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S216: EXTERNAL CAROTID ARTERY TO VERTEBRAL ARTERY BYPASS WITH CRANIOCERVICAL DECOMPRESSION FOR VERTEBROBASILAR INSUFFICIENCY
Tyler Lazaro, MD; Varad Shenoy, MD; Basavaraj Ghodke, MD; Laligam Sekhar, MD; University of Washington

Introduction: Vertebrobasilar insufficiency (VBI) is a hemodynamic condition characterized by reduced perfusion to the posterior circulation, often causing vertigo, dizziness, or focal neurologic deficits. While medical and endovascular therapies have improved outcomes for many patients, a subset with medically refractory symptoms remains. Patients with severe stenosis or occlusion of the dominant vertebral artery are at particularly high risk. While external carotid artery (ECA) to vertebral artery (VA) bypasses have been described, there is also significant technical complexity and surgical risk involved. What is more, significant dynamic compression of the vertebral arteries may persist at the craniocervical junction. In this series, we report the results of ECA to V3 VA bypass and V3 atlantoaxial decompression.  

Objective: To evaluate the efficacy and safety of ECA to V3 VA bypass with atlantoaxial VA decompression in patients with medically refractory VBI.

Methods: A retrospective cohort study was conducted of patients with medically refractory VBI who underwent ECA to V3 VA bypass and decompression (Figure 1) between 2007 and 2025. Demographic, clinical, and radiographic data were obtained via chart review with independent angiographic analysis. The primary outcome was long-term symptom-free survival. Secondary outcomes included perioperative complications and long-term morbidity. 

Results: Fifteen patients underwent ECA to V3 VA bypass and decompression with a cumulative follow-up of 29.9 person-years. Dizziness was the most common presenting symptom (93.3%), and nearly all patients had hypertension and hyperlipidemia (92.9%). While short-term and long-term improvement in symptoms was 100%, durable symptom-free survival was achieved in 75% of patients (Figure 2). There were no perioperative neurologic complications or deaths. Chronic neck pain was the most frequent long-term complication, affecting 42.9% of patients (Table 1).

Conclusion: ECA to V3 VA bypass with atlantoaxial decompression is a safe and effective surgical option for patients with medically refractory VBI, offering durable symptom control and a low risk of neurologic complications. While postoperative neck discomfort is not uncommon, the overall safety profile and efficacy of the procedure support its consideration in carefully selected patients

 

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