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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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FA-to-VA Bypass 335
p
Fig. 15.1p–r CT angiograms at diff erent phases confi rm
r
patency of the bypass ( arrows ).
q
16 VA Reconstruction and
VA-to-CCA Transposition
338 Color Atlas of Cerebral Revascularization
A VA-to-CCA transposition is an excellent way to achieve blood fl ow in a VA with signifi cant stenosis at its
origin or in an occluded but patent VA. Almost the only time a patient has symptoms related to VA insuffi ciency is when the contralateral VA is vestigial entering the PICA or is occluded. The insuffi ciency can be
exacerbated by rotation of the head, which compromises blood fl ow at C2-C1 and the skull base.
The subclavian artery is exposed through a transverse supraclavicular incision with a longitudinal extension along the CCA. If further length is needed, the VA is exposed and freed from its bony canal. After the CCA
is occluded proximally and distally, the artery is opened with a vascular punch. An end-to-side anastomosis
is created with the VA using 6–0 or 7–0 suture.
Fig. 16.0a Schematic representation of a supraclavicular exposure shows the
CCA and VA along with the subclavian artery and its branches.
Fig. 16.0b Schematic representation of the completed VA-to-CCA
transposition. (Used with permission from Journal of Neurosurgery .)
VA Reconstruction and VA-to-CCA Transposition 339
Case 16-1
Diagnosis: Traumatic dissection of right VA at C6
Bypass: Direct VA reconstruction with saphenous
vein graft
Approach: Right anterior cervical
Fig. 16.1a Selective angiographic injection of the right VA shows a
dissecting pseudoaneurysm at C6.
Fig. 16.1b A vertical incision is made
along the anterior border of the SCM
muscle.
340 Color Atlas of Cerebral Revascularization
Fig. 16.1c The sternal head of the SCM muscle is divided between suture ligatures. Next, the omohyoid muscle is
sectioned. The SCM muscle and carotid sheath are pushed laterally, and the esophagus and trachea are retracted medially.
Fig. 16.1d The longus colli muscles are completely dissected from the transverse processes and the transverse
foramina are drilled away. A venous plexus often surrounds the VA.
Fig. 16.1e The venous plexus is removed, exposing the VA above and below the area of injury.
VA Reconstruction and VA-to-CCA Transposition 341
Fig. 16.1f High magnifi cation view of the injured segment
of the VA shows evidence of dissection and hemorrhage into
the vessel wall.
Fig. 16.1g The vessel is open through the area of injury, demonstrating the intimal dissection with associated
hemorrhage into the wall and marked narrowing of the lumen.
Fig. 16.1h The VA is endarterectomized and the pseudoaneurysm is removed. Temporary aneurysm clips secure the
two cut ends of the VA.
342 Color Atlas of Cerebral Revascularization
Fig. 16.1i A saphenous vein interposition graft reconstructs the VA, thereby preserving it.
Fig. 16.1j Postoperative lateral VA angiogram
confi rms good fl ow in the artery.
VA Reconstruction and VA-to-CCA Transposition 343
Case 16-2
Diagnosis: Left VA stenosis
Bypass: VA-to-CCA transposition with 17 years of
follow-up
Approach: Left transverse supraclavicular
Fig. 16.2a Three-dimensional MR angiographic
reconstruction of the right VA shows that it terminates
in the PICA. In 1988, the patient had presented
with severe symptoms referable to the BA, which
was treated with a left VA-to-CCA transposition. He
returned 17 years later with a new BA ischemic event
that led to an angiographic injection of the VA.
344 Color Atlas of Cerebral Revascularization
Fig. 16.2b The repeat VA angiogram shows the fully
patent VA-to-CCA transposition.
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