Nov 8, 1993 - Department of Neurosurgery, Kochi Medical School, Nankoku, Kochi. Abstract. A 51-year-old male suffering from recurrent cerebral ischemia ...
Successful Percutaneous Transluminal Angioplasty of the Intracranial Vertebral Artery 1 Month after Total Occlusion —
Shinya
HONDA,
Masahiko
Takahisa
ARISAWA,
Department
Case
Report—
MORI, Toshihiko
of Neurosurgery,
Masaaki
FUKUOKA,
NISHIMURA,
Kochi Medical
and
Ken Koreaki
School, Nankoku,
KAJITA, MORI Kochi
Abstract A 51-year-old male suffering from recurrent cerebral ischemia due to total occlusion of the bilateral in tracranial vertebral arteries more than 1 month old was successfully treated by percutaneous transluminal angioplasty (PTA). The totally occluded portion from the right intracranial vertebral artery to the basilar artery was adequately dilated. Follow-up angiography approximately 3 months after angioplasty demonstrated no evidence of restenosis. His symptoms have not recurred. PTA is potentially a much less invasive and safer reconstruction than bypass surgery the intracranial vertebral arteries less than 3 months old. Key words:
angioplasty,
total
occlusion,
intracranial
Introduction Percutaneous transluminal angioplasty (PTA)') has recently been advocated for treating supra-aortic ex tracranial lesions,6,8,10,12,15,16) particularly in patients with other operative risks.9"14) Recent advances in microcatheter technology have allowed PTA for stenotic lesions involving the intracranial vertebro basilar arteries. 1,4,11) Extracranial-intracranial (EC-IC) bypass surgery is an option for patients with obstructed lesions in volving the basilar or bilateral intracranial vertebral arteries. However, the procedure is often accom panied by significant morbidity and mortality.') Therefore, PTA has an advantage in reducing pa tient risk. In addition, experience with coronary angioplasty shows that total occlusions after the acute stage and less than 3 months old can often be successfully dilated. 13) We describe a 51-year-old male with recurrent cerebral ischemia due to total occlusion of the bilateral intracranial vertebral arteries more than 1 Received Author's
November present
8, 1993;
address:
S. Honda,
Accepted M.D.,
March Department
for total occlusions
of
artery
month old. PTA of the totally occluded right in tracranial vertebral artery was performed because the recurrent symptoms indicated aggressive treat ment.
Case
Report
A 51-year-old right-handed male had often experi enced transient ischemic attack (TIA) manifesting as diplopia and left-sided hypesthesia lasting for a few minutes, especially in the sitting position, since October, 1992. On January 2, 1993, he suddenly experienced right-sided hemiplegia and dysarthria for 20 minutes. He was admitted to another hospi tal. Magnetic resonance imaging, computed tomog raphy, and single photon emission computed tomog raphy demonstrated no causative lesions, so his symptoms were diagnosed as due to TIA. His arteriosclerotic risk factors included a history of hypertension, hyperlipidemia, hyperuricemia, cigarette smoking, and angina pectoris on exertion. Pravastatin (10 mg/day), lisinopril (10 mg/day), and
7, 1994 of Neurosurgery,
Kubokawa
Hospital,
Kochi,
Japan.
apy. Therefore, hemodynamic cerebral ischemia of the basilar artery territory was diagnosed as the cause of the TIAs. On January 28, 1993, he was referred to our hospital for reconstructive vascular surgery. Diagnostic angiography was repeated to exactly evaluate the lesions. The occlusion from the right vertebral artery to the basilar artery appeared to be short (i.e., approximately 1.0 cm) (Fig. 2 left). When isosorbide dinitrate (ISDN) (5 mg) was ad ministered into the right vertebral artery, contrast material penetrated faintly beyond the occluded site
Fig. 1
Preoperative
left vertebral
angiogram,
antero
posterior projection, showing total occlusion (arrow) of the left vertebral artery distal to the left PICA.
Fig. 2 left: Preoperative right vertebral angiogram, anteroposterior projection, demonstrating the total occlusion (arrow) in the right vertebral artery distal to the right PICA. right: Right vertebral angiogram after administration of ISDN 5 mg, showing faint penetration of con trast material (arrowhead).
allopurinol (300 mg/day) were administered. Smok ing was forbidden. Cerebral angiography on January 4, 1993 demonstrated totally occluded bilateral vertebral ar teries in the intracranial portions distal to the poste rior inferior cerebellar artery (PICA), and insuffi cient collateral circulation through the posterior communicating arteries and from the PICAs to the basilar artery (Fig. 1). Although hemiparesis and dysarthria no longer occurred, TIA manifesting as diplopia and left-sided hypesthesia recurred several times despite antiplatelet and anticoagulation ther
(Fig. 2 right). We therefore suspected that the vessel had recently occluded, presumably on January 2, 1993 when he suddenly experienced severe TIA manifesting as right-sided hemiplegia and dysar thria. His many risk factors, and the high incidence of morbidity and mortality associated with EC-IC bypass surgery of the posterior cerebral circulation indicated PTA of the totally occluded right ver tebral artery. We hoped to cannulate the basilar artery with a guide wire through the occluded le sion from the right vertebral artery to the basilar artery. Aspirin (243 mg/day) had been administered oral ly since January 28, 1993 and was continued after PTA. Low-molecular-weight dextran (2000 ml/day) was also given before PTA and continued until the next day. Angiographic imaging used nonionic con trast medium (lopamiron; Schering AG, Berlin, Ger many). PTA was performed using a right transfemoral ap proach and a 7-F introducer under local anesthesia on February 10, 1993. Heparin (10,000 U) was ad ministered to prevent thromboembolism during the procedure. An extended guide wire (Radifocus 260 cm; Terumo, Tokyo) was inserted into the right vertebral artery through a 6-F diagnostic catheter (Selecon; Clinical Supply, Co., Ltd., Gifu) and subse quently replaced by a 7-F guiding catheter (Silascon; Kaneka Medix, Co., Tokyo). After administration of ISDN (5 mg), we succeed ed in engaging the vertebral and basilar arteries with the guide wire (Seeker; Target Therapeutics, Fre mont, Cal., U.S.A.) using penetrated contrast material as a guide. Following confirmation of cor rect wire positioning by contrast injections and visualization in two or more radiographic projec tions to assess the distal vessel wire position, a balloon catheter (2.5 mm diameter and 1.0 cm length) (Stealth; Target Therapeutics) was advanced over the wire and across the occluded portion. The Seeker wire was subsequently replaced by a valve wire (4.0 cm coil extension) (Target Therapeutics).
Fig. 3
left: Postoperative right vertebral angiogram, showing adequate dilation of the occluded por tion (arrowheads) and better visualization of the basilar artery. right: Follow-up right vertebral angiogram 3 months after PTA, demonstrating no evidence of restenosis.
Six inflations
of 60-second
duration
at 6 atm were
performed over the occluded segment from the basilar artery end to the vertebral artery end. An excellent angiographic result was obtained (Fig. 3 left). The collateral circulation immediately disappeared, and no complications occurred during or immediately after the procedure. Follow-up angiography on April 30, 1993 demonstrated no evidence of restenosis (Fig. 3 right). No TIA or stroke has occurred up to February 10, 1994.
have a success rate of less than 60%, and the risk of abrupt closure is high. According to this classifica tion, our patient's lesion was type B, because it was not in the acute stage, short, and occluded for less than 3 months. A technical success rate ranging from 60% to 85% was therefore anticipated. In fact, we achieved dilation of the total occlusion. The lesion-specific characteristics of intracranial arteries may resemble those of coronary arteries, so we propose that total occlusions less than 3 months old involving the intracranial arteries can also be dilated with PTA. A classification based on cerebral angiographic patterns is required to evaluate the likelihood of a successful procedure. Elective or emergency bypass surgery often follows unsuccessful or complicated PTA in the cor onary or peripheral vasculature where the effect of bypass surgery is certain.') In contrast, the effect of EC-IC bypass surgery remains uncertain,') and bypass surgery in the posterior cerebral circulation may be accompanied by significant morbidity and mortality. Therefore, there is no effective rescue surgery following unsuccessful or complicated PTA of the intracranial vertebral artery. PTA for a totally occluded intracranial vertebral artery is much less invasive than surgical reconstruc tion in the posterior cerebral circulation. However, PTA for the intracranial vertebral artery should carefully be considered and informed consent is essential. Acknowledgment
Discussion
Our unorthodox use of PTA to treat a totally oc cluded intracranial vertebral artery more than 1 month old was successful in this case. Such a use of PTA has not previously been reported. Angioplasty requires careful consideration of the likelihood of a successful procedure. Experience with coronary angioplasty has identified angio graphic patterns outlining the morphological char acteristics of vessels as specific to lesions. The American College of Cardiology/American Heart Association task force") proposed three types of le sion-specific characteristics (type A, B, and C le sions) as guidelines for coronary angioplasty. Type A lesions, which are discrete, concentric, and less than totally occlusive, have a success rate of 85% or more, and the risk of abrupt vessel closure is low. Type B lesions, with tubular shape, eccentricity, and/or total occlusion less than 3 months old, have success rates from 60% to 85%, and the risk of ab rupt closure is moderate. Type C lesions, which are diffuse or total occlusions more than 3 months old,
We would like to thank Fong Y. Tsai, M.D., Depart ment of Radiology, University of Missouri (Kansas City, Mo., U.S.A.) for his review of this manuscript and suggestions. References 1)
2)
3)
4)
Ahuja A, Guterman LR, Hopkins LN: Angioplasty for basilar artery atherosclerosis. Case report. J Neurosurg 77: 941-944, 1992 Dotter CT, Judkins MP: Transluminal treatment of arteriosclerotic obstruction. Description of a new technique and a preliminary report of its applica tion. Circulation 30: 654-670, 1964 The EC⁄IC Bypass Study Group: Failure of ex tracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med 313: 1191-1200, 1985 Higashida RT, Tsai FY, Halbach VV, Dowd CF, Smith T, Fraser K, Hieshima GB: Transluminal angioplasty for atherosclerotic disease of the
vertebral 198, 1993
5)
6)
7)
8)
9)
10)
11)
and
basilar
arteries.
J Neurosurg
78:
192 -
Hopkins LN, Budny JL: Complications of in tracranial bypass for vertebrobasilar insufficiency. J Neurosurg 70: 207-211, 1989 Kachel R, Basche ST, Heerklotz I, Grossmann K, Endler S: Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially the internal carotid artery. Neuroradiology 33: 191-194, 1991 Mathur VS, Guinn GA, Anastassiades LC, Chahine RA, Korompai FL, Montero AC, Luchi RJ: Surgical treatment for stable angina pectoris. Prospective ran domized study. N Engl J Med 292: 709-713, 1975 Mori T, Arisawa M, Honda S, Fukuoka M, Kurisaka M, Mori K: Three months angiographic follow-up after successful percutaneous transluminal angioplas ty. No Shinkei Geka 21: 141-146, 1993 (in Japanese) Mori T, Arisawa M, Honda S, Fukuoka M, Mori K: Percutaneous transluminal angioplasty of supra-aor tic arterial stenoses in patients with concomitant cerebrovascular and coronary artery disease. Report of two cases. Neurol Med Chir (Tokyo) 33: 368-372, 1993 O'Leary DH, Clouse ME: Percutaneous transluminal angioplasty for the cavernous carotid artery for recur rent ischemia. AJNR 5: 644-645, 1984 Purdy PD, Devous MD Sr, Unwin DH, Giller CA, Batjer HH: Angioplasty of an atherosclerotic middle cerebral artery associated with improvement in regional cerebral blood flow. AJNR 11: 878-880,
1990
12)
13)
14)
15) 16)
Rostomily RC, Mayberg MR, Eskridge JM, Goodkin R, Winn HR: Resolution of petrous internal carotid artery stenosis after transluminal angioplasty. J Neurosurg 76: 520-523, 1992 Ryan TJ, Loop FD, Faxon DP, Peterson KL, Gun nar RM, Reeves TJ, Kennedy JW, Williams DO, King SB, Winters WM Jr: Guidelines for per cutaneous transluminal coronary angioplasty: A report of the American College of Cardiology⁄ American Heart Association task force on assess ment of diagnostic and therapeutic cardiovascular procedures (Subcommittee on percutaneous trans luminal coronary angioplasty). J Am Coll Cardiol 12: 529-545, 1988 Sharma S, Kaul U, Misra N, Rajani M: Case report: Percutaneous transluminal angioplasty in a high risk coronary patient. Clin Radio! 42: 57-59, 1990 Theron J: Angioplasty of supra-aortic arteries. Semin Intervent Radiol 4: 331-339, 1987 Tsai FY, Matovich V, Hieshima G, Shah DC , Mehringer CM, Tiu G, Higashida R, Pribram HF: Percutaneous transluminal angioplasty of the carotid artery. AJNR 7: 349-358, 1986
Address of
reprint
requests
Neurosurgery,
Oko-cho,
Nankoku,
to: T. Mori, Kochi Kochi
Medical 783,
M.D.,
Department
School, Japan.
Kohasu,
