by Cate and Scott.6 Since then advances in diagnostic and surgical techniques have made reconstruction of the vertebral artery an important adjunct in the management of cerebrovascular disease. Identification of transient ischemic attacks (TIAs) by Fisher11 in 1951 increased our understanding of the anterior (carotid) versus posterior (vertebral) cerebral circulation. Categorizing symptoms in terms of anterior or posterior cerebral circulation is not always easy. The characterization of vertebrobasilar insufficiency as described by Kubik and Adams16 has helped define the contribution of vertebral circulation to symptomatic posterior circulation insufficiency.

Section snippets

ANATOMY

The vertebral arteries arise at nearly 90-degree angles as the first branches of the subclavian arteries. Their anatomic course has been broken down into four segments, designated as V1 to V4 (Fig. 1). V1 is the first segment and travels cephalad until it enters the transverse foramina at C6 or C5. The V2 segment runs through a protective bony canal composed of the transverse foramina from C6 to C2. The distal extracranial vertebral artery, V3, extends from the bony canal at C2 to the point

PATHOPHYSIOLOGY

Pathology affecting the vertebral arteries includes atherosclerosis, compressive mechanisms, blunt and penetrating trauma, fibromuscular dysplasia, arteritis, and dissection. Atherosclerosis is the most common source of pathology in the vertebral artery.12 The most common sites of disease in white men occur at the vertebral origin, followed by the proximal subclavian artery, the intracranial vertebral artery, and the basilar artery. The V3 segment is rarely involved. Premenopausal women,

CLINICAL PRESENTATIONS

The signs and symptoms of posterior ischemia or infarction are many and varied. A history of bilateral or alternating hemisensory or motor deficits, dizziness, syncope, vertigo, tinnitus, perioral numbness, complete or partial hemianopsia, ataxia, dysarthria, and syncope may occur alone or in any combination (Table 1). The vertebrobasilar system is the source of blood supply for 10 of the 12 cranial nerves; the auditory, visual, and vestibular systems; parts of the cerebral hemispheres; and all

VERTEBRAL ARTERY RECONSTRUCTION

Indications for surgical revascularization are severe atherosclerotic lesions obstructing the vertebral, proximal subclavian, or innominate arteries that are thought to have caused vertebrobasilar symptoms or posterior circulation infarctions. Additional indications include increasing total cerebral blood flow in symptomatic patients with occluded carotid arteries and treating arteriovenous fistulas or spontaneous and traumatic dissections of the vertebral artery.

The most common and one of the

SUMMARY

Vertebral artery revascularization is indicated for symptomatic vertebral artery disease. Safe and effective revascularization can be offered to such patients with good long-term outcomes. Percutaneous transluminal angioplasty, with and without stents, may eventually develop a role. However, prospective trials to compare angioplasty with the safety and long-term efficacy of surgical revascularization are needed before any benefit can be assumed.

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  • Cited by (13)

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      Citation Excerpt :

      However, these procedures are reserved for symptomatic patients.506-508 Outcomes of combined stroke and death are less than 1% for vertebral artery operation alone, but 5.7% when combined with carotid disease intervention.507 Endovascular treatment for proximal vertebral artery disease has been reported in multiple small case series, often with a high risk of restenosis (40%-50%)498,509-512 Distal embolic protection is often difficult because of the small size of the vertebral artery,494,513 and both angioplasty alone and in combination with stent has been described.494,509-512

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    Address reprint requests to Thomas C. Naslund, MD, Vanderbilt Medical Center, D-5237 Medical Center North, Nashville, TN 37232–2735

    *

    Division of Vascular Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee

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