Occipital artery to extracranial vertebral artery anastomosis for bilateral vertebral artery stenosis at the origin: A case report

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1 SNI: Neurovsculr OPEN ACCESS For entire Editoril Bord visit : Editor: Kzuhiro Hongo, M.D., Shinsui University, Mtsomoto, Jpn Cse Report Occipitl rtery to extrcrnil verterl rtery nstomosis for ilterl verterl rtery stenosis t the origin: A cse report Mshito Ktsuki, Ysung Ymmoto, Nomichi Wd, Yukinri Kkizw Deprtment of Neurosurgery, Suw Red Cross Hospitl, Kogndori, Suw, Ngno, Jpn E mil: Mshito Ktsuki ktk1122nigt@gmil.com; Ysung Ymmoto mss_chi_3@yhoo.co.jp; Nomichi Wd yosouemon@gmil.com; *Yukinri Kkizw ykkizwjp@yhoo.co.jp *Corresponding uthor Received: 17 Jnury 18 Accepted: 12 Mrch 18 Pulished: 16 April 18 Astrct Bckground: Revsculriztion of posterior circultion is essentil in ptients with severe ilterl verterl rtery (VA) stenosis despite dministering mximl medicl tretment, due to the high mortlity of posterior circultion stroke. Cse Description: We present 69 yer old mn with ilterl severe VA stenosis t the origins, treted with occipitl rtery (OA) distl VA nstomosis. Conclusion: Endovsculr tretment nd other surgicl tretments, such s ypss grfting, re effective, ut OA VA nstomosis is sfe nd effective procedure for revsculriztion of the posterior circultion. Videos Aville on: Access this rticle online Wesite: DOI: /sni.sni_20_18 Quick Response Code: Key Words: Arteril reconstruction, occipitl rtery verterl rtery trnsposition, verterl rtery stenosis, verterosilr insufficiency INTRODUCTION Bilterl verterl rtery (VA) stenosis cn cuse posterior circultory insufficiency when the posterior communicting rtery or other collterls re poorly developed. The proximl portion, especilly the origin, of the VA is the most common loction (92%) of therosclerotic occlusive disese in VA. [16] Symptomtic VA stenosis refrctory to medicl tretment hs 5 11% rte of stroke or deth t 1 yer [8] nd mortlity of posterior circultion stroke rnges from 20 to 30%. [8,15,18,20] Therefore, revsculriztion of the posterior circultion is essentil in ptients with severe ilterl VA stenosis despite dministering mximl medicl tretment. Here, we descrie cse of successful revsculriztion tht ws chieved using occipitl rtery (OA) to distl extrcrnil VA nstomosis in ptient with severe ilterl VA stenosis t the origin. CASE DESCRIPTION Cse Report A 69 yer old mn ws dmitted to our hospitl ecuse of ilterl txi nd dizziness. He hd not een tking ny medictions nd hd een smoking 40 cigrettes per dy for 49 yers. Lortory tests reveled mild dyslipidemi nd impired glucose tolernce. Blood pressure on dmission ws 188/92 mmhg. Mgnetic resonnce imging (MRI) showed cute rin infrction t the ilterl cereellr hemispheres nd the right thlmus. The lesions in the cereellum were not perfectly consistent with vessel dominnt regions supplied y the nterior inferior cereellr rtery or posterior inferior cereellr rtery. Hed mgnetic resonnce ngiogrphy (MRA) showed ilterl VAs ut posterior communicting rteries were not oserved This is n open ccess journl, nd rticles re distriuted under the terms of the Cretive Commons Attriution-NonCommercil-ShreAlike 4.0 License, which llows others to remix, twek, nd uild upon the work non-commercilly, s long s pproprite credit is given nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Ktsuki M, Ymmoto Y, Wd N, Kkizw Y. Occipitl rtery to extrcrnil verterl rtery nstomosis for ilterl verterl rtery stenosis t the origin: A cse report. Surg Neurol Int 2018;9: Surgicl Neurology Interntionl Pulished y Wolters Kluwer Medknow

2 ilterlly. Neck MRA indicted right VA ut did not show left VA [Figure 1]. Contrst enhnced three dimensionl computed tomogrphic ngiogrphy (3D CTA) showed right VA severe stenosis t the origin nd did not show the left VA from the osti to the lower edge of the second cervicl verter [Figure 2, left]. Reltively thick OA ws lso shown. Cererl ngiogrphy reveled right VA severe stenosis similr to 3D CTA, ut showed ner occlusion of the osti of the left VA nd mrkedly delyed poststenotic lood flow in the left VA. Stenosis ws detected only t the osti, in contrst to 3D CTA. Argtron, ntipltelet mediction (spirin 100 mg nd clopidogrel 75 mg dily), rosuvsttin, nd omrigliptin were strted. After the cute phse, mlodipine nd olmesrtn tretment were lso egun. The ptient ws dischrged home with mild ilterl txi. We plnned surgicl reconstruction of posterior circultion in order to void ftl rin infrction due to posterior circultory insufficiency, which is relted to high moridity nd mortlity. In terms of preopertive neurologicl symptoms, the muscle tones of extremities were intct. The git on flt surfce ws norml without ssistnce, ut the tndem git ws unstedy when ttempting to touch the heel of the right foot to the toe of the left foot. Mild dysmetri ws seen when finger nose finger test ws performed with the left forerm. He felt difficulty to use his left hnd s sujective symptom. Dysrthri ws mild to moderte with some slurring of speech so tht we sked the ptient to repet sometimes. Opertion We performed left OA to left distl extrcrnil VA nstomosis 3 months fter the first dmission voiding hemorrhgic infrction [Video 1]. The OA nd VA were crefully exposed with mintennce of lood flow y dissecting suoccipitl muscles lyer y lyer through the lterl suoccipitl pproch. Crniotomy ws not required ecuse the rteries were extrcrnil. The VA from the formen trnsversrium of C2 to formen mgnum (V3) ws temporrily trpped nd incised to mke 3.5 mm hole y vessel punch. The OA ws cut dequtely for end to side nstomosis to the VA with 16 sutures using 8 0 monofilment nylon t the occipito tlntl (C0 C1) level. The temporry occlusion time ws 38 min nd 40 s [Figure 3]. Postopertive course On the dy following the opertion, the ptient wlked without ssistnce ut wtching nd the ilterl txi improved. 3D CTA just fter the opertion showed tht the nstomosis ws ptent, nd the left VA ws oserved from the osti to the union [Figure 2, right]. In terms of postopertive neurologicl symptoms, he ws le to wlk more swiftly thn efore the opertion nd the tndem git ws slightly improved. The mild dysmetri ws still seen when finger nose finger test ws performed with the left forerm, ut the sujective symptom tht he felt difficult to use his left hnd ws improved. Dysrthri ws improved little so tht wht the ptient sid could e understood esily. Furthermore, the mini mentl stte exmintion score nd the frontl ssessment ttery t edside score were improved from 24 to 29 nd from 15 to 17, respectively. The ptient ws dischrged home under his own multion. Three months fter the opertion, MRA indicted tht the ypss ws widely ptent, nd OA hd developed from 3.0 to 3.6 mm in dimeter. The ptient remins under oservtion nd hs experienced no recurrent symptoms due to posterior circultory stroke for 6 months. He restrted to work in his frm field. DISCUSSION Posterior circultory insufficiency crries risks of severe moridity nd mortlity. Up to 25% of trnsient ischemic ttcks (TIAs) nd strokes re ssocited with posterior Figure 1: Diffusion weighted mgnetic resonnce imging showed cute rin infrction t the ilterl cereellr hemispheres nd the right thlmus (). Hed MRA showed the ilterl VAs ut posterior communicting rteries were not oserved ilterlly (). Neck MRA indicted the right VA ut not the left VA (c) c Figure 2: Posterior view of contrst enhnced 3D CTA efore the opertion (left) showed right VA severe stenosis t the origin (sterisk) nd did not show the left VA from the osti to the lower edge of the second cervicl verter (white rrowheds). Wheres, 3D CTA just fter the opertion (right) showed tht the nstomosis ws ptent (white rrow) nd the left VA ws shown from the osti to the union (lck rrowheds)

3 Figure 3: Intropertive findings of left OA to left extrcrnil VA nstomosis. After dissecting the OA nd the VA (), the OA ws moilized nd nstomosed end to side to the VA (). The VA ws oserved in the occipito tlntl (C0 C1) level within the suoccipitl tringle ounded y the rectus cpitis posterior mjor muscle, oliquus cpitis superior muscle, nd oliquus cpitis inferior muscle [Video 1] circultion, nd ptients with symptomtic VA stenosis hve 30 35% risk of stroke over 5 yers nd 5 11% comined risk of stroke nd deth t 1 yer. [12,17,25] Moreover, the mortlity rte fter posterior circultion stroke is up to 25%. [18,20] Therefore, we performed vsculr reconstruction of posterior circultion to prevent stroke in the verterosilr territory of this ptient. Open surgery nd/or endovsculr tretment re plnned to revsculrize VA. In terms of endovsculr tretment, previous rndomized controlled trils (RCTs), such s The Verterl Artery Stenting Tril (VAST) [5] nd The Verterl Artery Ischemi Stenting Tril (VIST), [13] showed no dvntges of stenting/ngioplsty, compred to est medicl tretment lone in ptients with extrcrnil VA stenosis. In ddition, the rtes of periopertive stroke nd deth re comprle for open versus endovsculr pproches. The min difference etween surgicl nd endovsculr tretment is durility. The periopertive stroke rtes of open surgery nd endovsculr tretment re lmost the sme (0 4%). However, the ptency rte nd stroke free rte of open surgery re oth 90% t 10 yers. [3] Despite the high rtes of technicl success, endovsculr tretment of VA disese is ssocited with high rtes of restenosis, rnging etween 13 nd 50% in ville reports. [2,11,21,23] Therefore, s descried in the Jpnese Guidelines for the Mngement of Stroke 2015, there is insufficient scientific evidence to perform percutneous ngioplsty nd stent plcement for extrcrnil nd intrcrnil rteril stenosis except in the cervicl internl crotid rtery (ICA). [14] However, it should e noted tht endovsculr tretment is less invsive nd reltively esy, nd tht the procedure cn e performed without generl nesthesi, enling continuous neurologicl monitoring of the ptient. [5] In ddition, the ltest RCT, VIST, suggested tht stenting my reduce longer term stroke risk, lthough this remins to e confirmed in lrger trils. [13] The VA in the neck region gives off numerous rnches reconstituting the distl VA s collterls, [4] so there is possiility tht endovsculr tretment my e n esy procedure to gin time for collterls to develop. Furthermore, in prticulr cses with severe VA stenosis, it hs een reported tht hyrid opertions comining surgicl mnipultion of the proximl VA nd endovsculr techniques cn e sfe nd effective. [26] In ddition, lthough endovsculr tretment of VA stenosis is ssocited with high rtes of restenosis, surgicl revsculriztion cn e performed fter restenosis. With regrd to cute stroke, emergent revsculriztion of VA occlusion hs een reported. [1] In ptients with such cute stroke, it is useful to perform surgicl revsculriztion fter VA stenting in the cute phse s two stge surgery. Thus, endovsculr tretment is fesile option for tretment of VA stenosis. On the contrry, open surgery lrgely consists of two procedures: ypss grfting nd trnsposition. Bypss grfting involves crotid ypss to the VA from the osti to the trnsverse formen of C6 (V1) or V3, or suclvin ypss to the V1, with vein grfting. Trnsposition involves nstomosing VA to ICA, the externl crotid rtery (ECA), or OA to VA, or VA to the suclvin rtery. [6] Severl cse series of open surgery for revsculriztion of symptomtic verterosilr rtery stenosis or posterior circultory lesion hve een reported etween 1985 nd the present [Tle 1]. [6,7,9,10,22,24,27] The lrgest series of distl VA reconstruction indicted ptency rte of 89.3% nd significnt verterosilr symptom free rte of 94% t 5 yers. [7] In one report, trnsposition provided sttisticlly significnt improvement in primry ptency over ypss grfting for 80 months, [7] ut whether ypss grfting or trnsposition is superior remins controversil. To our knowledge, there hve een only 19 previous cse reports of OA VA trnsposition, s performed in our cse. These previous reports indicted good ptency nd no complictions of OA VA trnsposition [Tle 2]. [6,9,10,22,24,27] Complictions of open surgery were minly oserved in ptients requiring comined ICA nd distl VA reconstruction. [7] So OA VA trnsposition is sfe y voiding the risk of ICA tretment.

4 Tle 1: Cse series of surgicl revsculriztion of symptomtic verterosilr rtery stenosis [6,7,9,10,22,24,27] Author, yer Period No. Bypss grft Trns position Others Ptency, period Compliction, period Hdley, Ptent, postopertive No new deficit, postopertive Tked, %, 1-84 months 33%, postopertive Hns, %, 3-48 months 0%, postopertive Rmon, %, postopertive Not descried Edourd, %, 10 yers 2.2%, postopertive Yong, Not descried Not descried Dwn, %, 60 months 18%, postopertive Totl Tle 2: Cse series of OA VA nstomosis for symptomtic verterosilr rtery stenosis [6,9,10,22,24,27] Author, yer Period OA VA nstomosis Ptency, period Complictions, period Hdley, Ptent, postopertive No new deficit, postopertive Tked, (ECA or OA VA) 100%, 6-84 months 0% complictions, postopertive Hns, %, 3-48 months 0% complictions, postopertive Rmon, Not descried Not descried Yong, Ptent, 2 yers No new deficit, 2 yers Dwn, (ECA or OA VA) Not descried Not descried Our cse, Ptent, 3 months No new deficit, 3 months Totl 20 In our cse, we chose OA VA nstomosis insted of ypss grfting, VA suclvin trnsposition, or endovsculr tretment. Bypss grfting requires temporry occlusion of the ICA or common crotid rtery (CCA), which mrkedly reduces cererl lood flow, nd therefore the opertion must e performed quickly. Although lood flow in the ICA or CCA cn e mintined using n internl shunt tue or prtil vessel occlusion with curved clip, the possiility of lood flow decrese is not zero. Furthermore, ypss grfting requires invsive nd complicted procedures, such s wide skin incision, hrvesting of the venous grft, two nstomoses, nd multiple temporry clipping nd occlusion procedures. VA suclvin trnsposition cn improve the VA stenosis nd ws recommended y Ogw [19] ecuse it is less invsive compred to other surgicl reconstruction methods. However, it requires skin incision round clvicle or sternocleidomstoid muscle, ut this pproch is not populr mong neurosurgeons s there is risk of cervicl sympthetic nerve injury. In ddition, it requires moderte length of VA, nd nstomosis cn e difficult when the suclvin rtery hs mny of its importnt rnches. In ddition, the right VA is the solitry feeding rtery for the rinstem, so it is difficult to nstomose the right VA to the suclvin rtery with temporry occlusion of the right VA. Endovsculr tretment lso requires trnsient occlusion, so endovsculr ngioplsty for the right VA is unsfe for the sme reson, nd ngioplsty itself cn cuse strokes due to emoliztion of deris despite using n emolic protection device, such s filter. Endovsculr ngioplsty for the left VA is lso difficult ecuse insertion of the guidewire cnnot e performed esily due to ner occlusion of the left VA. Bsed on the points discussed erlier, we performed left OA VA nstomosis. Of course, it required temporry occlusion of the left VA. However, the left VA ws lmost occluded prior to surgery nd the right VA could mintin its flow during temporry left VA occlusion. Therefore, OA VA nstomosis ws sfe procedure in this cse [Figure 4]. The dimeter of the vessel incresed in response to the demnds of lood flow, similr to superficil temporl rtery (STA) middle cererl rtery (MCA) ypss. This cse suggests novel surgicl indiction of OA VA nstomosis for posterior circultory insufficiency similr to STA MCA ypss for MCA stenosis or occlusion nd symptomtic ICA stenosis or occlusion. Furthermore, when trnsposition of V1 to the suclvin rtery is needed s rdicl opertion or two stge opertion, OA VA nstomosis efore V1 suclvin trnsposition cn mintin flow of the VA for the rinstem vi nstomosis t V3 during V1 suclvin trnsposition with temporry occlusion of the proximl VA. Therefore, OA VA nstomosis cn e sfe procedure nd led to rdicl opertion. CONCLUSION OA to distl extrcrnil VA nstomosis is good cndidte for symptomtic ilterl severe VA stenosis t

5 Figure 4: The surgicl strtegy in this cse. Schem of rteries in this cse (). The VA is divided into four segments: V1, origin to trnsverse formen of C6; V2, from the trnsverse formen of C6 to the trnsverse formen of C2; V3, from C2 to the dur; V4, from the dur to their union to form the silr rtery. In our cse, the right VA ws the solitry feeding rtery for the rinstem, so it ws difficult to perform procedures requiring temporry occlusion of the right VA, such s nstomosing the right VA to the suclvin rtery nd endovsculr ngioplsty for the right VA. In ddition, the left VA showed severe stenosis, so nstomosing the left VA to the suclvin rtery nd endovsculr ngioplsty for the left VA hd no gurntee of success (). On the contrry, left occipitl rtery VA nstomosis ws sfe. Of course, it required temporry occlusion of the left VA. However, the left VA ws lmost occluded prior to surgery nd the right VA ws le to mintin its flow during temporry left VA occlusion (c) the origin nd cn e performed more sfely nd more esily thn ypss grfting nd endovsculr tretment. Declrtion of ptient consent The uthors certify tht they hve otined ll pproprite ptient consent forms. In the form the ptient(s) hs/hve given his/her/their consent for his/her/ their imges nd other clinicl informtion to e reported in the journl. The ptients understnd tht their nmes nd initils will not e pulished nd due efforts will e mde to concel their identity, ut nonymity cnnot e gurnteed. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Ae A, Okuo S, Onozw S, Nkjim M, Suzuki K, Hrd Ae M, et l. Acute verterl rtery origin occlusion leding to silr rtery thromosis successfully treted y ngioplsty with stenting nd thromectomy. 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