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The V3 Segment of the Vertebral Artery As a Robust Donor for Intracranial-To-Intracranial Interpositional Bypasses: Technique and Application in 5 Patients

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The V3 Segment of the Vertebral Artery As a Robust Donor for Intracranial-To-Intracranial Interpositional Bypasses: Technique and Application in 5 Patients TECHNICAL NOTE J Neurosurg 129:691–701, 2018 The V3 segment of the vertebral artery as a robust donor for intracranial-to-intracranial interpositional bypasses: technique and application in 5 patients Ali Tayebi Meybodi, MD, Arnau Benet, MD, and Michael T. Lawton, MD Department of Neurological Surgery, and Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, California The V3 segment of the vertebral artery (VA) has been studied in various clinical scenarios, such as in tumors of the craniovertebral junction and dissecting aneurysms. However, its use as a donor artery in cerebral revascularization procedures has not been extensively studied. In this report, the authors summarize their clinical experience in cerebral revascularization procedures using the V3 segment as a donor. A brief anatomical description of the relevant techniques is also provided. https://thejns.org/doi/abs/10.3171/2017.4.JNS163195 KEY WORDS far-lateral approach; interpositional bypass; extended retrosigmoid approach; anastomosis; posterior fossa vascular insufficiency syndrome; aneurysm; vascular disorders; surgical technique VARIETY of bypasses are available to revascularize tive donor because of its large size and tolerance to tem- the cerebral circulation, including first-generation, porary occlusion with a competent contralateral VA, but it low-flow extracranial-intracranial (EC-IC) by- is located deep within the suboccipital muscular triangle Apasses with scalp arteries (e.g., occipital artery [OA]1,11,12 and surrounded by complex anatomy that is unfamiliar to or superficial temporal artery [STA]); second-generation, many neurosurgeons. We describe the surgical technique high-flow EC-IC bypasses with interposition grafts that for accessing the V3 segment and our experience with the connect the cervical carotid artery (e.g., external carotid V3 (suboccipital) segment as a donor site for IC-IC inter- artery [ECA]) to intracranial recipients;9,17,23,31 and third- positional bypasses. generation intracranial-intracranial (IC-IC) bypasses that use adjacent intracranial arteries as donors to nearby re- Methods cipients. While the range and versatility of these bypasses give the neurosurgeon great flexibility for most indica- The study was approved by the institutional review tions, unusual cases with complex pathology and unfavor- board and performed in compliance with Health Insurance able anatomy might eliminate classic bypass choices. Al- Portability and Accountability Act regulations. The pro- ternative donor arteries are needed when previous surgery, spective database of the vascular neurosurgery service at radiation therapy, or intraoperative injury prevents the use the University of California, San Francisco, was queried, of scalp arteries or cervical carotid arteries as donors. The and patients for whom the V3 segment was used as a donor internal maxillary artery and the V3 segment of the verte- site in the bypass were identified. Medical records were bral artery (VA) are examples of alternative donor arter- retrospectively reviewed, as were preoperative and postop- 8,14,27,35 ies. The V3 segment has been used in a variety of by- erative images, angiograms, and technical considerations. passes to treat posterior circulation vascular insufficiency Bypasses using the V3 segment were considered IC-IC syndrome,7,24 complex vertebrobasilar aneurysms,2,18, 27,35 interpositional bypasses and differentiated from EC-IC in- 29,35 and skull base tumors. The V3 segment is an attrac- terpositional bypasses based on the need for a second in- ABBREVIATIONS AICA = anterior inferior cerebellar artery; EC = extracranial; ECA = external carotid artery; IC = intracranial; ICA = internal carotid artery; MCA = middle cerebral artery; OA = occipital artery; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; PSA = posterior spinal artery; RAG = radial artery graft; SCA = superior cerebellar artery; SCM = sternocleidomastoid; STA = superficial temporal artery; SVG = saphenous vein graft; VA = vertebral artery. SUBMITTED December 21, 2016. ACCEPTED April 14, 2017. INCLUDE WHEN CITING Published online October 6, 2017; DOI: 10.3171/2017.4.JNS163195. ©AANS 2018, except where prohibited by US copyright law J Neurosurg Volume 129 • September 2018 691 Unauthenticated | Downloaded 09/24/21 08:36 AM UTC A. Tayebi Meybodi, A. Benet, and M. T. Lawton cision remotely. Most EC-IC interpositional bypasses use point (46% of the distance from mastoid tip; Fig. 1F). This the cervical carotid artery and require a neck incision and landmark is relatively independent of patient positioning a tunnel for the graft between sites. IC-IC interpositional because it relies on 2 bony landmarks, and these land- bypasses are typically interpositional bypasses that are marks are palpable before skin incision and in all stages entirely intracranial, but also include those that have the of surgical exposure.34 The belly of the superior oblique donor vessel within the intracranial surgical field without muscle is another practical guide to the VA bulge that is a second remote site. available during the dissection.34 After finding the tip of the C-1 transverse process and ascending approximately 2 Surgical Technique for V3 Exposure cm along the medial edge of the superior oblique muscle, Patient position, skin incision, and craniotomy depend the VA bulge will be found 1 cm medially along the atlan- on the recipient site, and the exposure needed to access it. tomastoid line. With the posterior inferior cerebellar artery (PICA), ante- The V3 segment can give rise to a large muscular branch rior inferior cerebellar artery (AICA), superior cerebellar (artery of Salmon), an extradural PICA, and an extradu- artery (SCA)/posterior cerebral artery (PCA), and middle ral posterior spinal artery (PSA; Fig. 1G and H).3,5,28 An cerebral artery (MCA) as possible recipients, a variety extradural PICA and PSA both have surgical importance of positions and incisions are used depending on the ap- and must be preserved. The V3 segment is invested in an proach, which might be a far-lateral, extended retrosig- abundant venous plexus (Fig. 1D). moid, subtemporal, or pterional craniotomy, respectively. Any incision over the retromastoid region will access the Surgical Technique for V3 Bypass suboccipital triangle and the V3 segment. The distal anastomosis in the intracranial space is the The suboccipital triangle lies in the third or deep mus- more difficult one and is therefore performed first. After cular layer of the craniocervical junction and is exposed completing this anastomosis, the proximal end of the graft by elevating the superficial and intermediate muscular is brought into the suboccipital triangle and trimmed ap- layers. An incision along the superior nuchal line and the propriately. A length of 15–20 mm of the V3 segment is crest of the mastoid process exposes the underlying mus- available for completing the proximal end of the bypass. cles. The first or superficial muscular layer consists of the Circumferential exposure allows full control of the ar- sternocleidomastoid (SCM) muscle laterally and trapezius tery and application of the proximal and distal clips. The muscle medially, with both muscles inserting at the su- foraminal segment of the V3 (V3f) can be exposed and perior nuchal line (Fig. 1A). The posterior border of the mobilized by unroofing the foramen transversarium of SCM muscle is elevated anteriorly to expose the posterior C-1 with a diamond drill bit, in cases of limited proxi- edge of the mastoid process. The second or intermediate mal control, atherosclerotic plaque, arterial dissection, or muscular layer is formed by the splenius capitis, semispi- external bony compression. The V3 segment is enveloped nalis capitis, and longissimus capitis muscles (Fig. 1B and in a rich venous plexus that can bleed extensively during C). The distal or posterior intermuscular course of the its exposure. Bipolar cautery, packing with oxidized cel- OA runs under the splenius capitis, emerging between the lulose, and injection with fibrin glue can be used to induce 35 splenius and semispinalis muscles, and then continuing on hemostasis. Prominent muscular branches from the V3 top of the semispinalis muscle (Fig. 1C). segment can be recognized in preoperative angiography The muscles of the suboccipital triangle—superior and divided as needed. oblique capitis, inferior oblique capitis, rectus capitis pos- Large V3 segments may not be occluded completely terior major, and rectus capitis posterior minor muscles— with temporary clips; permanent aneurysm clips are more form the third or deep layer of muscles (Fig. 1D). The effective. The V3 segment shares more common features suboccipital triangle contains the V3 segment of the VA with the cervical carotid artery in its wall characteristics coursing toward the sulcus arteriosus of the C-1 vertebra, than an intracranial artery and therefore requires an ex- usually buried beneath a fat pad. The V3 segment is divid- cisional arteriotomy (as with an aortic punch) rather than ed into 3 subsegments: 1) a foraminal part (V3f), consist- an incisional arteriotomy. After trapping a 10- to 15-mm- ing of the proximal V3 passing through the C-1 transverse long segment of the donor artery and making a small foramen; 2) a sulcal part (V3s), running along the sulcus arteriotomy, an aortic punch is used to excise a circular arteriosus of C-1; and 3) a dural part (V3d), between the 33 piece of the wall. An atherosclerotic plaque
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