Vertebral artery revascularization
- Mark D Morasch, MD, FACS, RPVI
Mark D Morasch, MD, FACS, RPVI
- Director, Division of Vascular Surgery
- Billings Clinic
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Many pathologic processes, including atherosclerosis, trauma, fibromuscular dysplasia, dissections, and aneurysm, among others, can lead to symptoms referable to the vertebral artery. Atherosclerotic vertebral artery disease is often under-diagnosed as a cause of posterior circulation ischemia because of the frequently vague nature of patient presentation. Clinicians may be reluctant to pursue pathologic diagnosis or to recommend treatment, but revascularization of the vertebral artery should be considered in symptomatic patients for whom medical therapy has failed. Intervention is not indicated in asymptomatic patients.
Both surgical and endoluminal approaches are options for treating vertebral artery pathology, with the choice between the two often determined by the anatomic location of the lesion. Clinicians must carefully balance the risks of surgery versus the limitations of endoluminal intervention before proceeding. Open techniques for revascularization of the vertebral artery have proven clinical durability and acceptable surgical morbidity in experienced hands. Endovascular techniques, which have gained momentum over the past decade, are clinically feasible but have yet to deliver on durability benchmarks set by open surgical revascularization. As such, vertebral artery stenting should be reserved for select centers with high-volume experience that have established acceptable outcomes in both clinical success and safety.
The indications for, evaluation and preparation of, and methods of vertebral artery revascularization are reviewed here.
The vascular supply to the brain is divided into the anterior and posterior circulations originating from the carotid and vertebral arteries, respectively (figure 1). The circle of Willis connects the anterior and posterior circulations, but is completely intact and symmetric in only about 20 percent of individuals . The anatomic variability of the collateral circulation helps explain the variability of clinical presentations of patients with vertebral artery disease.
The vertebral arteries most commonly originate from the subclavian arteries. They originate directly from the aortic arch in 3 to 5 percent of individuals . The vertebral arteries are commonly asymmetric in diameter and it is not uncommon for one vertebral artery to be atretic, a finding that is slightly more common on the left than the right . In some patients, an atretic vertebral artery can perfuse an isolated ipsilateral posterior inferior cerebellar artery.
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- ANATOMIC CONSIDERATIONS
- VERTEBROBASILAR DISEASE
- Mechanisms of ischemia
- - Hemodynamic
- - Embolism
- INDICATIONS FOR REVASCULARIZATION
- History and physical
- - Vascular imaging
- - Cerebral imaging
- Cardiac evaluation
- - Open surgery versus endovascular treatment
- - Approach by segment
- Open surgical repair
- - Vertebral artery transposition
- - Distal vertebral artery bypass
- Endovascular treatment
- SUMMARY AND RECOMMENDATIONS