A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease.

PURPOSE

The aim of our study was to assess the outcome of distal vertebral artery (VA) reconstructions through a retrospective review conducted at a university-affiliated referral center.

METHODS

One hundred consecutive distal VA reconstructions had been performed during a period of 14 years (98 patients) and included reversed saphenous vein bypass from the ipsilateral common, internal, or external carotid to the third portion of the VA at the C1-2 level (68 reconstructions) or the C0-1 level (4); transposition of the external carotid or its occipital branch to the VA (23); and transposition of the third portion of the VA onto the internal carotid artery (2). Other methods were used in 3 additional patients. Eighteen patients underwent concomitant carotid operations, and 1 patient underwent a concomitant subclavian transposition. Symptoms were present in 98% of patients and included vertebrobasilar ischemia (89%), vertebrobasilar plus hemispheric ischemia (7%), and hemispheric ischemia (2%). Two asymptomatic patients with bilateral carotid occlusions underwent operations to provide a single artery for cerebral perfusion (2%). Sixty-three lesions were atherosclerotic, 18 were dynamic bony compressions, and 14 were dissection, fibromuscular dysplasia, arteritis, or aneurysm. Five had miscellaneous anatomic indications.

RESULTS

Stroke caused the four perioperative deaths that occurred. There was one occurrence of nonfatal hemispheric stroke. Routine postoperative arteriography identified 16 graft abnormalities; 11 patients underwent attempted revision. The introduction of the use of intraoperative angiography in 1990, halfway through the series, lowered the incidence of graft abnormalities from 28% to 4% and the incidence of perioperative death from 6% to 2%. Eighty-seven percent of patients had complete or significant resolution of symptoms. Follow-up ranged from 1 to 168 months (mean, 79 months). Ten patients were lost to follow-up. Twenty late deaths occurred; none were stroke related. Five reconstructions required late revision. The cumulative primary patency at 5 and 10 years was 75% +/- 6 and 70% +/- 7 (mean +/- SE), respectively; cumulative secondary patency was 84% +/- 5 and 80% +/- 6 at 5 and 10 years, respectively. Median survival was 107 months.

CONCLUSIONS

Distal VA reconstruction provides excellent long-term patency and stroke protection. Intraoperative angiography is mandatory.