Background For vertebrobasilar insufficiency, endovascular therapy impracticalness can be resulted from tortuous or occluded VA. We report 3 cases of different situations.
Cases presentation Case 1 was a VAO severe stenosis. Right VAO stenting was tried but failed. As the plaque extended to subclavian artery (SubA), proximal SubA was blocked by an dilated 8F balloon catheter, rather than a vascular clamp. Distal SubA and its branches was blocked by aneurysm clips. VAO was too deep to perform endarterectomy. Patient was treated by transposition of VAO. Case 2 was a basilar artery (BA) severe stenosis, complicated by bilateral VAs tortuosity. Patient’s left V1 was exposed and dissociated. Blood flow of proximal left SubA was blocked by a vascular clamp. Then left VA was cut open with a short cleft through which endovascular therapy for BA was possible. A 6F guiding catheter was delivered to V2 segment with the help of a snare. A balloon-expandable stent was deployed at the stenosis of BA. Case 3 had bilateral VAs occlusion and BA fenestration which was suspected as BA severe stenosis preoperatively. Proximal SubA was blocked by dilated balloon guiding catheter. Expose and dissociate left V1, cut it open to disassociate the plaque, but do not take it away immediately. Through the balloon guiding catheter, interventionalist delivered microcatheter to the operating field. Then, along the latent space between plaque and vessel wall, interventionalist and surgeon cooperated to deliver microcatheter (with microwire inside) into the distal lumen. Under monitoring of radiogram, microcatheter was deliver to distal segment of V2. Perform hand-pushing angiography to confirm tip of microcatheter was in the real lumen of VA. Fix microcatheter. Pull the plaque out along with the connected thrombus. Suture the vessel wall. Perform angiography again. Dissection of distal V2 was found, so a balloon-expandable stent was deployed to close it.
Results Symptoms of all patients disappeared. Postoperative MRI of case 2 showed small new lesions of high diffusion-weighted imaging (DWI) signal at left cerebellum, but patient had no uncomfortable complaints. Horner’s syndrome happened in case 1 and 2, both were proved to improve at follow-up of 1 month later. Postoperative hospital stay was 5, 3 and 4 days respectively.
Conclusions For some endovascular-therapy-impractical vertebrobasilar insufficiencies, including VAO stenosis with V1 tortuosity, BA stenosis with bilateral VAs tortuosity, and BA stenosis with bilateral VAs occlusion, hybrid operations of combining surgical manipulation of V1 and endovascular technique can be safe and
Disclosures X. Lu: None. Y. Ma: None. B. Yang: None. Y. Wang: None. P. Gao: None. L. Jiao: None.
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