A REVIEW OF 100 CONSECUTIVE RECONSTRUCTIONS OF THE DISTAL VERTEBRAL ARTERY FOR EMBOLIC AND HEMODYNAMIC DISEASE

Purpose: The aim of our study was to assess the outcome of distal vert ebral artery (VA) reconstructions through a retrospective review condu cted at a university-affiliated referral center, Methods: One hundred consecutive distal VA reconstructions had been performed during a peri od of 14 years (98 patients) and included reversed saphenous vein bypa ss from the ipsilateral common, internal, or external carotid to the t hird portion of the VA at the C1-2 level (68 reconstructions) or the C 0-1 level (4); transposition of the external carotid or its occipital branch to the VA (23); and transposition of the third portion of the V A onto the internal carotid artery (2). Other methods were used in 3 a dditional patients. Eighteen patients underwent concomitant carotid op erations, and 1 patient underwent a concomitant subclavian transpositi on. Symptoms were present in 98% of patients and included vertebrobasi lar ischemia (89%), vertebrobasilar plus hemispheric ischemia (7%), an d hemispheric ischemia (2%). Two asymptomatic patients with bilateral carotid occlusions underwent operations to provide a single artery for cerebral perfusion (2%). Sixty-three lesions were atherosclerotic, 18 were dynamic bony compressions, and 14 were dissection, fibromuscular dysplasia, arteritis, or aneurysm. Five had miscellaneous anatomic in dications. Results: Stroke caused the four perioperative deaths that o ccurred. There was one occurrence of nonfatal hemispheric stroke. Rout ine postoperative arteriography identified 16 graft abnormalities; 11 patients underwent attempted revision. The introduction of the use of intraoperative angiography in 1990, halfway through the series, lowere d the incidence of graft abnormalities from 28% to 4% and the incidenc e of perioperative death from 6% to 2%, Eighty-seven percent of patien ts had complete or significant resolution of symptoms. Follow-up range d from 1 to 168 months (mean, 79 months). Ten patients were lost to fo llow-up. Twenty late deaths occurred; none were stroke related. five r econstructions required late revision. The cumulative primary patency at 5 and 10 years was 75% +/- 6 and 70% +/- 7 (mean +/- SE), respectiv ely; cumulative secondary patency was 84% +/- 5 and 80% +/- 6 at 5 and 10 years, respectively. Median survival was 107 months. Conclusions: Distal VA reconstruction provides excellent long-term patency and stro ke protection. Intraoperative angiography is mandatory.