Surgical reconstruction of the extracranial vertebral artery: Management and outcome

Purpose: The purpose of this study was to identify the risk and outcome of reconstruction of the extracranial vertebral artery (ECVA). Method: The study was conducted as a retrospective review of 369 consecutiv e ECVA reconstructions. Results: The clinical presentations consisted of hemispheric symptoms alone in 4% of the cases, hemispheric and vertebrobasilar symptoms in 30%, and v ertebrobasilar symptoms alone in 60%. The cause of the lesion was atheroscl erosis (n = 300), extrinsic compression (n = 42), dissection (n = 7), radia tion arteritis (n = 5), intimal hyperplasia (n = 3), fibromuscular dysplasi a (n = 2), previous surgical ligation (n = 3), aneurysm (n = 2), and other (n = 5). All the patients underwent preoperative arteriography. There were 252 proximal ECVA reconstructions (218 transpositions, 42 bypass grafting p rocedures, and two other) and 117 distal ECVA reconstructions (85 bypass gr afting procedures, 25 transpositions, and seven other). In 83 patients, the ECVA operation was performed concomitant with a carotid or supraaortic tru nk reconstruction. This series was analyzed in two separate sets: before 19 91 (n = 215), when changes in indications and management were occurring; an d after 1991 (n = 154), when we acquired a dedicated anesthesia team and di gital arteriography in the operating room and established uniform protocols for the management of ECVA disease. The stroke, death, and stroke/death ra tes for the period before 1991 were, respectively, 4.1%, 3.2% and 5.1%. The stroke, death, and stroke/death rates for the period after 1991 were, resp ectively, 1.9%, 0.6% and 1.9%. The patency rate at 5 years was 80%. The sur vival rate at 5 years was 70%. Most of the deaths during the follow-up peri od were caused by cardiac disease. Among the survivors, the protection rate from stroke was 97%. Conclusion: The changes in operative selection and management have improved the results of ECVA reconstruction. The data reported far ECVA reconstruct ion in patients who underwent operation since 1991 reflect the outcome of E CVA reconstruction today. In our experience, a reconstruction of the ECVA i s less risky than a carotid reconstruction.