Pellenc Quentin, Renard Régis, Gaudemer Augustin, Amarenco Pierre, Lavallée Philippa
Department of Vascular and Endovascular Surgery, La Cote HealthCare Group, EHC Hospital, Morges, Switzerland.
Marfan Syndrome and Related Disorders National Referral Center, Bichat University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
J Vasc Surg Cases Innov Tech. 2023 Jul 5;9(3):101260. doi: 10.1016/j.jvscit.2023.101260. eCollection 2023 Sep.
Symptomatic vertebrobasilar atherosclerotic disease is rarely encountered but represents a high-risk factor for recurrent transient ischemic attack or stroke. Posterior strokes are usually associated with embolism or hemodynamic impairment. Extensive disease involving the V3 and V4 segments of the vertebral artery (VA) remains infrequent, and optimal management is limited owing to the infrequency of this disease. We illustrate the case of a 65-year-old man who presented with recurrent transient episodes of dizziness with acute onset of instability, nausea, and left visual blurring. Magnetic resonance imaging findings of the head were normal, and computed tomography angiography revealed severe atherosclerotic disease of both VAs, with proximal occlusion of the right VA and multiple tight stenoses of the left VA at the V1 and V4 segments. Duplex ultrasound found markedly reduced anterograde flow in the VAs and basilar arteries and nonsignificant stenosis of the internal carotid arteries. Optimal medical treatment led to a decrease of transient symptoms. However, the patient developed a cerebellar infarction in the left posteroinferior cerebellar artery territory with left VA V4 segment occlusion. Surgical revascularization of the right VA was decided by the multidisciplinary team. Through an anterolateral approach of the right VA V3 segment, revascularization was performed using a common carotid artery-to-right VA bypass using a reversed saphenous vein graft. The patient fully recovered and was free of symptoms during the next 14 months of follow-up. In the case of extensive VA occlusive disease, surgical reconstruction of the distal VA using a bypass from the common carotid artery represents an option to improve hemodynamics and/or eliminate an embolic source of posterior stroke on a case-by-case basis.
有症状的椎基底动脉粥样硬化疾病很少见，但却是复发性短暂性脑缺血发作或中风的高危因素。后部中风通常与栓塞或血流动力学损害有关。累及椎动脉（VA）V3和V4段的广泛性疾病仍然少见，由于这种疾病罕见，最佳治疗方法有限。我们举例说明一名65岁男性患者，他出现反复发作的短暂性头晕，伴有急性发作的不稳、恶心和左眼视物模糊。头部磁共振成像检查结果正常，计算机断层血管造影显示双侧椎动脉严重粥样硬化疾病，右侧椎动脉近端闭塞，左侧椎动脉在V1和V4段有多处严重狭窄。双功超声检查发现椎动脉和基底动脉的顺行血流明显减少，颈内动脉无明显狭窄。最佳药物治疗使短暂性症状有所减轻。然而，患者在左侧椎动脉V4段闭塞后，在左后下小脑动脉区域发生了小脑梗死。多学科团队决定对右侧椎动脉进行手术血运重建。通过右侧椎动脉V3段的前外侧入路，使用倒置的大隐静脉移植物进行颈总动脉至右侧椎动脉搭桥术进行血运重建。患者完全康复，在接下来14个月的随访中无症状。对于广泛性椎动脉闭塞性疾病，根据具体情况，使用颈总动脉搭桥对远端椎动脉进行手术重建是改善血流动力学和/或消除后部中风栓子来源的一种选择。
