Acute reperfusion therapy via occluded vertebral artery using a guiding sheath for posterior circulation tandem occlusion: illustrative case

Kohei Ishikawa Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; and
Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan

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Hideki Endo Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; and
Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan

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Ryota Nomura Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; and
Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan

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Daishi Yamaguchi Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; and
Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan

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Koji Oka Department of Neurosurgery, Nakamura Memorial South Hospital, Hokkaido, Japan; and

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Hirohiko Nakamura Department of Neurosurgery, Nakamura Memorial Hospital, Hokkaido, Japan

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BACKGROUND

Vertebral artery (VA) size, anatomy, and occlusion status should be considered when selecting endovascular access for basilar artery mechanical thrombectomy. In a patient with concomitant basilar artery and VA occlusion and a patent but hypoplastic contralateral VA, the occluded VA should be selected. The authors report a technique that utilizes advancing a guiding sheath with attached dilator via an occluded VA.

OBSERVATIONS

A 65-year-old male presented with disturbed consciousness because of an acute infarction of the brainstem and cerebellum caused by a basilar artery occlusion. Cerebral angiography showed a hypoplastic right VA and occlusion of the left VA at the origin. A regular wire was easily advanced through the occlusion and a 4-Fr diagnostic catheter was advanced into the distal left VA. A 6-Fr guiding sheath with attached dilator was placed in the left VA beyond the occlusion by exchanging it over a long wire. After removing the basilar artery thrombus, balloon angioplasty was performed at the left VA origin. Complete revascularization of the posterior circulation was achieved.

LESSONS

A guiding sheath with dilator can advance across and dilate a VA occlusion at the origin to provide rapid access to the basilar artery.

ABBREVIATIONS

PTO = posterior circulation tandem occlusion; VA = vertebral arteries

BACKGROUND

Vertebral artery (VA) size, anatomy, and occlusion status should be considered when selecting endovascular access for basilar artery mechanical thrombectomy. In a patient with concomitant basilar artery and VA occlusion and a patent but hypoplastic contralateral VA, the occluded VA should be selected. The authors report a technique that utilizes advancing a guiding sheath with attached dilator via an occluded VA.

OBSERVATIONS

A 65-year-old male presented with disturbed consciousness because of an acute infarction of the brainstem and cerebellum caused by a basilar artery occlusion. Cerebral angiography showed a hypoplastic right VA and occlusion of the left VA at the origin. A regular wire was easily advanced through the occlusion and a 4-Fr diagnostic catheter was advanced into the distal left VA. A 6-Fr guiding sheath with attached dilator was placed in the left VA beyond the occlusion by exchanging it over a long wire. After removing the basilar artery thrombus, balloon angioplasty was performed at the left VA origin. Complete revascularization of the posterior circulation was achieved.

LESSONS

A guiding sheath with dilator can advance across and dilate a VA occlusion at the origin to provide rapid access to the basilar artery.

ABBREVIATIONS

PTO = posterior circulation tandem occlusion; VA = vertebral arteries

Concomitant occlusion of the basilar artery and one of the vertebral arteries (VAs), or posterior circulation tandem occlusion (PTO), has a worse prognosis than basilar artery occlusion alone.1,2 Faster recanalization is associated with better clinical outcome.3 In patients with a PTO and hypoplastic patent VA, mechanical thrombectomy of the basilar artery lesion should be performed via the occluded VA. However, techniques of rapid basilar artery access through an occluded VA are not well-established. We report a patient with PTO in whom rapid basilar artery thrombectomy was performed after obtaining access by advancing a guiding sheath with attached dilator through the occluded VA.

Illustrative Case

A 65-year-old male with no significant medical history presented with disturbed consciousness and was transferred to our hospital. Estimated time of symptom onset was 10 hours prior to arrival. Initial National Institutes of Health Stroke Scale score was 33. The patient’s Glasgow Coma Scale score was 6. Examination of the eyes showed skew deviation. Magnetic resonance imaging with angiography revealed an acute infarction of the brainstem and cerebellum and occlusion of the upper basilar artery (Fig. 1).

FIG. 1.
FIG. 1.

Magnetic resonance imaging on arrival showed an acute brainstem and cerebellar infarction (A–C). Magnetic resonance angiography showed occlusion of the upper basilar artery. Both intracranial VAs appeared patent (D).

The patient was taken urgently to the interventional neuroradiology suite for angiography and mechanical thrombectomy. A 4-Fr sheath was inserted in the right femoral artery. Cerebral angiography confirmed the basilar artery occlusion and showed a hypoplastic right VA (Fig. 2A) and occlusion of the left VA at the origin (Fig. 2B). The left intracranial VA received collateral flow from the left thyrocervical trunk. Blood flow was stagnant between the entry point of collateral flow and the left VA origin (Fig. 2C). Because the right VA was hypoplastic, we elected to obtain access via the occluded left VA. A 0.035-inch guide wire (Radifocus, Terumo) was easily passed through the left VA occlusion site. Then, a 4-Fr diagnostic catheter was advanced into the distal left VA (Fig. 3A). A 6-Fr guiding sheath (Axcelguide, Terumo) with a dilator, which was included in the same package, was then advanced beyond the left VA occlusion site by exchanging it over a long wire (Fig. 3B). The left VA was relatively straight and no resistance was encountered as the guiding sheath was advanced through the occlusion. An aspiration catheter was then used to remove the basilar artery thrombus, which resulted in recanalization (Fig. 3C and D). A microwire (ASAHI CHIKAI 14, ASAHI Intecc Co., Ltd.) was left in the left VA and the guiding sheath lowered to the left subclavian artery. Balloon angioplasty was then performed at the left VA origin using a semicompliant balloon catheter (Rx-Genity, Kaneka). Although basilar artery recanalization was achieved rapidly after femoral puncture, the patient died because of his extensive infarction.

FIG. 2.
FIG. 2.

Preoperative angiographic findings. Digital subtraction angiography revealed a hypoplastic right VA (A) and occlusion of the left VA origin (arrow, B). Collateral flow from the thyrocervical trunk to the distal left VA was visualized; however, blood flow was stagnant between its entry point and the left VA origin (arrowheads, C).

FIG. 3.
FIG. 3.

Intraoperative angiographic findings. A regular wire was easily advanced through the left vertebral artery occlusion site and a 4-Fr diagnostic catheter was advanced distally (A). A 6-Fr guiding sheath with attached dilator was then placed beyond the occlusion site using an exchange method with a long wire (B). The basilar artery thrombus was then removed using an aspiration catheter (C and D).

Discussion

Observations

The patient in this report presented with tandem occlusion of the basilar artery and left VA and had a hypoplastic right VA. Acute reperfusion was achieved via the occluded left VA using a dilator attached to a guiding sheath, which enabled rapid catheter insertion distal to the occlusion and aspiration of the basilar artery thrombus. PTO is identified in up to 25% of patients presenting with basilar artery occlusion.4 Those with tandem occlusion at the origin of the VA and collateral flow distal to the occlusion site, as in our patient, may develop vertebral artery stump syndrome.5 VA size, anatomy, and occlusion site must be considered when performing mechanical thrombectomy of basilar artery occlusion in patients with PTO.

The basilar artery can be accessed via the patent or the occluded VA, and each route has advantages and disadvantages.4,6,7 The patent VA approach is safe and can be performed rapidly. However, it does not address the contralateral VA occlusion. The risk of recurrent stroke in patients with a recanalized basilar artery occlusion and persistent stenosis or occlusion at the VA ostium is 33%.4 Recurrent basilar artery occlusion may occur if the VA lesion is not addressed. The occluded VA approach allows treatment of the VA lesion after basilar artery thrombectomy.8 However, this approach is time consuming, which is important to consider in a patient with an acute basilar artery stroke; rapid recanalization is paramount. If the patent VA is normal in size and anatomy, it should be selected as the access route to the basilar artery; however, if it is hypoplastic or severely tortuous, the occluded VA should be selected.

Rapid recanalization of the basilar artery should be attempted even when the occluded VA approach is required. In our patient, a regular wire was easily advanced through the occluded VA and a diagnostic catheter could be placed distal to the occlusion. There was no resistance at hand when guide wire and catheter insertion, so we thought that the true lumen of the distal VA was secured. Because there was no time to prevent expansion of the brainstem infarction, to obtain rapid recanalization of the basilar artery, a guiding sheath with attached dilator was then inserted by exchanging it over a long wire. Most guiding sheaths have an attached dilator which is tapered shape. When a guiding catheter is inserted with the inner catheter and regular wire, it may not pass through the occlusion site because of caliber difference.9 A guiding sheath with dilator enables dilation and advancement across the occlusion (Fig. 4). However, this technique may be difficult to perform when the VA origin is severely tortuous, which preludes regular wire insertion, or occluded. If the VA origin is completely occluded (no contrast visualization), advancement through the occlusion is unlikely. If some degree of contrast visualization is present within the origin, advancement is possible.10 A snare wire can be advanced through an occluded VA origin to strengthen support of the guiding catheter.11 If the occlusion lesion is stiff because of calcification, arterial dissection may occur when inserting the guiding sheath. But arterial dissection can occur even when a microwire insertion or balloon angioplasty. Thus, in any cases, it is important that the false lumen must not be entered, and do not proceed the procedure when feel resistance at hand. Although advancing the guiding sheath with attached dilator distal to the occlusion may sometimes be difficult, this technique can be effective.

FIG. 4.
FIG. 4.

A regular wire is advanced distal to the left VA occlusion site (A). A guiding catheter may not be able to advance across the occlusion site because of a caliber difference with the coaxial system (B). A guiding sheath with dilator can advance across the occlusion site (C).

Lessons

When performing mechanical thrombectomy for patients with a PTO and hypoplastic patent VA, rapid recanalization of the basilar artery via the occluded VA should be required. A guiding sheath with dilator can advance across and dilate a VA occlusion at the origin to provide rapid access to the basilar artery.

Acknowledgments

We thank Daisuke Mori, Tamio Ito, and Yoshihiro Sumi for their support. We also thank Edanz for editing a draft of this manuscript.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Ishikawa, Endo, Nakamura. Acquisition of data: Ishikawa, Endo, Nomura, Yamaguchi, Oka. Analysis and interpretation of data: Ishikawa, Endo. Drafting the article: Ishikawa, Endo. Critically revising the article: Ishikawa, Endo, Nomura, Yamaguchi, Nakamura. Reviewed submitted version of manuscript: Ishikawa, Endo, Oka. Approved the final version of the manuscript on behalf of all authors: Ishikawa. Statistical analysis: Ishikawa. Administrative/technical/material support: Endo, Nomura, Yamaguchi, Nakamura. Study supervision: Endo, Nakamura.

Supplemental Information

Previous Presentations

This material was presented at the 16th congress of World Federation of Interventional and Therapeutic Neuroradiology, held in Kyoto, Japan on August 21–25, 2022.

References

  • 1

    Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med. 2021;384(20):19101920.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Siebert E, Bohner G, Zweynert S, et al. Revascularization techniques for acute basilar artery occlusion: technical considerations and outcome in the setting of severe posterior circulation steno-occlusive disease. Clin Neuroradiol. 2019;29(3):435443.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):10091018.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Baik SH, Jung C, Kim BM, Kim DJ. Mechanical thrombectomy for tandem vertebrobasilar stroke: characteristics and treatment outcome. Stroke. 2020;51(6):18831885.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Kawano H, Inatomi Y, Hirano T, Yonehara T. Vertebral artery stump syndrome in acute ischemic stroke. J Neurol Sci. 2013;324(1-2):7479.

  • 6

    Cohen JE, Leker RR, Gomori JM, et al. Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations-Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke. J Clin Neurosci. 2016;34:7076.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Weinberg JH, Sweid A, Sajja K, et al. Posterior circulation tandem occlusions: classification and techniques. Clin Neurol Neurosurg. 2020;198:106154.

  • 8

    Xing PF, Zhang YW, Li ZF, et al. The “distal-to-proximal” strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience. Neuroradiology. 2020;62(7):867876.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Maeoka R, Nakagawa I, Ohnishi H, Kuga Y, Nakase H, Ohnishi H. A thread of hope for successful revascularization for acute embolic basilar artery occlusion due to miserable vertebral artery stump syndrome. A technical report. J Clin Neurosci. 2020; 73:299303.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Ji R, Li B, Xu Z. Retrograde recanalisation for vertebral artery stump syndrome: a case report. Stroke Vasc Neurol. 2022;7(5):462464.

  • 11

    Nii K, Abe G, Iko M, et al. Endovascular angioplasty for extracranial vertebral artery occlusion without visualization of the stump of the artery ostium. Neurol Med Chir (Tokyo). 2013;53(6):422426.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    Magnetic resonance imaging on arrival showed an acute brainstem and cerebellar infarction (A–C). Magnetic resonance angiography showed occlusion of the upper basilar artery. Both intracranial VAs appeared patent (D).

  • FIG. 2.

    Preoperative angiographic findings. Digital subtraction angiography revealed a hypoplastic right VA (A) and occlusion of the left VA origin (arrow, B). Collateral flow from the thyrocervical trunk to the distal left VA was visualized; however, blood flow was stagnant between its entry point and the left VA origin (arrowheads, C).

  • FIG. 3.

    Intraoperative angiographic findings. A regular wire was easily advanced through the left vertebral artery occlusion site and a 4-Fr diagnostic catheter was advanced distally (A). A 6-Fr guiding sheath with attached dilator was then placed beyond the occlusion site using an exchange method with a long wire (B). The basilar artery thrombus was then removed using an aspiration catheter (C and D).

  • FIG. 4.

    A regular wire is advanced distal to the left VA occlusion site (A). A guiding catheter may not be able to advance across the occlusion site because of a caliber difference with the coaxial system (B). A guiding sheath with dilator can advance across the occlusion site (C).

  • 1

    Langezaal LCM, van der Hoeven EJRJ, Mont’Alverne FJA, et al. Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med. 2021;384(20):19101920.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Siebert E, Bohner G, Zweynert S, et al. Revascularization techniques for acute basilar artery occlusion: technical considerations and outcome in the setting of severe posterior circulation steno-occlusive disease. Clin Neuroradiol. 2019;29(3):435443.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):10091018.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Baik SH, Jung C, Kim BM, Kim DJ. Mechanical thrombectomy for tandem vertebrobasilar stroke: characteristics and treatment outcome. Stroke. 2020;51(6):18831885.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Kawano H, Inatomi Y, Hirano T, Yonehara T. Vertebral artery stump syndrome in acute ischemic stroke. J Neurol Sci. 2013;324(1-2):7479.

  • 6

    Cohen JE, Leker RR, Gomori JM, et al. Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations-Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke. J Clin Neurosci. 2016;34:7076.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Weinberg JH, Sweid A, Sajja K, et al. Posterior circulation tandem occlusions: classification and techniques. Clin Neurol Neurosurg. 2020;198:106154.

  • 8

    Xing PF, Zhang YW, Li ZF, et al. The “distal-to-proximal” strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience. Neuroradiology. 2020;62(7):867876.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Maeoka R, Nakagawa I, Ohnishi H, Kuga Y, Nakase H, Ohnishi H. A thread of hope for successful revascularization for acute embolic basilar artery occlusion due to miserable vertebral artery stump syndrome. A technical report. J Clin Neurosci. 2020; 73:299303.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Ji R, Li B, Xu Z. Retrograde recanalisation for vertebral artery stump syndrome: a case report. Stroke Vasc Neurol. 2022;7(5):462464.

  • 11

    Nii K, Abe G, Iko M, et al. Endovascular angioplasty for extracranial vertebral artery occlusion without visualization of the stump of the artery ostium. Neurol Med Chir (Tokyo). 2013;53(6):422426.

    • PubMed
    • Search Google Scholar
    • Export Citation

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