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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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This view is performed to rule out anomalous vertebral
artery origin. Using a 0.035 glidewire or J‐wire, insert a
5 Fr Berenstein catheter via the femoral access sheath
(alternatively, a 5 Fr or 6 Fr Judkins right, internal
mammary, or Vitek curve catheters are acceptable). If
brachial or radial access is obtained, a multipurpose or
Judkins right catheter is used instead. Carefully engage
the vertebral artery ostium, while monitoring continuous
pressure. Perform high‐quality angiograms of all four
supra‐aortic main vessels, laying out vertebral artery
anatomy (Figure 3.2), especially the target lesion (Figure
3.3). Proceed to image the cervical carotid and vertebral
arteries and intracranial arteries (Figure 3.4). Digital
subtraction techniques are essential when imaging
intracranial anatomy. A minimum image intensifier size
of 12 in. is necessary to adequately image the intracranial
vessels. A complete angiographic evaluation includes an
aortic arch and four‐vessel study with selective
angiography of bilateral carotid and vertebral arteries
including intracranial imaging to ensure collateral blood
supply and define the circle of Willis. Nonionic, iso‐
osmolar contrast is used for intracranial angiography.
Importantly, femoral access is used 80% of the time.
Ipsilateral brachial or radial artery access is used 20% of
the time if the proximal vertebral artery is acutely
angulated when imaged from the femoral access. A
combination of femoral and upper extremity access is
used in complex cases involving subclavian artery
atherosclerotic disease.
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Figure 3.1 Aortic arch angiography showing main
supra‐aortic vessels.
Figure 3.2 Vertebral artery anatomy.
Source: From Jenkins and Collins (2011).
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Figure 3.3 Ostial right vertebral artery stenosis
(Arrow).
Figure 3.4 Circle of Willis anatomy.
Source: J. Stephen Jenkins (co‐author).
A 4 Fr diagnostic catheters do not provide adequate
visualization when performing selective vertebral or
carotid artery angiography; hence, larger catheters and
sheaths should be used.
Step 2. Vertebral Artery Intervention
(Percutaneous Transluminal Angioplasty)
Using the usual coronary intervention equipment (wire
introducer and hemostasis valve), insert an
appropriately sized coronary Rapid exchange (RX) or
monorail balloon over a 0.014 soft guidewire. Balloon
length is determined by the lesion length and should
cover the lesion completely. Balloon diameter should be
0.5 mm less than the reference vessel.
The reference vessel diameter should be determined with
quantitative angiography. After correct positioning is
confirmed with a contrast test under fluoroscopy, dilate
the lesion completely by inflating the balloon (following
the balloon rated burst pressure recommendation to
avoid complication) (Figure 3.5). Remove the balloon
and with the guidewire still distal to the lesion, perform
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an angiogram of the dilated lesion to assess for
successful and satisfactory lesion dilatation (Figure 3.6).
Importantly, a 6–8 Fr Judkins right or multipurpose
guiding catheter can be used to perform most vertebral
interventions. If intervention will be performed, the
operator may upsize the 6 Fr sheath for an 8 Fr sheath
over a Supra Core wire, Wholey wire 0.035‐in. exchange‐
length wire (Mallinckrodt, St. Louis, MO, USA) or
diagnostic J‐wire. Balloon length is determined by the
lesion length and should cover the lesion completely.
Balloon diameter should be 0.5 mm less than the
reference vessel. An EPD should be used in all vertebral
arteries with an adequate landing zone distal to the index
lesion. This is off‐label, as there is no embolic protection
device with US Food and Drug Administration (FDA)
approval for use in the vertebral artery. In our previously
published retrospective series (Jenkins JACC 2010 we
did not use embolic protection devices), there were 0%
stroke and 1% TIA.
Figure 3.5 Balloon dilatation of lesion: multipurpose
guide and 0.014 guidewire with 3.5 × 20 angioplasty
balloon.
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Figure 3.6 Result of balloon angioplasty – Not
satisfactory result.
Step 3. Vertebral Artery Intervention (Stenting)
If after balloon dilatation of the lesion, there is
suboptimal result, dissection, or perforation the operator
should proceed to stenting: Over a 0.014 guidewire,
insert a balloon expandable coronary or peripheral stent
over the lesion. Extend the stent flush with 1–2 mm into
the subclavian artery if stenting the proximal vertebral
artery to assure complete coverage of the ostium. A Flash
Balloon (Cordis, Santa Clara, CA, USA) may be useful to
prevent future procedures in the subclavian artery from
damaging the vertebral stent. Ensure the stent is well
seated with fluoroscopy prior to deployment (Figure 3.7).
Both balloon expandable and self‐expanding stents are
acceptable in the V1 and V2 segments if the vertebral
artery ostium is not involved. Balloon expandable
coronary or peripheral stents on a 0.014 platform work
well in the VO position. One needs to be certain that the
proximal portion of the stent covers the vertebral ostium.
It is not uncommon for the proximal stent to extend into
the subclavian artery by 1–2 mm. If extension into the
subclavian artery is excessive, a Flash Balloon may be
used to flair the ostium. Inflate and deploy the stent
appropriately (Figure 3.8). The guidewire should always
be kept within view during the procedure to prevent
perforation and causing fatal intracranial hemorrhage.
Care should be exercised when using a hydrophilic
guidewire. Depending on the size of stents, deploy with
6–8 atm inflations. If high‐pressure post‐dilation will be
carried out, withdraw the balloon slightly to prevent
distal edge dissection. After stent deployment,
angiography should be performed to include the
posterior intracranial circulation and exclude distal
dissection or vessel perforation (Figure 3.9).
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Figure 3.7 4.0 × 23 mm Stent positioned 2 mm
proximal to vertebral artery ostium.
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