Radical treatment for bilateral vertebral artery dissecting aneurysms by reconstruction of the vertebral artery

Abstract

OBJECTIVE Bilateral vertebral artery dissecting aneurysms (VADAs) have a poor prognosis because progressive enlargement of the aneurysms compresses the brainstem or causes subarachnoid hemorrhage. The trapping of 1 vertebral artery (VA) places increased hemodynamic stress on the contralateral VA and may lead to enlargement and rupture. Therefore, management strategies are controversial. This study describes a radical treatment for bilateral VADAs using bypass surgery. METHODS Seven patients with bilateral VADAs were included. Three patients were treated by trapping of 1 VA via coiling or clipping at another hospital; the previously treated VA in 1 patient and the contralateral untreated VA in 2 patients subsequently enlarged. The other 4 patients presented without previous intervention and progressive enlargement of the aneurysms. RESULTS The post-coil embolization patients underwent V₃-posterior cerebral artery (PCA) bypass and trapping. The other 4 patients underwent VA reconstruction via V₃-V₄ or V₄-V₄ bypass, with contralateral trapping on a separate day in 3 patients and observation in 1 patient. Perioperative complications included 1 case of cerebrospinal fluid leakage for which the patient required an additional operation, 1 case of dysphagia and facial palsy due to sigmoid sinus thrombosis, and 1 case of dysphagia. The long-term outcomes of these patients were favorable. CONCLUSIONS Patients with bilateral VADAs require treatment on both sides. If VA trapping is performed first, the treatment options for the other side are limited to V₃-PCA bypass and trapping. This procedure is effective; however, it is also invasive and technically difficult. In cases of bilateral VADAs in which it is feasible to reconstruct 1 side, the best approach is to begin by reconstructing the VA that appears technically easiest, followed by trapping of the contralateral VADA. This strategy allows enough time to suture vessels because contralateral reverse flow is maintained.

Keywords: AICA = anterior inferior cerebellar artery; CN = cranial nerve; CTA = CT angiography; OA = occipital artery; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; RAG = radial artery graft; SAH = subarachnoid hemorrhage; SCA = superior cerebellar artery; STA = superficial temporal artery; SVG = saphenous vein graft; V3-PCA bypass; V3–V4 bypass; V4–V4 bypass; VA = vertebral artery; VADA = VA dissecting aneurysm; bilateral vertebral artery dissecting aneurysm; mRS = modified Rankin Scale; vascular disorders; vascular reconstruction.