case_images: PMC10548121_01
case_images: Pre- and post-treatment CT evaluation of the patient. (A) Pre-treatment non-contrast CT scan demonstrated a hypodensity lesion in the left thalamus. (B) Cervical and cerebral CT angiography (CTA) showed proximal occlusion with a non-tapered stump (white arrow) and distal severe stenosis of the left vertebral artery. (C) CTA showed that the right vertebral artery did not join in the basilar artery. (D) Post-treatment CTA indicated that the left vertebral artery was recanalized with stent placed inside (white arrow).
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case_images: PMC10548121_01_fneur-14-1246151-g0001.jpg
case_images: F1
case_images: CT demonstrated a hypodensity lesion in the left thalamus (Figure 1A). CT angiography (CTA) showed proximal non-tapered occlusion and distal severe stenosis of the left VA (Figure 1B), and that the right VA did not converge with the left VA into the basilar artery (Figure 1C). After the procedure, the patient underwent a repeated CTA examination, which indicated successful recanalization of the left VA (Figure 1D).
case_images: Endovascular procedure of the patient. (A) The micro guidewire was unable to across the occluded segment of the left vertebral artery. (B) Angiogram showed abundant collateral from the left deep cervical artery to the V3 segment of the left vertebral artery (white arrow), a tapered stump in the distal part of the occluded segment of the left vertebral artery (red arrow). (C, D) The micro guidewire reversely traversed the occluded segment of the left vertebral artery via the left deep cervical artery and was placed in the left subclavian artery [white arrow in (D)]. (E) Balloon dilation of the left vertebral artery occlusion (white arrow). (F) Occluded left vertebral artery was successfully reopened but remained with severe stenosis (white arrow). (G) Angiogram showed severe stenosis of the V4 segment of the left vertebral artery (white arrow). (H) A balloon-expandable stent was implemented in the stenotic segment of the left vertebral artery (white arrow). (I) After stenting, the stenosis of the V4 segment has been relieved (white arrow). (J) Stent placement of the V1 segment of the left vertebral artery to prevent restenosis (white arrow).
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case_images: PMC10548121_01_fneur-14-1246151-g0002.jpg
case_images: F2
case_images: In the beginning, multiple attempts were performed with the coaxial assembly of a PT 0.014-in micro guidewire (Boston Scientific, Boston, USA) and an Excelsior SL-10 microcatheter (Stryker, Michigan, USA) to facilitate navigation across the occluded segment but failed (Figure 2A). At the moment, robust deep cervical collateral to the distal V3 segment of the left VA and a tapered stump of the distal part of the occluded segment were noted (Figure 2B). Therefore, the exchange of a Synchro 0.014-in micro guidewire (Stryker, Michigan, USA) was performed to reach the distal V3 segment through the left deep cervical artery, which then reversely traversed the occluded segment to the left subclavian artery successfully (Figures 2C, D). A Neuro RX 2.75 x 15 mm balloon (Sinomed, Tianjin, China) was subsequently advanced to the VA ostium along the micro guidewire to dilate the occluded segment (Figure 2E). After balloon dilation, the occluded segment was successfully recanalized but remained in severe stenosis (Figure 2F). DSA revealed severe stenosis of the V4 segment and antegrade filling of the basilar artery and both posterior cerebral arteries (Figure 2G). Tianjin, China) was implemented in the stenotic segment (Figures 2H, I). To prevent restenosis of the V1-V2 segment, a RX 4.0 x 18 mm balloon-expandable stent (Abbott, California, USA) and a Bridge 4.0 x 18 mm rapamycin drug-eluting stent (Microport, Shanghai, China) were consecutively implanted in the recanalized segment (Figure 2J).
case_images: The timeline of the present case.
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case_images: PMC10548121_01_fneur-14-1246151-g0003.jpg
case_images: F3
case_images: Figure 3 summarizes the timeline of the present case.