Symposium: Surgery of the Vertebral ArteryThe surgical reconstruction of the proximal subclavian and vertebral artery*
Section snippets
Historical perspective
Successful carotid reconstructive surgery was achieved by Eastcott et al.1 in England and DeBakey2 in the United States in 1954 and 1953, respectively. Thromboendarterectomy continues to be the best operation to relieve symptoms created by disease at the origin of the ICA.
Two decades ago Hutchinson and Yates3 recognized the role that the extracranial vertebral arteries played in the production of cerebellar and brain-stem ischemia. The first successful surgical correction for proximal
Diagnostic studies
In the evaluation of approximately 3000 patients with cerebral symptoms, operations were performed in 498 patients (16.6%) to control significant stenosis of the proximal vertebral, subclavian, or innominate arteries or combinations of these arteries. Clinical manifestations ranged from dizziness and ataxia to paresthesia and visual disturbances. During the past decade, our operative procedure has been to perform an anastomosis between the end of the subclavian or vertebral artery, distal to
Operative approach
The three basic operations of endarterectomy, bypass grafting, and direct arterial anastomosis are all suitable for stenotic lesions of the brachiocephalic or vertebral arteries. The exposure of the origins of the innominate, subclavian, and left carotid arteries are all limiting factors in the performance of an endarterectomy.
Although an extrathoracic approach can be used in the exposure of the base of the right subclavian and common carotid arteries, adequate control of the innominate artery
Discussion
Since we believed the need existed for restoration of direct flow into the basilar system, we explored the possibility of a direct anastomosis of the involved subclavian and vertebral artery to its adjacent common carotid artery.
During the past decade we have performed direct arterial anastomosis in the treatment of stenotic lesions of the proximal subclavian or vertebral arteries. Our total experience with direct anastomosis now totals 411 procedures. The results for both proximal vertebral
Summary
Endarterectomy, bypass, or direct arterial anastomosis are used to restore flow in a compromised vertebral or subclavian artery. During 20 years of experience in surgical relief of stenosis of the proximal vertebral and subclavian arteries, we now prefer an anastomosis between the involved vertebral or subclavian artery. We have performed 411 such procedures. There has been one death (0.2%), with reoperation necessary in three patients (0.0%). No neurologic morbidity has been associated with
References (17)
- et al.
Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia
Lancer
(1954) - et al.
Carotico-vertebral stenosis
Lancet
(1957) - et al.
Carotid-subclavian bypass for “subclavian steal syndrome.”
J Thorac Cardiovasc Surg
(1968) - et al.
Thrombo-obliterative disease of the greater vessels arising from the aortic arch
J Thorac Cardiovasc Surg
(1962) - et al.
Extrathoracic repair of branch occlusion of the aortic arch
Am J Surg
(1976) - et al.
Rationale for aorto-subclavian artery bypass
J Thorac Cardiovasc Surg
(1965) - et al.
The surgical treatment of the subclavian steal syndrome
J Thorac Cardiovasc Surg
(1965) Successful carotid endarterectomy for cerebrovascular insufficiency. Nineteen-year follow-up
JAMA
(1975)
Cited by (34)
Minimally Invasive Surgical Repair of Vertebral Artery Ostium Stenosis in Patients with Ischemic Stroke: A Single-Center Case Series
2021, World NeurosurgeryCitation Excerpt :Our procedure differs from classic reports of VA surgery. We have opted for a 3-cm incision, smaller than that originally reported for open surgical repair (5-7 cm).34 In our experience, we were able to maintain an adequate surgical view by stabilizing the incision site using the surgical retractor, which supports recovery and allows for a more aesthetic scar.
Hybrid Technique for the Treatment of Refractory Vertebrobasilar Insufficiencies
2017, World NeurosurgeryCitation Excerpt :Case 1 was VAO severe stenosis, most of which could be treated endovascularly. A few specialists can alternatively provide surgical treatment that includes endarterectomy and V1 reconstruction, which mainly includes side-to-side anastomosis of the VA and common carotid artery (CCA) or SubA, vein bypass grafting, VA-to-SubA transposition, and VA-to-CCA transposition.9-13 Both transposition strategies have been reported to be safe and effective based on long-term follow-up of tens of cases.11-13
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/ SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease
2011, Journal of the American College of CardiologyCitation Excerpt :Distal reconstruction of the vertebral artery, necessitated by total occlusion of the midportion, may be accomplished by anastomosis of the principal trunk of the external carotid artery to the vertebral artery at the level of the second cervical vertebra (678). Such operations, although rare, can relieve symptoms, with low rates of morbidity and mortality in appropriately selected patients (670,679–686). Although angioplasty and stenting of the vertebral vessels are technically feasible, as for high-risk patients with carotid disease, there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: Executive summary
2011, Journal of the American College of CardiologyCitation Excerpt :Distal reconstruction of the vertebral artery may be accomplished by anastomosis of the principal trunk of the external carotid artery to the vertebral artery (322). In appropriately selected patients, these operations can relieve symptoms, with low morbidity and mortality (314,323-330). There is little evidence from randomized trials that endovascular management is superior to best medical management.
Surgery for Vertebrobasilar Insufficiency
2009, Comprehensive Vascular and Endovascular Surgery: Second EditionSurgical treatment of patients with symptomatic vertebrobasilar insufficiency
1998, Annals of Vascular Surgery
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