Combined Carotid Endarterectomy and Vertebral Transposition or Bypass for Cerebral and Vertebrobasilar Insufficiency

Abstract

The purpose of this report is to determine the indication for a combined carotid endarterectomy and vertebral transposition or bypass in patients who have transient ischemic attack (TIA) or stroke and intractable vertebral ischemic symptoms of dizziness and syncope. A retrospective review was made on 49 patients with the combined symptoms of generalized global ischemia, TIA, amaurosis fugax or stroke, and vertebral basilar insufficiency manifested as syncope, intractable dizziness, and unsteady gait. Diagnostic studies employed were carotid duplex scan, computed tomography (CT) or magnetic resonance imaging (MRI) brain scan, xenon blood flow study, transcranial Doppler analysis, electronystagmography, electroencephalography, and cardiac arrhythmia evaluation. Twenty-one of 49 patients (43%) with internal carotid occlusion underwent carotid endarterectomy plus vein patch or internal carotid to external carotid onlay patch angioplasty and proximal vertebral to common carotid artery transposition (n: 19), or bypass (n:2). Twenty-seven of 49 patients (57%) received carotid endarterec tomy and vertebral transposition (n:27) or bypass (n:2) for carotid and vertebral stenosis. There was no operative mortality, stroke, or neurologic deficit following the carotid and vertebral operations in the 49 patients. Six patients had transient palpebral ptosis. Postoperative cerebral angiogram or magnetic resonance angiogram showed patent vertebral arteries. All 49 patients have resolution of TIA, dizziness, syncope, and unsteady gait. Combined carotid endarterectomy and vertebral transposition or bypass should be considered in patients with solitary, dominant, or bilateral vertebral artery critical stenosis whose symptoms are unrelated to vestibular, cardiac, or seizure disorders and lateralized TIA or stroke.