eMedicine Specialties > Neurosurgery > Vascular

Vertebral Artery Atherothrombosis: Treatment

Author: Mark K Eskandari, MD, Associate Professor, Departments of Radiology and Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University; Attending Surgeon, Division of Vascular Surgery, Northwestern Memorial Hospital; Consulting Staff, Division of Vascular Surgery, Northwestern Medical Faculty Foundation; Consulting Staff, Department of Surgery, Jesse Brown Veterans Affairs Medical Center; Consulting Staff, Department of Surgery, Evanston Northwestern Healthcare
Coauthor(s): Mark D Morasch, MD, Clinical Practice Director, Division of Vascular Surgery, Assistant Professor of Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine
Contributor Information and Disclosures

Updated: Feb 20, 2007

Treatment

Medical Therapy

Patients with symptomatic vertebrobasilar ischemia who are not amenable to surgery or investigational endoluminal therapy may be treated medically with long-term anticoagulation to prevent thrombosis.

Surgical Therapy

Previous experience has shown that with appropriate diagnosis and surgical correction, complete resolution of hemodynamic and embolic symptoms can occur predictably. Vertebral artery reconstruction can be performed successfully with fewer ischemic complications than carotid artery surgery and with durable long-term results. The location of disease dictates the type of surgical reconstruction required.

Intraoperative Details

The two main options for treating offending ostial lesions (V1 segment) are transposition of the proximal vertebral artery onto the common carotid artery or vertebral artery bypass. The bypass can originate from either the common carotid artery or the adjacent subclavian artery (see Image 4). Choices of conduit include either saphenous vein grafts or prosthetic material (polytetrafluoroethylene [PTFE] or Dacron). Subclavian-vertebral artery endarterectomy is less commonly performed.

The V2 segment, which ascends within the foramina of the cervical vertebrae, is the site of a wide variety of disorders. External compression is most likely to occur in this segment because of osteophytes, the edge of the transverse foramina, or the intervertebral joints. Positional changes, such as rotation or extension of the neck, usually trigger compression of the vertebral artery in this segment. The V2 segment is also the site of aneurysmal degeneration (see Image 5), fibromuscular diseases, and embolizing atherosclerotic plaques (see Image 6).

Elective surgical reconstruction is very rarely undertaken within this segment; however, ligation (at the C1-C2 level) and bypass to the distal (V3 segment) vertebral artery may be indicated. Extrinsic lesions can be corrected to relieve kinking or compression of the artery. The most common indication for exposure of this segment of the artery is for control of hemorrhage, which is best relieved with proximal and distal ligation of the artery. An alternative for traumatic injuries to the V2 segment includes coil embolization. Neither of these has been associated with worsening neurologic sequelae.

Reconstruction of the distal (V3 segment) vertebral artery is usually performed at the C1-C2 level. The techniques most often used to reconstruct the distal vertebral artery at this level include (1) saphenous vein bypass from the common carotid, subclavian, or proximal vertebral artery; (2) transposition of the external carotid or hypertrophied occipital artery to the distal vertebral; and (3) transposition of the distal vertebral artery to the side of the distal internal carotid artery.

More distal pathology can be accessed surgically above the level of the transverse process of C1. At this level, the vertebral artery is vulnerable to direct trauma and stretch injuries that can lead to intimal damage, thrombosis, embolization, and dissection. This segment is also prone to arteriovenous fistula formation and aneurysmal degeneration. Surgical exposure at the suboccipital segment requires resection of the C1 transverse process and part of its posterior arch. Reconstruction at this level is limited to saphenous vein bypass from the distal internal carotid artery.

Postoperative Details

Postoperatively, patients should be monitored and should receive long-term antiplatelet therapy (eg, aspirin).

Follow-up

Follow-up care and monitoring is primarily based on clinical assessment of recurrent symptoms. The presence of new symptoms consistent with vertebrobasilar ischemia mandates imaging studies as previously outlined.

Complications

The perioperative complication rates differ for proximal versus distal vertebral artery repairs. The technically easier proximal operations have been reported to have a combined morbidity/mortality rate of 0.9%. Distal reconstructions have a combined morbidity/mortality rate of 3-4%. Perioperative complications include stroke, hematoma, thrombosis, lymphocele, and nerve injury (eg, Horner syndrome, spinal accessory nerve, vagus nerve). The occurrence of ptosis (drooping of the eyelid) on the operative side is a known complication of proximal vertebral artery reconstructions. This condition is usually temporary and is attributed to a traction injury of the lower cervical sympathetic nerves.

• Search for CME/CE on This Topic »