Internal Thoracic Artery to Vertebral Artery Bypass Surgery: A Cadaveric Feasibility Study.

OBJECTIVE: Posterior circulation strokes account for over one quarter of all ischemic strokes. The frequency of vertebral artery origin stenosis (VAOS) in patients with vertebrobasilar insufficiency (VBI) has been estimated to be as high 26%-32%, and VAOS is the direct cause of posterior circulation strokes in 9% of patients. This association could have a significant genetic component. This study examines the feasibility of the internal thoracic artery (ITA) as a donor vessel for revascularization in patients with VAOS. METHODS: Ten sides from 5 fresh-frozen white cadaveric necks derived from 3 women and 2 men were used in this study. The mean age of the cadavers at death was 77.2 years (range, 68-88 years). The subclavian artery, vertebral artery, and ITA were dissected. The length and diameter (proximal and distal) of the V1 segment and the length and diameter of the ITA were recorded. Finally, the ITA was transposed to the V1 segment of the vertebral artery (VA1). RESULTS: The mean length of the VA1 and its diameter at the proximal and distal parts were 35.51 and 3.69 mm, respectively. The mean length and diameter of the ITA were 26.53 and 3.27 mm, respectively. Rerouting the ITA to the VA1 was feasible without tension on all sides. CONCLUSIONS: This study indicates that the ITA is anatomically and hemodynamically an excellent option for bypass surgery in a VAOS scenario. We present convincing and reproducible data to aid neurosurgeons in choosing the procedure best suited to their patients.

Nonexpanded Prefabricated Anterior Perforator of Transverse Cervical Artery Flap for Full Facial Reconstruction.

BACKGROUND: Prefabricated flap is an important technique to reconstruct facial skin defects. There is no any procedure for full facial reconstruction, and we are the first one to accomplish it. METHODS: Instead of the traditional supraclavicular island flap, we choose nonexpanded flap pedicled by the anterior perforator of transverse cervical artery (ap-TCA) to repair the whole facial deformity. RESULTS: Nonexpanded prefabricated ap-TCA flap repaired full facial deformity successfully. CONCLUSION: Nonexpanded prefabricated ap-TCA flap is one of the best options for male full facial deformity patients.

The V3 segment of the vertebral artery as a robust donor for intracranial-to-intracranial interpositional bypasses: technique and application in 5 patients.

The V3 segment of the vertebral artery (VA) has been studied in various clinical scenarios, such as in tumors of the craniovertebral junction and dissecting aneurysms. However, its use as a donor artery in cerebral revascularization procedures has not been extensively studied. In this report, the authors summarize their clinical experience in cerebral revascularization procedures using the V3 segment as a donor. A brief anatomical description of the relevant techniques is also provided.

Trapping and V3-radial artery graft-V4 bypass for ruptured dissecting aneurysm of the vertebral artery.

The authors show a surgical technique of trapping/resection of ruptured dominant vertebral artery aneurysm in conjunction with reconstruction of vertebral artery by V3-radial artery (RA) graft-V4 bypass through suboccipital craniotomy and far lateral approach. Step by step muscle dissection in posterior fossa enable fine exposure of occipital artery for possible OA-PICA bypass and V3 portion of vertebral artery. Extradural drilling of posterior one-third condyle and condylar fossa facilitate exposure of triangular surgical corridor made by medulla, spinal root of 11th nerve and lower cranial nerves, and thus enabling aneurismal resection and RA-V4 anastomosis. The video can be found here: http://youtu.be/LxsARGdHSVw .

Bypass using V2-V3 segment of the vertebral artery as donor or recipient: technical nuances and results.

OBJECTIVE: Surgical revascularization (bypass) technique has been used to treat vascular diseases of the posterior circulation, including ischemia, aneurysms, and tumors encasing a major artery. We focused on procedures using the V2-V3 segment of the vertebral artery (VA) as either the donor or recipient of the bypass. We have described technical nuances developed over time and evaluated the surgical results of those cases. METHODS: Data on all patients who underwent bypasses using the V2-V3 segment were collected retrospectively from a prospectively maintained database. RESULTS: Twenty patients had bypasses using V2-V3 distal VA as either the donor (13) or recipient (7); 19 patients had an intervening graft and in 1 patient, the VA was used for reimplantation of the posterior inferior cerebellar artery. Except for 1 patient, who died during the perioperative period, the mean follow-up time for the rest of the patients was 24.7 months (range 1-72 months). One patient developed postoperative stroke. One radial artery graft occluded, and a redo saphenous vein graft also occluded in the same patient. All the other bypasses were patent without flow limitation at the latest follow-up. Fourteen patients had a modified Rankin Scale score of 2 or better at the latest follow-up, and 2 died of unrelated causes as the result of their tumors. CONCLUSIONS: The V2-V3 segment of the VA can be used both as a donor and a recipient for bypass surgery. Using the technical steps perfected over time, we are able to achieve surgical results with high rate of graft patency and good functional outcome in patients.

Vertebral artery-to-vertebral artery bypass with interposed radial artery or occipital artery grafts: surgical technique and report of three cases.

BACKGROUND: The treatment of unclippable vertebral artery (VA) aneurysms incorporating the posterior inferior cerebellar artery with parent artery preservation is among one of the most formidable challenges for cerebrovascular microsurgery and endovascular surgery. We propose that intracranial VA reconstruction using an extracranial VA-to-intracranial VA (VA-VA) bypass with a radial artery graft or an occipital artery graft may be an additional technique in the armamentarium to treat these formidable lesions. The rationale, surgical technique, and complications are discussed. METHODS: Three illustrative cases are described, in which the lesions were a VA dissecting aneurysm with ischemic lesions, bilateral asymptomatic unruptured VA aneurysms, and a VA giant aneurysm with subarachnoid hemorrhage. RESULTS: The partial extreme lateral infrajugular transcondylar approach was used. Computed tomographic angiography was useful for preoperative evaluation of the depth of the distal aneurysmal neck. A VA-VA bypass was performed in two patients. Because there was another ipsilateral aneurysm at the V2 segment in one patient, an external carotid artery-VA bypass was performed. Although two patients were discharged with good clinical results, one patient with subarachnoid hemorrhage died because of brainstem infarction. CONCLUSIONS: The VA-VA bypass using a radial artery graft or an occipital artery graft is an option that can be considered in the strategy for treating VA aneurysms to preserve the normal anatomic vascular configuration in the posterior circulation.

Endovascular management of vertebral artery disease.

Symptomatic disease of the vertebrobasilar circulation is often underdiagnosed and undertreated. In recent years, endovascular revascularization of vertebral artery stenosis has been heralded as a less invasive treatment option in comparison to open surgery, with the inherent risk of morbidity. Although a growing number of case reports and small nonrandomized case series suggest that endovascular intervention in the posterior circulation may be safe and technically feasible, the safety and benefit of angioplasty and stent placement in cases of symptomatic vertebral disease, as compared with the most effective medical therapy, remains to be elucidated.