Endovascular Recanalization via Ascending Cervical Artery for Non-Conical Stump Vertebral Artery Occlusion

Overview

This case study reports successful endovascular recanalization of a non-tapered stump vertebral artery occlusion using a retrograde approach through the ascending cervical artery. The technique overcame the technical challenges associated with non-conical stump morphology, resulting in restoration of blood flow and symptom resolution.

Background

Vertebral artery occlusion (VAO) is a significant cause of posterior circulation ischemic stroke, often due to atherosclerosis. Endovascular recanalization is an effective treatment, but success depends on the morphology of the occlusion stump, with tapered stumps being easier to treat. Non-tapered or non-conical stumps present technical challenges and lower success rates. Alternative approaches, such as retrograde recanalization via collateral arteries like the ascending cervical artery, have been reported as feasible strategies.

Data Highlights

The patient, a 61-year-old man with hypertension, diabetes, and coronary artery disease, presented with impaired consciousness and a National Institutes of Health Stroke Scale (NIHSS) score of 26. Imaging revealed occlusions of the right vertebral artery V4 segment, proximal left vertebral artery, and basilar artery apex. Initial attempts to cross the left vertebral artery occlusion antegradely failed. Retrograde access through the ascending cervical artery was successfully used to cross the occlusion and achieve recanalization.

Key Findings

• VAO with non-tapered stump morphology is associated with lower technical success in endovascular recanalization.
• Retrograde endovascular approach via the ascending cervical artery can provide access to the distal vertebral artery beyond the occlusion.
• In this case, repeated antegrade attempts to cross the occlusion failed, but retrograde crossing with a GAIA-3 guidewire succeeded.
• The procedure was performed under local anesthesia with intravenous tirofiban infusion to reduce thrombotic risk.
• Successful recanalization resulted in restoration of blood flow and clinical improvement.

Clinical Implications

For patients with symptomatic vertebral artery occlusion and non-tapered stumps, retrograde recanalization through collateral arteries such as the ascending cervical artery offers a viable alternative when antegrade approaches fail. This technique may expand treatment options and improve outcomes in challenging VAO cases. Careful angiographic assessment of collateral pathways is essential to identify suitable access routes.

Conclusion

This case demonstrates that endovascular recanalization via the ascending cervical artery is a feasible and effective strategy for treating non-conical stump vertebral artery occlusions, overcoming limitations of traditional antegrade approaches.

References

1. Author/Source/Year -- Endovascular recanalization for symptomatic intracranial VAO
2. Author/Source/Year -- Technical success related to VAO stump morphology
3. Author/Source/Year -- Retrograde endovascular approach via ascending cervical artery