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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 132-135

Vertebral-carotid transposition can treat various diseases


1 Department of Vascular Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
2 National Center for Cardiovascular Disease, Department Party and Government Office, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China

Date of Submission15-Jun-2020
Date of Decision16-Jun-2020
Date of Acceptance17-Jun-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Chenxi Ouyang
Department of Vascular Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, 167 Beilishi Road, Xi Cheng District, Beijing 100037
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_18_20

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  Abstract 


Vertebral-carotid transposition (VCT), which is a treatment of vertebral artery stenosis, has excellent long-term efficacy. VCT can also be suitable for various situations where the blood supply of the vertebral artery must be reconstructed. Here, we present an early result of six cases for these anomalies by VCT. Case 1: A 58-year-old male presented with the severe stenosis at the left vertebral V1 segment. Case 2: A 59-year-old female suffered from moderate-to-severe stenosis at the first portion of the left subclavian artery. Case 3: A 55-year-old female experienced severe stenosis at the left vertebral V1 segment, which the wire could not pass through. Case 4: A 53-year-old female presented with the subclavian aneurysm at the origin of the right vertebral artery. Case 5: A 65-year-old male suffered from the long complete occlusion at the origin of the left subclavian artery, a severe stenosis at the origin of the left internal carotid artery, a severe stenosis at the origin of the right internal carotid artery, and a severe stenosis at the right vertebral V1 segment. Case 6: A 56-year-old male experienced the thrombus in the stent of the vertebral artery which had been placed 6 months ago. There are six cases, in which VCT was adapted. VCT is safe and effective for various situations when the blood supply of the vertebral artery must be reconstructed.

Keywords: Subclavian aneurysm, vertebral V1 segment, vertebral-carotid transposition


How to cite this article:
Gu Y, Sun Y, Ren J, Ouyang C. Vertebral-carotid transposition can treat various diseases. Vasc Invest Ther 2020;3:132-5

How to cite this URL:
Gu Y, Sun Y, Ren J, Ouyang C. Vertebral-carotid transposition can treat various diseases. Vasc Invest Ther [serial online] 2020 [cited 2021 Jan 26];3:132-5. Available from: https://www.vitonline.org/text.asp?2020/3/4/132/304835




  Introduction Top


Vertebral-carotid transposition (VCT) has been proved to be a safe and effective treatment for patients with vertebral artery stenosis and provide wonderful long-term patency, stroke protection, and symptomatic relief.[1],[2] In recent years, more and more patients choose endovascular interventions because of no invasive, less postoperative complications, and lower mortality.[3],[4] However, VCT with significant advantages treats various situations when the blood supply of the vertebral artery must be reconstructed. The patients consent form has been obtained from all. The following will introduce these various situations.


  Case Reports Top


Case 1

A 58-year-old male smoker with a history of diabetes presented with paroxysmal dizziness for 6 years, and the symptom of dizziness was exacerbated in the past 6 months. Computed tomography angiography (CTA) revealed severe stenosis at the left vertebral V1 segment and a hypoplastic right vertebral artery [Figure 1]a. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. VCT was performed to anastomose the distal left vertebral artery to the posterior lateral wall of the left common carotid artery [Figure 1]b. The symptom of dizziness completely disappeared after surgery. The patient had no postoperative complications.
Figure 1: A 58-year-old male presented with left vertebral artery stenosis and underwent the successful vertebral-carotid transposition. (a) The preoperative computed tomography angiography depicted a severe stenosis of the left vertebral V1 segment (red arrowhead), a hypoplastic right vertebral artery (yellow arrowhead). (b) The postoperative computed tomography angiography indicated a successful transposition of left vertebral artery to common carotid artery (red arrowhead)

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Case 2

A 59-year-old female with a history of hyperlipidemia complained of paroxysmal dizziness. CTA revealed a moderate-to-severe stenosis at the first portion of the left subclavian artery and a hypoplastic right vertebral artery [Figure 2]a. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. VCT was performed to anastomose the distal left vertebral artery to the posterior lateral wall of the left common carotid artery [Figure 2]b. The symptom of dizziness completely disappeared after surgery. The patient had neither left upper limb ischemic symptoms nor postoperative complications.
Figure 2: A 59-year-old female presented with left subclavian artery stenosis and underwent the successful vertebral-carotid transposition. (a) The preoperative computed tomography angiography depicted a moderate-to-severe stenosis at the first portion of the left subclavian artery (red arrowhead). (b) The postoperative computed tomography angiography indicated a successful transposition of left vertebral artery to common carotid artery (red arrowhead), a moderate-to-severe stenosis at the first portion of the left subclavian artery (yellow arrowhead)

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Case 3

A 55-year-old female with a history of hyperlipidemia and hypertension complained of paroxysmal dizziness for 2 years. CTA revealed severe stenosis at the left vertebral V1 segment [Figure 3]a. Endovascular angiography/stenting had been tried but without success, because the wire could not pass through the stenosis. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. VCT was performed to anastomose the distal left vertebral artery to the posterior lateral wall of the left common carotid artery [Figure 3]b. The symptom of dizziness completely disappeared after surgery. The patient had no postoperative complications.
Figure 3: A 55-year-old female presented with left vertebral artery stenosis and underwent the successful vertebral-carotid transposition. (a) The preoperative computed tomography angiography depicted a severe stenosis at the left vertebral V1 segment (yellow arrowhead). (b) The postoperative computed tomography angiography indicated a successful transposition of left vertebral artery to common carotid artery (yellow arrowhead)

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Case 4

A 53-year-old female with a history of thoracic aortic stenting complained of paroxysmal dizziness. CTA revealed a subclavian aneurysm at the origin of the right vertebral artery [Figure 4]a. Interventional therapy was failure because the stent flushed to the distal right subclavian artery by blood flow. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. VCT was performed to anastomose the distal right vertebral artery to the posterior lateral wall of the right common carotid artery. During VCT performing, the stent was taken out, and the subclavian aneurysm was replaced by a length suitable artificial blood vessel [Figure 4]b. The symptom of dizziness completely disappeared after surgery. The patient had some postoperative complications (incisional hematoma and Horner syndrome).
Figure 4: A 53-year-old female presented with left right Subclavian aneurysm and underwent the successful vertebral-carotid transposition and subclavian aneurysm resection. (a) The preoperative computed tomography angiography depicted a subclavian aneurysm at the origin of the right vertebral artery (yellow arrowhead). (b) The postoperative computed tomography angiography indicated a successful subclavian aneurysm resection (yellow arrowhead) and a successful vertebral-carotid transposition (red arrowhead)

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Case 5

A 65-year-old male with a history of hyperlipidemia and hypertension presented with asphygmia of the left upper extremity. CTA revealed a long complete occlusion at the origin of the left subclavian artery, a hypoplastic left vertebral artery, a severe stenosis at the origin of the left internal carotid artery, a severe stenosis at the origin of the right internal carotid artery, and a severe stenosis at the right vertebral V1 segment [Figure 5]a and [Figure 5]b. To maximize the blood supply to the patient's brain, carotid endarterectomy (CEA) and VCT need to be performed simultaneously in the right neck. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. CEA with patchplasty was performed before VCT [Figure 5]c. The patient had no postoperative complications.
Figure 5: A 65-year-old male presented with left subclavian artery occlusion and underwent the successful vertebral-carotid transposition and carotid endarterectomy. (a) The preoperative computed tomography angiography depicted a hypoplastic left vertebral artery (yellow arrowhead), a severe stenosis at the origin of the left internal carotid artery (purple arrowhead), a severe stenosis at the origin of the right internal carotid artery (red arrowhead). (b) The preoperative computed tomography angiography depicted a long complete occlusion at the origin of the left subclavian artery (red arrowhead), a severe stenosis at the right vertebral V1 segment (yellow arrowhead). (c) The postoperative computed tomography angiography indicated a successful transposition of right vertebral artery to common carotid artery (yellow arrowhead) and a successful carotid endarterectomy (red arrowhead)

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Case 6

A 56-year-old male with a history of stenting for symptomatic stenosis of the left vertebral V1 segment a half year ago presented with paroxysmal dizziness. CTA revealed a thrombus in the stent [Figure 6]a. A longitudinal skin incision was made along the anterior margin of the sternocleidomastoid muscle. The stent with a thrombus was taken out, and VCT was performed to anastomose the distal left vertebral artery to the posterior lateral wall of the left common carotid artery [Figure 6]b and [Figure 6]c. The symptom of dizziness completely disappeared after surgery. The patient had no postoperative complications.
Figure 6: A 56-year-old male presented with thrombus in the left vertebral artery stent and underwent the successful vertebral-carotid transposition. (a) The preoperative computed tomography angiography depicted a thrombus in the left vertebral artery stent (red arrowhead). (b) The left vertebral artery stent with the thrombus. (c) The postoperative computed tomography angiography indicated a successful vertebral-carotid transposition (red arrowhead)

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  Discussion Top


Ehrenfeld et al. first reported VCT in 1969, in which vertebral artery was anastomosed to the ipsilateral common carotid artery.[5] In recent years, more and more patients choose endovascular interventions owing to their less trauma, less postoperative complications, and lower mortality.[3],[4] However, the long-term patency of VCT is satisfactory. In 2000, Berguer et al. reported that the 5-year patency rate of VCT can reach 80%.[6] In 2002, Kieffer et al. reported that the 5-year patency rate of VCT was 89.3% and the 10-year patency rate was 88.1%.[7]

The transverse incision of the supraclavicular fossa was used in the traditional VCT. In our center, the longitudinal skin incision along the anterior margin of the sternocleidomastoid muscle was used in VCT can fully expose the common carotid artery, subclavian artery, and vertebral artery. Longitudinal skin incision allows us to expose the internal carotid artery and external carotid artery by extending the skin incision upward. For patients with the ipsilateral carotid artery and vertebral V1 segment stenosis, CEA and VCT can be performed simultaneously through the longitudinal skin incision. VCT can not only treat patients with the stenosis at vertebral V1 segment, the stenosis at the origin of subclavian artery (without upper limb ischemic symptoms), failure intervention therapy, and thrombosis after stenting, but also can be combined with subclavian aneurysm resection to treat the subclavian aneurysm in the origin of vertebral artery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

  1. National Key R and D Program of China, Item No.: 2018YFC1105500.
  2. Beijing Municipal Science & Technology, Item No.: Z191100007619039.


Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sandmann W, Kniemeyer HW, Jaeschock R, Hennerici M, Aulich A. The role of subclavian-carotid transposition in surgery for supra-aortic occlusive disease. J Vasc Surg 1987;5:53-8.  Back to cited text no. 1
    
2.
Berguer R, Feldman AJ. Surgical reconstruction of the vertebral artery. Surgery 1983;93:670-5.  Back to cited text no. 2
    
3.
Binning MJ, Hopkins LN. Vascular disease: Endovascular treatment of vertebral artery stenosis. Nat Rev Cardiol 2010;7:245-6.  Back to cited text no. 3
    
4.
Ahmed AT, Mohammed K, Chehab M, Brinjikji W, Murad MH, Cloft H, et al. Comparing percutaneous transluminal angioplasty and stent placement for treatment of subclavian arterial occlusive disease: A systematic review and meta-analysis. Cardiovasc Intervent Radiol 2016;39:652-67.  Back to cited text no. 4
    
5.
Ehrenfeld WK, Chapman RD, Wylie EJ. Management of occlusive lesions of the branches of the aortic arch. Am J Surg 1969;118:236-43.  Back to cited text no. 5
    
6.
Berguer R, Flynn LM, Kline RA, Caplan L. Surgical reconstruction of the extracranial vertebral artery: Management and outcome. J Vasc Surg 2000;31:9-18.  Back to cited text no. 6
    
7.
Kieffer E, Praquin B, Chiche L, Koskas F, Bahnini A. Distal vertebral artery reconstruction: Long-term outcome. J Vasc Surg 2002;36:549-54.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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