Endovascular revascularisation of acute tandem vertebrobasilar artery occlusion: seven case series with literature reviews

Abstract

Background: The outcome of acute ischaemic stroke due to tandem vertebrobasilar artery occlusion was poor. Endovascular revascularisation may be a positive approach for acute basilar artery occlusion combined with vertebral ostium stenosis or occlusion. We reported seven patients with acute vertebrobasilar tandem occlusion by using angioplasty or stenting for proximal lesion and thrombectomy for distal occlusion.

Materials and methods: Consecutive patients with acute tandem vertebrobasilar artery occlusion at two centres were included in this study. We retrospectively analysed the clinical, technical and functional outcomes of the patients.

Results: From March 2016 to March 2017, seven patients were included. The mean age and National Institute of Health Stroke Scale score at admission was 57 years and 22, respectively. A reverse approach was used in five patients. The Thrombolysis in Cerebral Infarction score 2b-3 was acquired in all patients. There were no procedural complications. The modified Rankin Scale score was 1-2 for three patients and 4 for one patient at 3 months. Three patients died at 3 months of follow-up.

Conclusions: Endovascular revascularisation may be feasible for acute tandem vertebrobasilar artery occlusion, and more researches are needed.

Keywords: basilar artery; occlusion; stroke; tandem occlusion; thrombectomy.

Figure 1

Illustration of the reverse (A) and the antegrade (B) technique for the tandem vertebrobasilar artery occlusion through the occlusive or severe stenotic vertebral artery (dirty-road path). (A) A guiding catheter was advanced to the distal left vertebral artery (LVA) V2 segment through the stenosis segment over the partially reinflated balloon. A stent retriever was deployed at the segment of the basilar artery (BA). After successful recanalisation was achieved, the microguidewire was sent to the V2 segment and then the guiding catheter was gently pulled back to the proximal subclavian artery. A balloon-expandable stent was then implanted at the ostial vertebral artery. (B) A balloon-expandable stent was sent to the ostial vertebral artery over the microguidewire and was implanted at the lesion exactly. The guiding catheter was then navigated to the distal V2 segment through the partially reinflated balloon across the implanted stent gently. Subsequently, the stent-assisted thrombectomy was performed as described above.

Figure 2

Case example 1. (A) Left vertebral artery occlusion. (B) A 6 Fr catheter crossing the left vertebral artery through the stent over the partially reinflated balloon. (C) Right non-dominant ending in posterior inferior cerebellar artery. (D) Basilar artery occlusion. (E) Recanalisation of the basilar artery. (F) Final angiography of the left vertebral artery.

Figure 3

Case example 2. (A) Left vertebral artery occlusion. (B) Right vertebral artery ostial severe stenosis. (C) Predilation of the right vertebral artery stenosis. (D) Distal basilar artery clot. (E) Recanalisation of the basilar artery. (F) A stent-assisted angioplasty at the right vertebral artery.