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  • Direct V1 segment vertebral artery surgical exposure and cannulation for endovascular coil embolization of ruptured basilar apex aneurysm.

    Final Number:

    Sadashiva Karanth MBBS; Sean Meagher MD; Kenneth Fraser MD; Jeffrey Klopfenstein MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2012 Annual Meeting

    Introduction: Vertebral artery osteal stenosis, hypoplasia, or proximal tortuosity when present bilaterally can preclude catheter access via the conventional transfemoral approach. Described is a novel technique for selective cannulation of the vertebral artery V1 segment by direct open surgical exposure in a patient with high surgical morbidity with ruptured basilar bifurcation aneurysm.

    Methods: A 75- year-old female with mechanical aortic valve requiring anticoagulation presented with ruptured 6 mm basilar bifurcation aneurysm. Digital substraction angiogram revealed a hypoplastic right vertebral artery and a tortuous proximal left vertebral artery preventing selective cannulation for intervention. Upon multidisciplinary review, it was concluded that direct surgical access of the vertebral artery for endovascular management was superior to craniotomy for clip occlusion of the aneurysm given the patient’s anticoagulation requirements for her mechanical heart valve.

    Results: The V1 segment of vertebral artery was exposed surgically in the supraclavicular region and an access sheath was inserted under direct visualization (Fig). Successful coil embolization then was carried out in the angiography suite and the patient subsequently was taken back to the operating room for removal of the sheath under direct visualization. A small, asymptomatic dissection occurred during sheath placement presumably due to the limited access angle to the artery created by the position of the clavicle in relation to the V1 segment.

    Conclusions: When conventional transarterial routes are unavailable and yet endovascular management is deemed markedly superior to open surgery for management of posterior circulation pathology, the V1 segment of vertebral artery can be exposed surgically and cannulated effectively for endovascular intervention.

    Patient Care: The described technique gives another tool for vascular neurosurgeons/interventionalists for accessing posterior circulation as a salvage procedure.

    Learning Objectives: By the conclusion of this session participants should be able to describe alternative technique of accessing posterior circulation for endovascular intervention.


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