Andrew L. Carney, M. D.
Father - Distal Vertebral Artery Bypass 1977
University of Illinois at Chicago


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Surgery of he First and Second Part of the Vertebral Artery

Andrew L. Carney MD, Robert Emanuele MD
Photography by Joseph Kozicki – Medicom

This surgical movie was presented to the surgeons at the American College of Surgeons in 1976 and demonstrates the anatomy of the proximal and distal vertebral arteries.

There are three cases presented followed by a repetition of the principal issues in the cases. All the details of the cases are written up with angiograms in the book, by Anderson and Carney, DIAGNOSIS AND TREATMENT OF BRAIN ISCHEMIA, which was published in 1981 and is available on this website in pdf format.

Case 1 – Bernice B. Syncope precipitated by head position. Temporary relief with vertebral artery (VA) surgery. Subsequent Atrial Ventricular pacemaker.

This was an elderly lady, in her 70s, who was able to cause syncope as a teenager by acutely hyperextending her head. On the right, angiography revealed that she had an ansa subclavia which tightly encircled the right subclavian and vertebral arteries. This was divided with relief. Years passed, and dizziness developed but syncope did not recur. At this time, the proximal vertebral artery was bound to the spine and entrappedand tethered by the autonomic nerve fibers. With age the aorta and the subclavian artery rise in the chest and neck. In the neck, the subclavian artery rotates around the tether so the origin of the VA is on the underside rather than the dome of the subclavian A.. The vertebral artery was divided and reattached to the dome of the subclavian artery.Several years later, the patient had an atrial-sequential pacemaker inserted because The failing heart had become a factor in her symptoms. She was going strong at the age of 89.

Case 2 – Clarence W. Stokes Adams Syndrome – Dissection and Occlusion of the Proximal Left Vertebral Artery (VA) after Right Ventricular Pacing.

C.W. was a physician of slight build who has suffered from polio as a child and was left with a partially limp left leg. Fifteen years prior to this surgical encounter, the patient passed out and had a motor vehicle accident. Subsequently, he could sense impending syncope and would pull over to the side of the road, pass out, recover and drive on. When he collapsed in the hospital, he was found to have a bradycardia, for which a right ventricular pacemaker was put in place.

For the first time, he suffered from dizziness whenever the pacemaker fired. Angiography revealed that the carotid injections filled the basilar artery because of basilar artery hypotension. The right VA was hypoplastic. The left VA was occluded at its origin. At surgery, the proximal occlusion was found to be due to a dissection of the vertebral artery. This was reconstructed by hooking up a branch of the subclavian artery to the proximal VA.

Several years later, the patient presented with “spells” resembling petit mal seizures. At this time, the pacemaker was changed from a right ventricular to an atrial-ventricular sequential pacemaker which improved his ability to function.

The surgical demonstration of the difference between the cardiac function with right ventricular pacing vs atrial-ventricular pacing see the surgical film elsewhere on this website.

Case 3 Kathleen K. Syncope when looking up. Entrapment and obstruction of the both vertebral arteries at skull base. Worse on the right.

This young woman would pass out when looking up. Angiography revealed acute kinking of the vertebral arteries at skull base, but much worse on the right. She was taken to surgery and the involved kink was resected and the ends of the artery sutured together. She was relieved on any tendency to any tendency to syncope for the ten years of followup. Some time later, the angiograms were repeated and the reconstruction was in good condition. Cf The book cited above for a detailed discussion of the case with all pertinent angiograms.

Significant observations in this case.

(1) Both vertebral arteries at the C1-C2 levels were trapped and bound by nerves which caused the arteries to acutely kink. At surgery, the quality of the arterial wall on the flexion side was acutely deteriorated and fragile. Such an arterial wall would predispose to thrombi adherent to the intima of the artery and embolisation. Cf.Case A.E. in Volume 30.

(2) Do not divide the sternocleidomastoid (SCM). The surgical approach in this case involved dividing the insertion of the (SCM). Post-operatively, the absence of the SCM left a visible distortion of the normal neck appearance. Subsequently, an osteoplastic approach was utilized and the tip of the mastoid was then reattached at the end of the operation. This leaves a more cosmetic result.

(3) Divide the anterior ramus of the second cervical nerve and use it as a landmark. In this case, the anterior ramus of the second cervical nerve was not divided. Since it has no recognizable function, it was subsequently divided which makes surgical exposure much easier. Secondly, traction on the nerve ends serve to facilitate exposure of the vertebral artery at this level.

finis

Surgery of Vertebral Artery movie.

 

 
AV Pacing in Stokes Adams Syndrome
AV Pacing movie.
 
Amnesia, Seizures and Subclavian Steal movie.

 

 

 


 

 

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