Isolated reversal of flow in the vertebral artery – A missed entity

Isolated reversal of flow in the vertebral artery is a rare phenomenon occurring in the general population and is due to intrinsic anatomical defects. The most common cause is subclavian stenosis; however, reversal of flow in the vertebral artery can occur regardless of any detection of anatomic deterioration. In this series, we report three asymptomatic cases where the extracranial Doppler scan preceding off-pump coronary arterial bypass grafting showed isolated reversal of flow in the vertebral artery. No signs of subclavian stenosis or steal syndrome were elicited. However, all patients subsequently suffered from a posterior circulation stroke following off-pump coronary arterial bypass grafting but recovered fully with medical management. We conclude that a detailed pre-operative neurological investigation can mitigate this risk and improve neurological outcomes following off-pump coronary arterial bypass grafting.

Combined Transradial and Transfemoral Approach Using a Compliant Balloon for Emboli Protection at the Vertebral Artery During Subclavian Stenosis Stenting: 2-Dimensional Operative Video

Endovascular intervention has become the mainstay of treatment for subclavian artery stenosis in many centers, with high technical success and low complication rates.1,2 However, potential embolization during proximal subclavian artery intervention can lead to catastrophic posterior circulation ischemic complications.3-5 Although considered a rare complication, the presence of a contralateral hypoplastic vertebral artery with persisting anterograde vertebral blood flow on the affected side is likely to increase the risk of embolization.3 The use of embolic protection devices, such as filters and noncompliant balloons, has been previously described.3,6,7 However, there is still a risk of distal embolization and vessel injury with the use of these devices.7 We present a technical video of a patient in their 80s with left subclavian stenosis who underwent subclavian stent-assisted percutaneous transluminal angioplasty (SAPTA) using an anterograde-retrograde access technique with a dual-lumen compliant balloon catheter (Scepter XC; MicroVention, Aliso Viejo, California) placed at the proximal segment of the left vertebral artery. With this approach, the compliant balloon provides adequate protection while minimizing the risk of endothelial injury and distal embolization. Written informed consent was obtained for the procedure. Patient consent was waived because all health information was deidentified.