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Vertebral To Carotid Artery Transposition During Repair Of Thoracic Aortic Disease
Imani E. McElroy, MD MPH1, Ashley Hsu, MD
1, Ken Ziegler, MD
1, Miguel Manzur, MD
1, Sukgu Han, MD
1, Gregory Magee, MD
2.
1University of Southern California, Los Angeles, CA, USA,
2New York University, New York City, NY, USA.
Introduction: Preservation of antegrade flow to the vertebral arteries is recognized as an important factor to prevent neurological complications from repair of the thoracic aortic arch. Often this is achieved by left subclavian transposition or bypass, but in cases of an anomalous or very early branching vertebral artery, transposition of the vertebral artery to the carotid may be needed to preserve antegrade flow. Anomalous vertebral arteries are a common arch variant with a reported incidence of 4-6%, and these more frequently terminate in a posterior inferior cerebellar artery (PICA), which increases the risk of stroke if not revascularized. The aim of this study was to evaluate the outcomes of patients who underwent vertebral to carotid transposition for the management of thoracic aortic disease.
Methods: All vertebral to carotid transpositions performed for the management of thoracic aortic dissection or aneurysm from 2018 to 2025 at a single academic center were reviewed. The primary outcomes were postoperative stroke and patency of the transposed aLVA. Secondary outcomes were spinal cord ischemia, postoperative cranial nerve injury (CNI), and Horner’s syndrome.
Results: Twenty-four patients underwent vertebral-carotid transposition as an adjunct to management of aortic disease during the study period. Most patients were men (19) and the mean age was 52 (+/- 16 years). The primary indication for aortic repair was dissection in 11, aneurysm in 11, and Kommerell diverticulum in 2. Thirteen patients underwent zone 2 TEVAR, ten received open total arch repair, and there was one attempted total endovascular arch repair which was aborted due to unfavorable anatomy. Fourteen transpositions were performed prior to planned aortic repair due to high-risk cerebrovascular anatomy (4 PICA termination, 7 dominant aLVA, 4 intracranial left vertebral artery stenosis), and four were performed postoperatively for treatment of type II Endoleak. LVA diameter ranged from 2 – 6 mm (mean 3.4 mm). Mean estimated blood loss was 149 (+/-145) mL. No patients experienced 30-day postoperative spinal cord ischemia, stroke, or mortality. There were two cases of recurrent laryngeal nerve palsy, both of which resolved within 4 months. There were no cases of Horner’s syndrome. At follow-up (mean 307 days [6-714 days]), all transpositions were patent.
Conclusion: Vertebral-carotid transposition is a safe and effective adjunct to the management of thoracic aortic disease.
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