E-028 Stenting and angioplasty of a symptomatic long segment extracranial vertebral artery occlusion. (16th November 2010) - Sivapatham, T
Abstract : Introduction: We report a case of successful revascularization of a symptomatic long segment extracranial vertebral artery occlusion using stenting and angioplasty. A 55-year-old man with a history of tobacco abuse, hypertension and hyperlipidemia presented with dysarthria and diplopia that occurred 3 weeks earlier. The patient was noted to have bilateral vertebral artery occlusions on CT angiography and acute infarcts involving the posterior circulation on MRI. He was placed on dual antiplatelet therapy with aspirin 325 mg daily and clopidogrel 75 mg daily along with a lipid lowering agent. The patient had recurrent symptoms despite medical therapy. He was referred to our institution for further management. Materials and methods: Cerebral angiogram revealed a total occlusion of the left vertebral artery and a long segment occlusion of the extracranial right vertebral artery that reconstituted via muscular branches and thyrocervical branches. The intracranial posterior circulation remained patent due to these collaterals. No posterior communicating arteries were present. After a detailed discussion regarding surgical and endovascular options, we proceeded with the endovascular approach. The patient was placed under general anesthesia. A platelet aggregation panel prior to the procedure confirmed adequate platelet inhibition for both aspirin and clopidogrel. Intravenous heparin was administered to maintain an activated clotting time of 250–300 s throughout the procedure. A femoral artery approach was used and a 5 F diagnostic catheter was exchanged for a 6 F 90 cm Cook shuttle sheath that was positioned in the right subclavian artery for support. A 6 F Envoy guide catheter (100 cm length) was coaxially placed through the shuttle sheath into the stump of the vertebral artery. A Rapid Transit microcatheter and 0.014 in Synchro-2 microwire were initially used to attempt navigation across the occluded segment but were unsuccessful. The wire was replaced with a 0.018 in V-18 microwire and we were able to navigate across the occlusion with this wire/catheter combination. The catheter was removed over a 300 cm Transend floppy exchange wire and a total of five drug eluting, balloon-mounted Xience V stents were deployed in a telescoping fashion from the mid-cervical vertebral artery to the vertebral artery origin. Results: Post-stent angiography demonstrated good antegrade flow through the cervical vertebral artery. The patient recovered from anesthesia with no new neurologic deficits. Conclusion: Revascularization of a long segment total occlusion of the extracranial vertebral artery can be performed safely using endovascular techniques in symptomatic patients.