High-Flow Saphenous Vein Graft Bypass from Common Carotid Artery to Vertebral Artery (V2) for the Treatment of Vertebrobasilar Insufficiency Due to Bilateral Vertebral Artery Origin Stenosis

Vertebrobasilar insufficiency can lead to devastating brainstem and posterior cerebral infarction without timely treatment.¹ A 56-year-old man with a history of hypertension, hyperlipidemia, and diabetes mellitus presented to the clinic with right hemiparesis due to previous left cerebral hemispheric stroke. He also harbored a giant asymptomatic parieto-occipital meningioma incidentally diagnosed 2 years ago. Neuroimaging showed old left cerebral infarcts and a tumor that had remained stable in size. Cerebral angiography identified bilateral vertebral artery stenosis near their origin from the subclavian arteries with severe vertebrobasilar insufficiency. There was some collateral flow to the posterior cortex via the internal maxillary and occipital artery branch anastomoses. Despite recommendation, the patient decided to not undergo tumor resection, but opted for a high-flow bypass to the posterior circulation to prevent stroke. We used a saphenous vein graft to perform a high-flow extracranial-to-extracranial bypass revascularization of the ischemic vertebrobasilar circulation (Video 1). The patient tolerated the procedure well and was discharged without new deficits 4-days postoperatively. Most recent follow-up examination at 3 years after surgery revealed a patent bypass graft with no new adverse cerebrovascular events. The tumor remains asymptomatic without change in imaging characteristics. Cerebral bypasses remain useful tools in carefully selected patients for the treatment of complex aneurysms, complex tumors, and ischemic cerebrovascular diseases.^2-7 We demonstrate an extracranial-to-extracranial high-flow bypass to revascularize the posterior cerebral circulation using a saphenous vein graft in a patient with vertebrobasilar insufficiency.