Endovascular Angioplasty for Extracranial Vertebral Artery Occlusion Without Visualization of the Stump of the Artery Ostium

Abstract

An 87-year-old man presented with extracranial vertebral artery (VA) occlusion and progressive vertebrobasilar ischemia despite maximal medical management. Cerebral angiography showed left proximal VA occlusion, termination of the right VA at the ipsilateral posterior inferior cerebellar artery, and hypoplastic bilateral posterior communicating arteries. Although the stump of the left VA ostium was not visualized, the distal patent artery was reconstituted via muscular branches from the left subclavian artery (SCA). Endovascular angioplasty with a stent for left VA occlusion was performed. The nonvisualized VA ostium was extrapolated from the computed tomography angiography findings of the distal patent VA and the partial calcification of the SCA. The occluded VA was penetrated by the guide wire and revascularized by balloon angioplasty with the stent using the support of a snare wire inserted via the left brachial artery for stabilization of the guide catheter. This treatment resulted in resolution of the severe neurological findings.

Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome

“…There are several reports of endovascular treatment for BAO due to VASS. [ 3 , 4 , 10 - 12 ] Revascularization treatment (either angioplasty or stenting) is done during acute BAO, and Ecker et al . showed 100% (6 out of 6 patients) recanalization of the occluded VA prior to the acute BAO treatment.…”

Safety and Blood-Flow Outcomes for Hybrid Recanalization in Symptomatic Refractory Long-Segmental Vertebral Artery Occlusion—Results of a Pilot Study

“…Symptomatic long-segmental occlusion of V1 and V2 segments being refractory to the best medical treatment remains a challenging management issue. Neither primary endarterectomy nor interventional therapy can routinely achieve revascularization (6,7). In recent decades, hybrid techniques combining open surgery and interventional treatment have demonstrated special advantages in recanalization for long-segmental occlusive lesions (8)(9)(10).…”

Vertebral Artery Stump Syndrome

“…The following mechanism may explain the pathogenesis of ischemic stroke in patients with vertebral artery stump syndrome: (a) vertebral artery stump syndrome after ipsilateral occlusion of the origin of the VA can be caused by the distal limit of the propagated thrombus; and (b) the occurrence of ischemic events after the occlusion of the VA may be associated with emboli from the stagnating clot fragment and a low-flow state due to the collateral circulation via the deep cervical arteries, especially in the absence of any other embolic sources or hematological disorders ( 3 ). To date, 10 cases of vertebral artery stump syndrome involving the collateral pathway have been reported ( 2 , 3 , 7 ). In 9 of these, the collateral tract was derived from the deep cervical artery; in 1 case, it was derived from the ascending cervical artery.…”

“…For example, Nguyen et al ( 2 ) reported that coil embolization was performed to exclude the embolic source. Nii et al ( 7 ) reported that the occluded VA was penetrated by a guidewire and subsequently revascularized by endovascular angioplasty using a stent. Further studies are required to determine whether antiplatelet therapy, anticoagulation therapy, endovascular therapy, or a combination of these offer the best treatment for patients with posterior circulation ischemic stroke resulting from vertebral artery stump syndrome.…”