Radical treatment for bilateral vertebral artery dissecting aneurysms by reconstruction of the vertebral artery

Abstract

OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V-V or V-V bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.

Microsurgical Treatment Strategy of Vertebral Artery Fusiform Aneurysm—From the Standpoint of Hemodynamic Integrity and Perforator Preservation

“…Thus, there is no guarantee of permanent patency of the contralateral VA ( 2 , 59 ). Furthermore, increased hemodynamic load to the contralateral VA after occlusion of the affected VA may cause a higher risk of contralateral VA dissection ( 60 ). Thus, it is essential to preserve the affected VA and reduce hemodynamic load to the contralateral VA as much as possible.…”

“…In particular, in the case of giant VA aneurysms the distal V4 segment is often meandering and deflects outwardly to the vicinity of the internal auditory canal, while the distal V4 and branches of the VA are often stretched in an axial direction. Thus, the V4 stump can be easily transposed to the triangle corridor beneath LCNs without perforator injury ( 37 , 39 , 60 , 61 ). If reconstructive clipping is impossible and a V3-RAG-V4 bypass is difficult, then VA occlusion alone is insufficient.…”

Endovascular treatment of bilateral intracranial vertebral artery aneurysms: an algorithm based on a 10-year neurointerventional experience

“…In this case, open surgical might also be considered even though it is invasive and technically difficult. Saito et al 13 and Ota et al 14 reported that bypass of arteries for the bilateral IVADAs was an effective method to preserve the perforators and provide blood flow. Furthermore, trapping the VA places increased haemodynamic stress on the contralateral VA, which might lead to enlargement and possibly rupture.…”

Surgical removal using V3-radial artery graft-V4 bypass and occipital artery-posterior inferior cerebellar artery bypass for a giant thrombosed aneurysm of vertebral artery compressing brain stem: Case report

“…Second, in cases of serpentine VA aneurysms, the distal end of the dilated segment is often meandering and deflecting outwardly to the vicinity of the internal auditory canal and is stretched in an axial direction. [11] Thus, the V4 stump can be transposed to the triangle corridor made by the 11 th nerve, LCNs, and the medulla, or between the LCNs and the acoustic nerve, thus avoiding perforating branch injury of the VA.[12,18] In our case, the space widened by removal of the GTVA, and the patency of the contralateral VA that provided substantial ischemic tolerance, allowed a safe and reliable surgical procedure using V3-RAG-V4 anastomosis.…”