A case of basilar artery occlusion of traumatic vertebral artery dissection successfully managed by endovascular treatment

The author describes a case of basilar artery occlusion caused by vertebral artery dissection with vertebral fracture. A 61-year-old man was admitted with neck pain after a traffic accident. His symptoms suddenly deteriorated and cerebral angiography revealed an occlusion of the right vertebral artery, and complete occlusion of the basilar artery. Local-arterial fibrinolysis with urokinase for basilar artery occlusion and angioplasty with the use of a self-expandable stent for the site of the vertebral artery dissection was performed, and the basilar artery was partially recanalized. The patient's symptoms gradually improved. It should be emphasized that in cases of acute cervical spine injury after major trauma, vertebral artery dissection should be considered. Local-arterial fibrinolysis and angioplasty using a self-expandable stent was regarded as a useful treatment for basilar artery occlusion caused by vertebral artery dissection, in the acute stage.     

Therapeutic basilar artery occlusion for management of medically refractory basilar artery stenosis: case report

OBJECTIVE AND IMPORTANCE: To describe a novel therapeutic approach (endovascular basilar artery occlusion) to a notoriously difficult-to-manage clinical condition (actively symptomatic high-grade basilar artery stenosis) on the basis of assessment of the patient-specific mechanism of disease. CLINICAL PRESENTATION: An 81-year-old woman presented with recurrent episodes of brainstem ischemia refractory to aggressive medical therapy. Cerebral angiography revealed a high-grade proximal basilar artery stenosis. On the basis of clinical presentation and angiographic findings, the pathogenesis of this complex of symptoms was thought to be embolic rather than hemodynamic. INTERVENTION: Endovascular coil occlusion of the basilar artery was used, with excellent outcome (cessation of ischemic symptoms and independent level of functioning at 1 yr). CONCLUSION: Successful endovascular management of intracranial occlusive disease requires understanding of the mechanism responsible for the patient's symptoms.     

股动脉肱动脉联合入路在锁骨下动脉闭塞性病变腔内治疗中的应用

目的:探讨股动脉肱动脉联合入路在锁骨下动脉闭塞性病变腔内治疗中应用的适应证、优势及并发症。方法:回顾首都医科大学宣武医院血管外科2011年1月—2014年6月采用联合入路进行腔内治疗的57例锁骨下动脉闭塞性病变患者,分析患者病变特点、手术成功率、联合入路的优势、并发症及随访情况。结果:患者病变可分为3种类型,包括顺行无法开通的锁骨下动脉闭塞(31例);右锁骨下动脉起始部狭窄或闭塞(16例);紧邻椎动脉开口的远段锁骨下动脉狭窄或闭塞(10例)。全组腔内治疗成功率为91.2%,出现穿刺并发症3例。术后6、12、24、36个月,支架通畅率分别为100%、100%、90%、77.7%。结论:对于常规入路难以开通的锁骨下动脉闭塞,联合入路能够有效提高开通率,且有利于支架的精准定位减少并发症发生等优势。     

Acute coronary syndrome following arteriovenous fistula creation in a post CABG patient: A steal phenomenon from coronary artery to subclavian artery

A 70‐year‐old man with a history of coronary artery bypass grafting 15 years back and arteriovenous (AV) fistula creation in the left arm 1 month back presented with acute coronary syndrome (ACS). He had not received dialysis before his referral. We felt the most likely etiology for these complaints was increased cardiac oxygen demand from an increased cardiac output related to the newly formed left AV fistula. Coronary angiography was done to detect any significant stenosis in the native or grafted vessels. This revealed that the left subclavian artery was totally occluded in the ostioproximal segment and the coronary arteries did not have occlusions to explain the ACS setting. CT angiography confirmed the angiographic findings of the totally occluded left subclavian artery followed by a well‐developed and patent left internal mammary artery to left anterior descending artery. This led to the consideration of a steal syndrome from the coronary artery by the subclavian artery distal to the occlusion. A successful percutaneous endovascular intervention on the left subclavian artery occlusion was performed. Subsequently, the patient became asymptomatic and experienced a dramatic increase in left ventricular ejection fraction.     

Combined endovascular and open surgical approach for the management of subclavian artery occlusion due to thoracic outlet syndrome

A 32-year-old male with arterial thoracic outlet syndrome (TOS) underwent endovascular treatment for the chronic total occlusive lesion from the subclavian to the brachial artery after resection of the first rib and cervical rib. A combined endovascular and surgical treatment represents an attractive alternative to the traditional surgical approach for the treatment of complicated arterial TOS.     

Complete cervical rib. Possible neurovascular implications of the upper limb

The thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus or subclavian artery or vein in the region of the neck and shoulder girdle. The neurovascular bundle may be compressed at multiple sites: costoclavicular space, interscalene triangle, insertion of the pectoralis minor into the coracoid process. More than 90% of the patients present with neurologic symptoms: pain, paraesthesias or arm and hand weakness and 10% also have vascular problems. The diagnosis of TOS is always difficult and depends on careful clinical study of patients. For the neurological type of TOS, electromyograms, arteriograms and venograms are not helpful. The value of Doppler study and of arteriography is demonstrated in the present case of a woman with a five month history of pain and paraesthesias of the arm and hand, who shoved sudden occlusion of left humeral artery. Roentgenograms showed the presence of a well developed left cervical rib. Doppler study and arteriography showed the compression of subclavian artery with the arm abduction manoeuver. After first rib resection and humeral artery thrombectomy there was a complete return of humeral artery flow and of all neurologic functions. Thus the role of first cervical rib or other bone and muscular structures must be emphasyzed both in the brachial and in the subclavian artery or vein compression. Embolization of the axillary or humeral artery should be corrected as soon as possible when the cervical rib is corrected.     

Bilateral occlusion associated to steal phenomenon of internal carotid and left subclavian arteries: treatment by angioplasty and stenting

OBJECTIVE: Treatment of subclavian artery occlusion is still a matter of controversy due to the short- and long-term complications and patency issues. We report an unusual case of combined occlusion of the proximal segment of the left subclavian artery and subclavian steal phenomenon associated with bilateral occlusion of the internal carotid arteries. CASE DESCRIPTION: A 55-year-old male patient with previous history of myocardial infarction and hypertension presented with amblyopia and recurrent dizziness, mainly at work. Doppler fluxometry and digital subtraction angiography depicted proximal left subclavian artery occlusion and subclavian steal. Internal carotid arteries were occluded at the common carotid artery bifurcation. Percutaneous transluminal angioplasty and stenting (PTAS) were successfully performed by the left radial artery approach without complications. The patient had no recurrence of the symptoms, and the angiographic follow-up at 1 year showed good patency of the subclavian artery and normal flow through the left vertebral artery. CONCLUSION: The planned approach for the case (PTAS) was performed without complications and evidence of restenosis in the angiography study at the completion of the first year of the treatment. The described strategy is safe and should be considered the first-choice procedure in the treatment of the subclavian occlusion.     

Subclavian artery to internal carotid artery bypass with saphenous vein graft in the treatment of bilateral common carotid artery occlusion; a case report]

A case of left common carotid artery occlusion, which was treated by a saphenous vein graft, is reported. A 49-year-old right handed male was admitted to the hospital because of right hemiparesis and aphasia. These symptoms disappeared spontaneously two weeks after admission. However, visual acuity remained impaired on the left side due to occlusion of the central retinal artery. Angiography revealed complete occlusion of the common carotid arteries as well as patency of the internal carotid arteries on both sides. PET and 123I-IMP-SPECT studies showed hypoperfusion in the left cerebral hemisphere. To restore the blood flow as well as to remove the source of the emboli, endarterectomy was performed on the left internal carotid artery. This was followed by a saphenous vein graft between the left subclavian and the internal carotid artery. Postoperative angiography revealed patency of the bypass, and a SPECT study revealed increased blood flow in the left cerebral hemisphere. The patient has remained in stable condition during the following 30 months with no neurological problems. We conclude that in the treatment of complete occlusion of the common carotid artery and subsequent cerebral hypoperfusion, a bypass graft between the internal carotid and the subclavian artery is quite effective, and that the site of the bypass graft should carefully be sought for by using preoperative angiographic studies.     

Traumatic basilar artery occlusion caused by a fracture of the clivus--case report.

A 56-year-old man presented with a rare traumatic basilar artery occlusion caused by a fracture of the clivus. He fell from the height of 2 meters and immediately fell into a coma. Head computed tomography (CT) revealed an open depressed fracture, an acute epidural hematoma 1 cm thick in the left middle frontal fossa, and a longitudinal fracture of the clivus. Emergency removal of the hematoma was performed with cranioplasty. Head CT 8 hours 50 minutes after injury showed infarctions in the brain stem, cerebellum, and occipital lobes. Cerebral angiography revealed occlusion of the basilar artery in the middle part of the clivus. The patient died after 3 days. Autopsy revealed that the basilar artery was trapped in the clivus fracture site. Vertebrobasilar artery occlusion due to trapping in a clivus fracture has a very poor prognosis. Diagnosis is difficult and generally only confirmed at autopsy. Cerebral angiography is recommended in a patient in a deep coma without massive brain contusion at the early stage of head injury to identify the possibility of vertebrobasilar artery occlusion in a clivus fracture.     

Subclavian artery occlusion 42 years after mastectomy and radiotherapy

Left subclavian artery occlusion developed in a patient 42 years after a left radical mastectomy and radiotherapy. The vascular supply was successfully reconstructed by a graft from the right subclavian artery to the left brachial artery. Clinical and experimental evidence has demonstrated that radiotherapy can damage large vessels [2,4,5]. It is our contention that radiotherapy was the causative factor in the case of subclavian artery occlusion reported herein.     

Vertebrobasilar artery dissection with subarachnoid hemorrhage after brain stem infarct showing an improvement on angiography: case report

A 66-year-old male presented with dysarthria and right hemiparesis. Cerebral angiography at onset showed obliteration of the basilar artery and dilatation in the left vertebral artery. The patient's clinical symptoms were exaggerated and he was finally diagnosed to as suffering locked-in syndrome. Magnetic resonance imaging showed a brain stem infarction from the pons to the left middle cerebellar peduncle. We determined that the patient suffered dissection of the left vertebral artery at the basilar artery and treated, using the conservative therapy him of strict blood pressure control. A second angiography 13 days after onset showed recanalization of the basilar artery. At 29 days after onset, the patient fell into a coma with subarachnoid hemorrhage and acute hydrocephalus. Cerebral angiography revealed improvement in the irregularity and dilatation of the basilar artery, but the point of rupture could not be clearly identified. After performing proximal occlusion of the left vertebral artery by intravascular surgery, both right STA-SCA anastomosis and proximal occlusion of the right vertebral artery were carried out. Unfortunately, the patient died. Based on there data, it is appointed out that patients with a dissection of the vertebrobasilar artery must be followed up by serial angiography, and even if an angiographical improvement of the dissection is observed, the risk of subarachnoid hemorrhage still exists in patients suffering ischemic stroke.     

手术治疗锁骨下动脉闭塞症

目的探讨锁骨下动脉闭塞症的有效手术治疗方法。方法 2005年12月-2010年2月,收治锁骨下动脉闭塞症53例。男40例,女13例;年龄22～77岁,平均64岁。病程15d～20个月,平均6.5个月。动脉硬化闭塞症49例,大动脉炎4例。左锁骨下动脉闭塞35例,狭窄5例;右锁骨下动脉闭塞5例,狭窄4例;双侧锁骨下动脉闭塞4例。对39例单侧锁骨下动脉闭塞伴颈、脑动脉病变者采用腋动脉-腋动脉聚四氟乙烯(polytetra?uoroethylene,PTFE)人工血管转流术;10例不伴颈、脑动脉病变者行颈动脉-锁骨下动脉PTFE人工血管转流术。4例双侧锁骨下动脉闭塞者采用升主动脉-双锁骨下动脉PTFE人工血管转流术。术后常规应用抗凝及抗血小板药物治疗。结果 1例大动脉炎患者术后48h动脉吻合口及人工血管血栓形成;余52例手术均获成功,手术成功率98.11%。术中神经钳夹损伤2例,术后双侧吻合口周围血肿4例,均经保守治疗痊愈。52例手术成功患者均获随访,随访时间1～52个月,平均24.5个月。患者均存活,术前椎基底动脉及上肢动脉缺血症状均消失。彩色超声多普勒血流探测仪检查见吻合口及人工血管血流通畅,术后1年及2年人工血管通畅率均为100%;患侧椎动脉血流方向恢复正常。1例术后18个月出现腋动脉吻合口假性动脉瘤,行介入栓塞治愈。结论锁骨下动脉闭塞症的治疗术式较多,但应根据患者全身情况和病变特点进行合理选择。围手术期的正确处理及术中严格操作,是保证手术成功的关键。     

Das Thoracic-outlet-Syndrom

Congenital and acquired bone and/or fibromuscular anomalies, positional characteristics, and trauma play roles in the etiology of thoracic outlet syndrome (TOS). For clinical examination, the elevated arm stress test is most important. Visualization of the subclavian artery and vein by digital subtraction angiography with different arm positions in the upright patient is mandatory. About 75% of operated TOS patients show embolic occlusions of the digital arteries. Neurologic evaluation includes measuring the proximal ulnar and median nerve conduction times. Reduction in proximal nerve conduction times, morphologic lesions of the subclavian artery, extreme venous compression, disabling pain during the night, and abuse of analgesics are absolute indications of transaxillary exarticulation of the first rib. The results of primary operation are favorable: 85% completely pain-free, 12% markedly improved, and 3% unchanged or worse.     

The rudimentary first rib. A cause of thoracic outlet syndrome with arterial compromise

The symptoms of thoracic outlet syndrome are neurologic, not vascular, in more than 95% of cases. Subclavian artery compression is usually related to cervical ribs; however, congenitally abnormal first ribs may also produce vascular compromise. We review our two cases of thoracic outlet syndrome associated with significant subclavian artery compression caused by rudimentary first ribs and the prior literature emphasizing the mechanism of injury, diagnostic features, and treatment. Transaxillary resection of the first and second ribs was curative in both cases. The operative specimens demonstrated fusion of the rudimentary first rib to the second rib, with compression of the subclavian artery by a large first-rib exostosis. Patients with thoracic outlet syndrome and a rudimentary first rib should be examined for substantial vascular compromise, and, if it is found, the abnormal first and second rib complex should be resected early without prolonged conservative measures.     

Occlusion of the vertebral artery secondary to dissection of the subclavian artery--case report

A 34-year-old man presented with occlusion of the left vertebral artery (VA) secondary to dissection of the left subclavian artery manifesting as vertigo, nausea, vomiting, and neck pain. On admission, he was alert with left limb and truncal ataxia. Magnetic resonance (MR) imaging and MR angiography showed left cerebellar infarction and occlusion of the left VA. Conventional angiography and three-dimensional computed tomography (3D-CT) angiography showed stenosis with thrombosed pseudo-lumen of the left subclavian artery, and occlusion of the left VA. Presumably the idiopathic dissection of the left subclavian artery had reached the orifice of the left VA, and an embolism from the dissection had caused occlusion of the VA, leading to cerebellar infarction. After one month, he was discharged without severe neurological deficits. Idiopathic dissection of the subclavian artery is very rare. 3D-CT angiography is very useful for the diagnosis of arterial dissection.     

Two cases of main trunk artery occlusion associated with multiple cerebral aneurysms

We report 2 cases of multiple aneurysms (AN) associated with main trunk artery occlusion. CASE 1: A 52-year-old male was admitted to our hospital with dysarthria and weakness of the right side of the body. Computed tomography (CT) showed cerebral infarction in the left corona radiata. MR angiography and conventional angiography showed occlusion of the left middle cerebral artery (MCA) and saccular aneurysms (ANs) at the origin of the anterior communicating artery (A-com) and bifurcation of the right MCA. Subsequent 123I-IMP-single photon emission tomography (SPECT) revealed marked reduction of cerebral blood flow and disturbed reactivity to acetazolamide in the left cerebral hemisphere. Superficial temporal artery (STA)-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for AN of the A-com and right MCA. At 5 months after the first operation, neck clipping was performed successfully for the non-ruptured A-com AN and right MCA AN. CASE 2: A 65-year-old male was admitted to our hospital. CT revealed subarachnoid hemorrhage (SAH), and 3D-computed tomographic angiography (CTA) and cerebral angiography showed basilar top AN, A-com AN and right MCA AN associated with right internal carotid artery occlusion. Right ACA and MCA territories were visualized from the A-com artery and posterior cerebral artery. STA-MCA anastomosis was performed to improve cerebral blood flow and reduce hemodynamic stress for ANs. In the same operation, successful neck clipping was performed for BA top AN and right MCA AN. In such cases as these, particularly in ischemic cases associated with main trunk artery occlusion, it was important to consider surgery for AN after STA-MCA anastomosis in anticipation of improved cerebral blood flow and reduce hemodynamic stress for AN.     

Injuries to the cervical spine causing vertebral artery trauma: case reports

In four patients with lesions of the vertebral artery resulting from cervical spine injury, two were due to unilateral facet dislocation and two to fractures of the dens. There was one arterial occlusion with minor vertebrobasilar symptoms, and an arterial lesion with thrombosis causing embolic occlusion of the basilar artery with lethal outcome. In one patient a fresh fracture of the dens caused dislocation of C1/2 with reversible occlusion of the left and stenosis of the right vertebral artery, resulting in unconsciousness. In a patient with pseudarthrosis of the dens an aneurysm of the vertebral artery could be detected. Cerebellar or cerebral symptoms associated with cervical spine injury should be investigated by vertebral angiography because vertebral arterial injury may be more common than suspected and may simulate traumatic brain damage.     

Aneurysm of anterior communicating artery associated with aortitis syndrome--a treated case by aneurysmal neck clipping (author's transl)

A rare case of the cerebral aneurysm associated with aortitis syndrome was reported. It seems to be the first case in which neck clipping was successfully performed for aneurysm of the anterior communicating artery. The patient was a 48-year-old female afflicted with pulseless disease. She was admitted to Iwate Central Hospital with severe headache, vomiting and unconsciousness on November 16, 1980. Her radial pulse was faint on the right side. The left carotid angiography revealed an aneurysm in the anterior communicating artery, and neck clipping of the aneurysm was performed 17 days after the onset. The right serial brachiocephalic arteriography revealed occlusion of the right brachiocephalic artery and the right common carotid artery. The serial aortography revealed stenosis of the left common carotid artery and the left vertebral artery. In the literature, 4 cases of those 7 cases associated with aortitis syndrome had aneurysms at the basilar bifurcation or basilar top. It seems to be the reason that the vertebral artery outlasts longer in aortitis syndrome. In our case, we can relate the aneurysmal formation of the anterior communicating artery to the hemodynamic overload of the left A1. General anesthesia in such cases was discussed.     

Rescue use of endovascular snare for acute basilar artery embolic occlusion resistant to balloon angioplasty and fibrinolysis therapy.

A rescue clot disruption using a basket snare is described for acute basilar artery embolic occlusion resistant to balloon angioplasty and fibrinolysis therapy. In spite of failed balloon angioplasty in conjunction with fibrinolysis, a basket-shaped snare connected to a microguide wire could be used to catch and crush the clot in the upper basilar artery. The rescue use of a snare may be effective for angioplasty-resistant acute embolic stroke.