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Rossi SS, Iaccarino G, Bonura A, Calandrelli R, Spinelli F, Montelione N, Paraskevas KI, Di Lazzaro V, Stilo F, Pilato F. Exploring vertebral artery stump syndrome: An overlooked cause of posterior ischemic strokes. A narrative review of current management options. J Stroke Cerebrovasc Dis 2024; 33:107819. [PMID: 38878845 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/31/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION Stump syndrome is defined as a clinical syndrome resulting from a distal intracranial vessel embolic stroke due to an extracranial vessel occlusion. Similar to the anterior circulation, the recurrence of ischemic strokes in territories supplied by the posterior circulation in the presence of vertebral artery occlusion is termed Vertebral Artery Stump Syndrome (VASS). MATERIAL AND METHODS We conducted a literature review, identifying 72 patients with transient ischemic attacks (TIAs) or ischemic strokes attributed to VASS, according to Kawano criteria. We categorized all patients in two groups focusing on the therapeutic management those who underwent primary medical treatment and those who received endovascular or surgical treatment either in acute or chronic phase. RESULTS In the anticoagulant therapy group, only 1 patient had a stroke recurrence. Among the 4 on antiplatelets, all had recurrences, but 3 benefited from switching to anticoagulants or endovascular therapy. In the endovascular therapy group, worse outcomes were linked to acute large vessel occlusion. Endovascular treatment of the vertebral artery, in a chronic phase, was explored in literature for recurrent TIAs or minor strokes suggesting that this could be a viable therapeutic alternative when medical treatment failed in preventing recurrence of ischemic stroke. CONCLUSIONS Some studies suggest that anticoagulant medical therapy may be beneficial for VASS and endovascular therapy has also been reported for selected patients. However, data on treatment outcomes and prognosis are still underreported, making treatment decisions challenging. Randomized Controlled Trials are needed to establish the optimal treatment approach.
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Affiliation(s)
- Sergio Soeren Rossi
- Research Unit of Neurology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy
| | - Gianmarco Iaccarino
- Research Unit of Neurology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy
| | - Adriano Bonura
- Research Unit of Neurology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy
| | - Rosalinda Calandrelli
- Radiology and Neuroradiology Unit, Department of Imaging, Radiation Therapy and Hematology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Spinelli
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy; Vascular Surgery Division, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - Nunzio Montelione
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy; Vascular Surgery Division, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | | | - Vincenzo Di Lazzaro
- Research Unit of Neurology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy
| | - Francesco Stilo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy; Vascular Surgery Division, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy
| | - Fabio Pilato
- Research Unit of Neurology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Rome, Italy.
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Liu L, Wu J, Li A, Teng J, Jin Y, Ma B. The morphology of occlusion stump for endovascular recanalization in non-acute vertebral ostial occlusion. J Clin Neurosci 2024; 120:55-59. [PMID: 38194727 DOI: 10.1016/j.jocn.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE Non-acute vertebral ostial occlusion (VOO) is a debilitating condition with significant mortality and morbidity rates. However, currently, there is no consensus on the optimal treatment strategy for VOO. This study aims to examine the feasibility, effectiveness, and safety of endovascular recanalization in patients with VOO. METHODS We conducted a retrospective review of data from 21 consecutive patients with VOO who underwent endovascular recanalization between May 2018 and August 2023. The patients were divided into two groups based on a new angiographic classification proposed by Gao et al. Type I (tapered stump group) included patients with non-acute extracranial vertebral artery ostial occlusion presenting a tapered occlusion stump. Type II (nontapered stump group) consisted of patients with a nontapered occlusion stump. We collected data on recanalization rates, perioperative complications, and follow-up outcomes. RESULTS Our analysis included data from a total of 21 patients (22 lesions) with a mean age of 64.6 ± 10.6 years. The technical success rate was 66.7 % (14/21), and the rate of periprocedural complications was 14.3 % (3/21). The success rate of transitioning from the tapered stump group to the nontapered stump group was 90.9 % (10/11) and 40 % (4/10), respectively (P = 0.024). The perioperative complication rate for type I and type II patients was 18.2 % (2/11) and 10 % (1/10), respectively. Among these patients, 18 cases underwent endovascular recanalization using transfemoral access, while 3 patients underwent transradial access after failed transfemoral access, with successful outcomes for two patients. CONCLUSIONS This study suggests that endovascular recanalization may offer a safe, effective, and feasible treatment option for VOO patients. Additionally, the proposed angiographic classification may serve as a useful guide in selecting suitable candidates for surgery.
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Affiliation(s)
- Longlong Liu
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Jianming Wu
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Ailing Li
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Jingqian Teng
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Yuwen Jin
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Binwu Ma
- Department of Neurology, General Hospital of Ningxia Medical University, Yinchuan, China.
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Qiu H, Kang Z, Sun D, Mei B, Zhang J. Case report: Retrograde endovascular recanalization of vertebral artery occlusion with non-tapered stump via the deep cervical collateral. Front Neurol 2023; 14:1246151. [PMID: 37799285 PMCID: PMC10548121 DOI: 10.3389/fneur.2023.1246151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/25/2023] [Indexed: 10/07/2023] Open
Abstract
Introduction Vertebral artery (VA) occlusive disease is the major cause of posterior circulation ischemic stroke. Endovascular recanalization has been reported as a feasible treatment for patients with symptomatic VA occlusion refractory to optimal medical therapy. However, VA occlusion with non-tapered stump exhibits a low technique success rate when treated by antegrade endovascular therapy because of increased difficulty in passing the guidewire into the occluded segment. Herein, we presented a novel endovascular approach to recanalize chronically occluded VA with a non-tapered stump using a retrograde method via the deep cervical collateral, which has not been reported before. Case presentation The present case was a patient with VA ostial occlusion with non-tapered stump and distal severe stenosis of the left VA who had recurrent posterior circulation transit ischemic attacks under optimal medical therapy. CT angiography demonstrated proximal non-tapered occlusion and distal severe stenosis of the left VA, and that the right VA did not converge with the left VA into basilar artery. Endovascular treatment was recommended and performed on this patient. However, antegrade endovascular recanalization of the left VA origin occlusion failed because the micro guidewire was unable to traverse the occluded segment. Fortunately, robust collateral from the deep cervical artery to the V3 segment of the left VA developed, in which we advanced the micro guidewire to the V3 segment of the left VA and reversely passed the micro guidewire through the occluded segment. Then, the occlusion and stenosis of the left VA were successfully resolved with angioplasty and stenting. After the procedure, the patient reported no neurological symptoms under medical therapy during 3-month follow-up. Conclusion Antegrade endovascular recanalization of VA occlusion with a non-tapered stump is a challenge. The retrograde endovascular method via the cervical collateral may be an alternative for this type of VA occlusion, which requires further exploration.
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Affiliation(s)
- Han Qiu
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Hubei Province Clinical Research Center for Dementia and Cognitive Impairment, Wuhan, Hubei, China
| | - Zhiming Kang
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Hubei Province Clinical Research Center for Dementia and Cognitive Impairment, Wuhan, Hubei, China
| | - Dong Sun
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Hubei Province Clinical Research Center for Dementia and Cognitive Impairment, Wuhan, Hubei, China
| | - Bin Mei
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Hubei Province Clinical Research Center for Dementia and Cognitive Impairment, Wuhan, Hubei, China
| | - Junjian Zhang
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
- Hubei Province Clinical Research Center for Dementia and Cognitive Impairment, Wuhan, Hubei, China
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Okamoto A, Nakagawa I, Kotsugi M, Yokoyama S, Yamada S, Park YS, Nakase H. Endovascular vertebral artery orifice angioplasty for the prevention of acute ischemic stroke following vertebral artery stump syndrome. Surg Neurol Int 2022; 13:382. [PMID: 36128121 PMCID: PMC9479644 DOI: 10.25259/sni_515_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Vertebral artery stump syndrome (VASS) involves repeated acute ischemic stroke (AIS) in the posterior circulation following vertebral artery (VA) orifice occlusion. The presence of VA orifice occlusion makes endovascular thrombectomy (EVT) difficult to achieve and leads to posterior circulation stroke with unfavorable functional outcomes. Here, we report a case of endovascular VA orifice angioplasty for the right VA pseudo-occlusion to prevent AIS following VASS pathology. Case Description: In a 76-year-old man presenting with dizziness, angiography revealed right pseudo-occluded VA at the origin concomitant with the left VA occlusion. The posterior circulation depended on the right VA through collateral flow to the distal portion. Prophylactic endovascular VA angioplasty for the right pseudo-occluded VA at the orifice was achieved to prevent AIS with tandem lesions. In the present case, endovascular VA angioplasty can prevent acute embolic stroke in the posterior circulation following EVT-resistant VASS pathology. Conclusion: Clinicians should be aware that EVT is not easy in AIS following VASS due to access difficulties and the treatment strategy should be carefully considered.
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Zhang H, Han J, Sun X, Miao Z, Guo X, Xu G, Sun Y, Wen C, Wang C, Wu Y, Xu Y, Jiang Y, Zhang S, Liu C, Li D, Liu Y, Xu C, Gao F. Endovascular Recanalization and Standard Medical Management for Symptomatic Non-acute Intracranial Artery Occlusion: Study Protocol for a Non-randomized, 24-Month, Multicenter Study. Front Neurol 2021; 12:729534. [PMID: 34650509 PMCID: PMC8506001 DOI: 10.3389/fneur.2021.729534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The management of patients with symptomatic non-acute intracranial artery occlusion (sNA-ICAO), which is a special subset with high morbidity and a high probability of recurrent serious ischemic events despite standard medical therapy (SMT), has been clinically challenging. A number of small-sample clinical studies have also discussed endovascular recanalization (ER) for sNA-ICAO; however, there is currently a lack of evidence from multicenter, prospective, large-sample cohort trials. The purpose of our present study was to evaluate the technical feasibility and safety of ER for sNA-ICAO. Methods: Our group is currently undertaking a multisite, non-randomized cohort, prospective registry study enrolling consecutive patients presenting with sNA-ICAO at 15 centers in China between January 1, 2020 and December 31, 2022. A cohort of patients who received SMT and a cohort of similar patients who received ER plus SMT were constructed and followed up for 2 years. The primary outcome is any stroke from enrollment to 2 years of follow-up. The secondary outcomes are all-cause mortality, mRS score, NIHSS score and cognitive function from enrollment to 30 days, 3 months, 8 months, 12 months, 18 months, and 2 years of follow-up. Descriptive statistics and linear/logistic multiple regression models will be generated. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat. Discussion: The management of patients with sNA-ICAO has been clinically challenging. The current protocol aims to evaluate the technical feasibility and safety of ER for sNA-ICAO. Trial Registration Number:www.ClinicalTrials.gov, identifier: NCT04864691.
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Affiliation(s)
- Huijun Zhang
- Department of Neurology, Tong Ren Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianjia Han
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xu Guo
- Department of Neurology, Beijing Anzhen Hospital, Beijing, China
| | - Guodong Xu
- Department of Neurology, Hebei General Hospital, Shijiazhuang, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Chao Wen
- Department of Neurology, Taiyuan Central Hospital, Taiyuan, China
| | - Chaobin Wang
- Department of Neurology, Liangxiang Teaching Hospital, Beijing, China
| | - Yingchun Wu
- Department of Neurology, ORDOS Central Hospital, Ordos, China
| | - Yaoming Xu
- Department of Neurology, TongLiao City Hospital, Tongliao, China
| | - Yuanfei Jiang
- Department of Neurology, Tai'an Hospital of Traditional Chinese Medicine, Tai'an, China
| | - Shiyong Zhang
- Department of Interventional Neurology, Beijing You'anmen Hospital, Beijing, China
| | - Chao Liu
- Department of Neurology, Handan Central Hospital, Handan, China
| | - Di Li
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, China
| | - Yan Liu
- Department of Neurology, Jingjiang People's Hospital, Taizhou, China
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, Taizhou, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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Yamano A, Nakai Y, Akutagawa K, Igarashi H, Tsukada K, Terakado T, Uemura K, Ishikawa E. Fatal recurrent ischemic stroke caused by vertebral artery stump syndrome. Surg Neurol Int 2021; 12:445. [PMID: 34621560 PMCID: PMC8492412 DOI: 10.25259/sni_384_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/20/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Vertebral artery stump syndrome (VASS) develops into recurrent posterior circulation ischemic stroke after ipsilateral vertebral artery (VA) occlusion at its origin. Case Description: The patient was a 46-year-old man with the right posterior cerebral artery occlusion. We used a recombinant tissue plasminogen activator (rt-PA) and then performed mechanical thrombectomy using a stent retriever. Angiography revealed left VA occlusion and stagnant flow to the left VA from the right deep cervical artery; therefore, we diagnosed VASS. Within 24 h of the rt-PA injection, the symptoms had dramatically improved, and so we avoided additional antithrombotic agents. Only 13 h later, the patient developed a basilar artery occlusion and died in spite of a repeated mechanical thrombectomy. Conclusion: Vigilance against early (and sometimes fatal) recurrent stroke induced by VASS is required.
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Affiliation(s)
- Akinari Yamano
- Department of Neurosurgery, University of Tsukuba, Japan
| | - Yasunobu Nakai
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | | | - Haruki Igarashi
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
| | | | | | - Kazuya Uemura
- Department of Neurosurgery, Tsukuba Medical Center Hospital, Tsukuba, Ibaraki, Japan
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Gao F, Zheng H, Guo X, Sun X, Miao Z. A novel angiographic classification for the endovascular recanalization of symptomatic nonacute extracranial vertebral artery occlusion. J Neurointerv Surg 2021; 14:210-214. [PMID: 33722973 DOI: 10.1136/neurintsurg-2021-017283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND There remains major uncertainty regarding the optimal therapy for symptomatic nonacute extracranial vertebral artery occlusion (EVAO). Endovascular recanalization for EVAO is technically challenging, and limited data are available. This research aimed to report a multicenter clinical experience of endovascular recanalization for symptomatic nonacute EVAO and establish a novel angiographic classification. METHODS From June 2011 to December 2019, 50 symptomatic nonacute EVAO patients treated with endovascular recanalization in three regional referral stroke centers were retrospectively analyzed. All patients were categorized into four groups based on the angiographic classification. The rates of technical success, periprocedural complications, any stroke or death within 1 month, and follow-up data were assessed. RESULTS The rates of technical success, periprocedural complications, and any stroke or death within 1 month were 86.0% (43/50), 12.0% (6/50), and 4.0% (2/50), respectively. The recanalization rates gradually decreased from Type A to Type D (100%, 94.7%, 80%, and 63.6%, respectively; P=0.007). The EVAO patients in the Type A group with tapered stump and short-segment occlusions showed excellent recanalization effects, with 100% technical success rates and no complications. Conversely, the lowest recanalization rate of 63.6% (7/11) and the highest periprocedural complication rate of 27.3% (3/11) were observed for the Type D group. CONCLUSIONS Endovascular recanalization for symptomatic nonacute EVAO is technically feasible, especially Type A EVAO patients, which can provide an alternative treatment option for recurrent vertebrobasilar ischemia despite optimal medical therapy. The angiographic categorization established in this study is conducive to the selection of suitable patients prior to treatment decision.
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Affiliation(s)
- Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Hongbo Zheng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xu Guo
- Department of Interventional Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
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Zimoski R, Ugurov P, Veljanoska-Kiridjievska L, Hristov N, Idoski E, Gjorgon M, Milevska-Kostova N, Rosalia RA, Mitrev Z. Minimally Invasive Surgical Repair of Vertebral Artery Ostium Stenosis in Patients with Ischemic Stroke: A Single-Center Case Series. World Neurosurg 2020; 146:367-375.e2. [PMID: 33212278 DOI: 10.1016/j.wneu.2020.11.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ischemic stroke is the second leading cause of death in North Macedonia. Posterior circulation disease, caused by vertebral artery (VA) ostium (VAo) stenosis, is a common cause of ischemic stroke. We established a treatment approach using surgical revascularization of posterior circulation disease. In the present observational study, we assessed the outcome after surgical revascularization of the posterior circulation ischemia caused by VAo stenosis. METHODS A retrospective analysis of 20 consecutive patients who had undergone surgery from January 2017 to December 2019. The VA was accessed through a 3-cm incision in the upper medial clavicle. The corrective procedures consisted of resection and anastomosis (15 of 20), VA to subclavian artery transposition (16 of 20), endarterectomy (10 of 20), vein graft interposition techniques (4 of 20), and vein graft bypass (1 of 20). RESULTS The cohort included 9 acute cases. The mean patient age was 66.5 years (range 46-77). Of the 20 patients, 8 were women and 12 were men. Left-sided VA pathology was present in 75% of the cases. We observed rapid clinical improvement in 19 patients (95%). The total study period was 321 patient-months, with a median follow-up of 18 months (interquartile range, 5-24 months). One patient had died of an unknown cause after 12 months. During the follow-up period, 15 patients (75%) had reported permanent clinical improvement with no significant relapse of symptoms. CONCLUSIONS Minimally invasive surgical revascularization of the posterior brain circulation is a clinically effective therapeutic approach to manage ischemia caused by VAo stenosis. It can be performed safely, promote long-lasting symptom relief, and prevent recurrent strokes.
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Affiliation(s)
- Riste Zimoski
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Petar Ugurov
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | | | - Nikola Hristov
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Enver Idoski
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Marko Gjorgon
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | | | - Rodney Alexander Rosalia
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia; Maastricht School of Management, Maastricht, The Netherlands
| | - Zan Mitrev
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia.
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