Discussion

63 y/o man with frequent episodes of dizziness and visual loss. Pt is on coumadin and ASA, but I think his symptoms are more hemodynamic than thromboembolic. He basically has a stenotic right vertebral origin with a chronically occluded mid-basilar and left vertebral. Fortunately, he has good sized PCOMs.  I think that if his symptoms continue, I would be inclined to PTA that right vertebral origin and see how he does.

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Follow-Up

Turns out the patient has new insurance that doesn't include our facility...

Your Comments

 
Do you have a good vascular surgeon?  This is a prime candidate for a vert-carotid transposition of that proximal right vert - it is a redundant enough vessel that there is slack to work with for the surgeon; in my experience this is a great procedure with an excellent long-term patency rate (better than angioplasty or stenting in this location).  If you have to go the angioplasty route, you might consider a drug-eluting stent if the vessel isn't too big for the available stents.  I have a series of 12 patients with this procedure; 7 of whom I have gone on across the anastomosis 6 weeks later to angioplasty a distal lesion.  You may find that the basilar is not completely occluded if you improve the inflow.  You may be dealing with a point of competing flow and stagnation at that stenosis.  I would restudy the patient after the proximal lesion is fixed (CTA should be adequate) and go after the distal lesion if it is not truly completely occluded.

Greatest risks come with blood pressure swings, downward. Need to pay
attention to BP -- that it is not even given as part of profile
suggests that you are only looking at anatomy not physiology.
Even if you add some with right vert stenosis dilatation, BP is key.
Interesting that you don't show us selective left subclavian
reconstituting left vert by collaterals (only on MRA). Collaterals
beyond a proximal vertebral occlusion are rich, and would be rich for
right vert as it stenoses more. Interesting that you don't show us
collaterals from left occipital to left vert at C1 -- presumably
subclavian collaterals are already so good that there is not enough
pressure gradient from external to vert occipital to show that path.
BP needs to be understood (24 hour monitoring) and treated as
necessary. That will be a real treatment, maybe with anticoagulation,
to prevent catastrophe related to basilar occlusion. Goal of treatment
is to prevent clots forming adjacent to occluded segment; they are most
likely to form during low pressure states.
Vertebral stenosis dilatation has logic, may be useful if nothing bad
happens during the procedure, but will not prevent catastrophic stroke
if the patient is really suffering from hypotensive episodes.

I agree with your assessment and his symptoms could be due to that "trapped" vertebrobasilar segment whose inflow depends on a reconstituted and small left vert and stenotic right vert.
 Based on various reports, I believe restenosis here is common and I would primarily stent it with a balloon expandable coronary stent. If you have any trouble crossing or getting in consider a right brachial access.  A drug coated stent would be good if you could get one and you would not be the first to use one in the brachicephalic circulation, from what I hear.

I think I would ignore the basilar occlusion since the distal
collateral looks so good.  Regarding the Right Verterbral origin stenosis, I
think that I would treat it if she has failed medical therapy.  If she has
not had a trial of dual anti-platelet meds or can't take them then
stenting would be a reasonable option.  There is a high rate of restenosis
at this site and I have started to use drug eluting stents for this
purpose.  Of course, I can't advocate this off label use of a device but
it makes sense to me!

I would angioplasty and stent this stenosis. I have had good luck with
Taxus stent in handful of cases in this location. I have had restenosis
rate similar to that of angioplasty alone  with plain stents.

Did the individual fully recover from their pontine stroke?  Are they
experiencing further events on medication?