ECA-RA-VA Bypass for Surgical Treatment of Radiculopathy Caused by a Cervical Vertebral Artery Aneurysm

Introduction: Vertebral artery (VA) aneurysms are a rare cause of cervical radiculopathy. Described treatment options include parent artery occlusion, endovascular trapping, or stents. We present a case of a large right VA aneurysm at the C5–6 level, compressing the C6 nerve treated with a transverse foramen decompression and bypass of the aneurysm with an external carotid artery to V3 bypass.

Case Report: A 48-year-old right-handed female with no history of trauma or neck manipulation presented with debilitating pain in her right arm and hand for 2 months. Our endovascular colleagues felt a pipeline device may be limited due to the tortuosity and irregular appearance of her VA proximal to the aneurysm. The patient was interested in preserving her VA and she agreed to a surgical option.

Under general anesthesia, the patient was positioned with pins and head turned to the left in a far lateral position. A curved incision was made behind the ear extending into the anterior neck crease. The skin flap was then reflected anteriorly in the subplatysmal plan. The sternocleidomastoid muscle was identified, and the external carotid artery was dissected out anterior to the muscle. At the right suboccipital area, the splenius capitis, semispinalis capitis, and longissimus capitis were all reflected inferiorly. The superior oblique and inferior oblique muscles were identified and dissected off their attachment to the transverse process of C1. The lateral mass and transverse process of C1 was exposed further and the V3 segment of the VA was identified superior to the C1 arch. The C1 right VA canal was opened using a drill and the Kerrison rongeours. The VA was further exposed and circumferentially dissected with all muscular branches ligated off and hemostasis obtained.

A harvested 12-cm radial artery graft was anastomosed to the V3 segment in a side-to-end fashion using 8–0 prolene with single interrupted sutures. The graft was then tunneled under the sternocleidomastoid into the anterior triangle of the neck and anastomosed to the ECA in the same fashion. All temporary clips were removed, and patency confirmed with Doppler and intraoperative ICG angiography.

The patient was positioned prone for the posterior cervical fusion. After exposure, the left C5, C6, and C7 lateral mass screws were placed using anatomical landmarks. On the right the C5–6. The C6–7 facet joints were removed and the C6 transverse foramen was opened exposing the C6 nerve root and underlying aneurysm. The proximal end of the aneurysm was visualized then clipped. Doppler confirmed no flow within the aneurysm. C5 and C7 lateral mass screws were then placed followed by bilateral rods. After irrigation, decortication and placement of bone graft, the wound was closed in multiple layers in a standard fashion. The patient tolerated the procedure well and was extubated.

Conclusion: At 6 months of follow-up, patient is doing well with no residual arm pain and has resumed normal physical activity. VA bypass is an effective tool for treatment of symptomatic large extracranial VA aneurysms.

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Publication History

Article published online:
12 February 2021