Proximal severe V1 symptomatic stenosis with significant flow impairment in the basilar circulation

CASE PRESENTATION

• A 67-year-old male with PMH of acute distal basilar occlusion s/p thrombectomy with TICI 2b recanalization in 2016 with resultant Left PCA infarct presenting with new onset visual symptoms of blurry vision and transient binocular vision loss suggestive of TIA for past 2 weeks.
• Patient was started on Dual Antiplatelet Therapy (Aspirin + Plavix) per Neurologist and referred to Neurosurgery with CTA findings demonstrating proximal Left vertebral artery stenosis.

PREOPERATIVE IMAGES

Pre-op CTA demonstrating L vert origin stenosis

• DSA demonstrated a hypoplastic Right vertebral artery terminating in PICA and severe >85% stenosis of the proximal Left vertebral artery origin with significantly delayed filling of basilar artery and posterior circulation.

TREATMENT APPROACH

Balloon inflation to nominal pressure prior to stent deployment

• Patient was maintained on Aspirin and Plavix with p2y12 demonstrating adequate platelet inhibition (no baseline) and a Left vertebral artery origin balloon mounted stenting with a Resolute Onyx stent (Medtronic) 2.75x 12mm was performed. 
• Left common femoral artery puncture with 6 Fr. Sheath. 4500u IV Heparin was administered to achieve ACT 250-300. A 0.071’’ Benchmark (Penumbra) guide catheter was positioned just proximal to Left vertebral origin in the Subclavian artery.
• A Synchro-10 (Stryker) Microwire was used to deploy the Onyx Resolute stent across the stenotic lesion after inflating the balloon to nominal pressure.
• Post stenting angiography demonstrated improved flow in basilar artery with reduced transit time.

RESULTS

• Post-operative DSA:

• Patient discharged on POD #1 in stable condition and maintained on Aspirin and Plavix.