Abstract Number ‐ 103: Revascularization of a Persistently Occluded Left Vertebral Artery with Ongoing Symptoms and Poor Collaterals
Authors: Browen Adam , Lodi Yahia M 
Published: April 2023

Introduction
Ischemic stroke presents a significant burden to health globally, with those in the posterior circulation accounting for 20% of all strokes. [1]. Efforts to attempt endovascular revascularization in a chronically occluded vertebral artery is not prevalent but has been increasing abroad. In a single center in China, 22 subjects had attempted revascularization, with successful revascularization was achieved in 86.36% of patients using balloon dilation combined with stenting in 14 subjects. Improving technology and techniques have made these attempts more feasible. Objective: This report demonstrates a unique case of symptomatic vertebral artery revascularization 3 days after the initial onset of vertebral artery occlusion symptoms using balloon angioplasty and stenting in the proximal portion of the left vertebral artery.

Methods
Case report

Results
58‐year‐old man with history of hypertension, hyperlipidemia, and smoking presented to the Wilson Hospital ER with an abrupt onset syncopal episode. He was found crawling on the highway by EMS. Initial workup included MRI and CTA that were consistent with cerebellar strokes, a hypoplastic right vertebral artery, and occlusion of the left vertebral artery. Three days elapsed between recognition of the vertebral pathology and indication of appropriate endovascular intervention and angiography. Angiography revealed an acute occlusion of the left vertebral artery with significant reduction of anterograde flow. Initial blood flow transit time from VAO to left posterior circulation took 6 seconds compared to 2 seconds in the right posterior circulation. Inadequate vertebral collateral flow was appreciated from costocervical cervical trunk branches. An urgent stenting of the left vertebral artery was performed after informed consent from patient. Before the procedure, the patient was prepared with both aspirin (325mg), Plavix (150mg), and IV heparin to achieve 1.5‐2 times the baseline activated clotting time. Angioplasty was performed with a 2.5×20mm Maverick balloon loaded over a choice PT 14 compatible microwire. Integrilin (5mg) was delivered prior to catheterization to reversibly inhibit GPllb/llla. The left vertebral artery was catheterized, and angioplasty was performed two times with balloon inflation at 12 atmospheres. Using fluoroscopic guidance, a drug‐eluting stent measuring 4×22 was placed across stenotic vertebral artery via the existing vertebral wire. In placement, the balloon was inflated up to 10 atmospheric pressures to obtain an intraluminal diameter of 4.0. Post‐procedure angiogram showed that the lesion decreased from a near complete occlusion to less than 10% occlusion. Additionally, post‐procedure transit time was reduced to 2 seconds. Patient was asymptomatic at discharge and was given aspirin (325mg), clopidogrel (75mg), and was recommended to follow‐up after 4–6 weeks

Conclusions
This case study gives greater support to endovascular intervention in a delayed setting with revascularization with balloon dilation combined with stent implantation on a case‐by‐case basis. Further investigation of inclusion criteria is needed, as this patient was exceptional in collaterals and anatomy.