Combined carotid endarterectomy and vertebral transposition or bypass for cerebral and vertebrobasilar insufficiency

The purpose of this report is to determine the indication for a combined ca rotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral is chemic symptoms of dizziness and syncope. A retrospective review was made o n 49 patients with the combined symptoms of generalized global ischemia, TI A, amaurosis fugax or stroke, and vertebral basilar insufficiency manifeste d as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic res onance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppl er analysis, electronystagmography, electroencephalography, and cardiac arr hythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid o cclusion underwent carotid endarterectomy plus vein patch or internal carot id to external carotid onlay patch angioplasty and proximal vertebral to co mmon carotid artery transposition (n:19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterectomy and vertebral transpositi on (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid an d vertebral operations in the 49 patients. Six patients had transient palpe bral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogr am showed patent vertebral arteries. All 49 patients have resolution of TIA , dizziness, syncope, and unsteady gait. Combined carotid endarterectomy an d vertebral transposition or bypass should be considered in patients with s olitary, dominant, or bilateral vertebral artery critical stenosis whose sy mptoms are unrelated to vestibular, cardiac, or seizure disorders and later alized TIA or stroke.