Commentary: Aberrant vertebral arteries in aortic repair: Small but mighty!

Central MessageWhen the aberrant vertebral artery origin is located in the intended area of replacement or zone of endovascular coverage, critical steps must be taken to preserve its perfusion in certain situations.See Article page 53. When the aberrant vertebral artery origin is located in the intended area of replacement or zone of endovascular coverage, critical steps must be taken to preserve its perfusion in certain situations. See Article page 53. Aberrant origin of the vertebral artery (VA) is an uncommon anatomic variant. The VA originates as the first branch of the ipsilateral subclavian artery. Its aberrant origin is variable and can arise from the aortic arch, common, or internal or external carotid arteries.1Yuan S.M. Aberrant origin of vertebral artery and its clinical implications.Braz J Cardiovasc Surg. 2016; 31: 52-59PubMed Google Scholar,2Albayram S. Gailloud P. Wasserman B.A. Bilateral arch origin of the vertebral arteries.AJNR Am J Neuroradiol. 2002; 23: 455-458PubMed Google Scholar Despite being clinically asymptomatic, knowledge of the precise origin of aberrant VA can be critical before performing open surgical or endovascular procedures involving the arch or distal aorta. Martín-González and colleagues3Martín-González I. Gómez-Planas J. Tebar Botí E. Bilateral aberrant vertebral arteries from descending thoracic aorta in open thoracoabdominal aneurysm repair.J Thorac Cardiovasc Surg Tech. 2021; 7: 53-56Scopus (1) Google Scholar present a case of a patient with an extent I thoracoabdominal aortic aneurysm with aberrant right and left VAs originating distal to the left subclavian artery (LSA). They describe their open thoracoabdominal aortic aneurysm repair technique with preservation of both VAs through direct reimplantation. This report demonstrates that when the origin of 1 or more aberrant VAs is located in the intended area of replacement, critical steps must be taken to preserve perfusion in certain clinical situations. Multiple aberrant origins of both VAs have been reported.4Case D. Seinfeld J. Folzenlogen Z. Kumpe D. Anomalous right vertebral artery originating from the aortic arch distal to the left subclavian artery: a case report and review of the literature.J Vasc Interv Neurol. 2015; 8: 21-24PubMed Google Scholar The most common aberrancy is the left VA origin off the aortic arch between the left common carotid artery and LSA, with a prevalence of 2.4%-5.8%.1Yuan S.M. Aberrant origin of vertebral artery and its clinical implications.Braz J Cardiovasc Surg. 2016; 31: 52-59PubMed Google Scholar,5Al-Okaili R. Schwartz E.D. Bilateral aortic origins of the vertebral arteries with right vertebral artery arising distal to left subclavian artery: case report.Surg Neurol. 2007; 67 (discussion 6): 174-176Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 6Komiyama M. Morikawa T. Nakajima H. Nishikawa M. Yasui T. High incidence of arterial dissection associated with left vertebral artery of aortic origin.Neurol Med Chir (Tokyo). 2001; 41 (discussion-2): 8-11Crossref PubMed Scopus (62) Google Scholar, 7Lemke A.J. Benndorf G. Liebig T. Felix R. Anomalous origin of the right vertebral artery: review of the literature and case report of right vertebral artery origin distal to the left subclavian artery.AJNR Am J Neuroradiol. 1999; 20: 1318-1321PubMed Google Scholar In contrast, an aortic origin of the right VA is rare.2Albayram S. Gailloud P. Wasserman B.A. Bilateral arch origin of the vertebral arteries.AJNR Am J Neuroradiol. 2002; 23: 455-458PubMed Google Scholar Although the true incidence remains unknown,8Canyigit M. Akgoz A. Koksal A. Yucesoy C. Aberrant right vertebral artery: a rare aortic arch anomaly.Br J Radiol. 2009; 82: 789-791Crossref PubMed Scopus (11) Google Scholar only 13 cases of an aberrant right VA with an origin distal to the LSA have been reported.4Case D. Seinfeld J. Folzenlogen Z. Kumpe D. Anomalous right vertebral artery originating from the aortic arch distal to the left subclavian artery: a case report and review of the literature.J Vasc Interv Neurol. 2015; 8: 21-24PubMed Google Scholar VA variants are usually of no clinical significance except when treating cerebrovascular or thoracic aortic pathology.9Atkin G.K. Grieve P.P. Vattipally V.R. Ravikumar K.H. Das S.K. The surgical management of aortic root vessel anomalies presenting in adults.Ann Vasc Surg. 2007; 21: 525-534Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar,10Jakanani G.C. Adair W. Frequency of variations in aortic arch anatomy depicted on multidetector CT.Clin Radiol. 2010; 65: 481-487Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar Posterior circulation strokes or vertebrobasilar insufficiency and spinal cord ischemia are well-described complications of LSA coverage during thoracic endovascular aortic repair in patients with normal VA origins.11Patterson B.O. Holt P.J. Nienaber C. Fairman R.M. Heijmen R.H. Thompson M.M. Management of the left subclavian artery and neurologic complications after thoracic endovascular aortic repair.J Vasc Surg. 2014; 60: 1491-1497.e1Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Hence, indications to preserve perfusion of the aberrant VA can be extrapolated from published indications to preserve perfusion to the LSA.12Peterson B.G. Eskandari M.K. Gleason T.G. Morasch M.D. Utility of left subclavian artery revascularization in association with endoluminal repair of acute and chronic thoracic aortic pathology.J Vasc Surg. 2006; 43: 433-439Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar These include dominance of the aberrant VA; absent, atretic, or occluded contralateral VA; or inability to evaluate the anatomy of the vertebrobasilar circulation before intervention.13Matsumura J.S. Rizvi A.Z. Left subclavian artery revascularization: Society for Vascular Surgery practice guidelines.J Vasc Surg. 2010; 52: 65s-70sAbstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar As the VA provides perfusion to the spinal cord, planned extensive coverage of the descending thoracic or thoracoabdominal aorta, previous infrarenal aortic operation with previously ligated lumbar and middle sacral arteries, or internal iliac artery occlusion are also indications for preservation.13Matsumura J.S. Rizvi A.Z. Left subclavian artery revascularization: Society for Vascular Surgery practice guidelines.J Vasc Surg. 2010; 52: 65s-70sAbstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar,14Woo E.Y. Bavaria J.E. Pochettino A. Gleason T.G. Woo Y.J. Velazquez O.C. et al.Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.Vasc Endovasc Surg. 2006; 40: 367-373Crossref PubMed Scopus (28) Google Scholar In addition, in elective settings, where coverage of the aberrant VA is necessary, routine revascularization should be attempted when possible.13Matsumura J.S. Rizvi A.Z. Left subclavian artery revascularization: Society for Vascular Surgery practice guidelines.J Vasc Surg. 2010; 52: 65s-70sAbstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar The Figure 1 summarizes the indications for VA revascularization. Surgical options for VA revascularization are similar to the techniques used for symptomatic VA occlusive disease. The proximal VA can be revascularized by reattaching it on a patch to the aortic repair, transposing it to the common carotid artery, or by performing a vein graft bypass.15Berguer R. Bauer R.B. Vertebral artery reconstruction. a successful technique in selected patients.Ann Surg. 1981; 193: 441-447Crossref PubMed Scopus (46) Google Scholar,16Berguer R. Distal vertebral artery bypass: technique, the “occipital connection,” and potential uses.J Vasc Surg. 1985; 2: 621-626Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Proximal VA reconstructions can be performed safely with low stroke and mortality rates of 0.9%.15Berguer R. Bauer R.B. Vertebral artery reconstruction. a successful technique in selected patients.Ann Surg. 1981; 193: 441-447Crossref PubMed Scopus (46) Google Scholar, 16Berguer R. Distal vertebral artery bypass: technique, the “occipital connection,” and potential uses.J Vasc Surg. 1985; 2: 621-626Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 17Blumberg S.N. Adelman M.A. Maldonado T.S. Aberrant left vertebral artery transposition and concomitant carotid-subclavian bypass for treatment of acute intramural hematoma with thoracic endovascular aortic repair.J Vasc Surg. 2017; 65: 860-864Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In summary, although aberrant VA origins are usually asymptomatic, it is important to identify them before aortic arch or distal aortic intervention. VA artery revascularization is indicated in certain clinical situations before covering or ligating its origin during aortic repair. Bilateral aberrant vertebral arteries from descending thoracic aorta in open thoracoabdominal aneurysm repairJTCVS TechniquesVol. 7PreviewA 53-year-old male who had undergone a previous ascending aorta replacement (acute type A aortic dissection 4 years earlier) developed a type 1 thoracoabdominal aneurysm with distal arch involvement. The maximum diameter at the proximal descending thoracic aorta (pDTA) was 65 mm. A computed tomography scan showed that both vertebral arteries (VAs) were aberrant, arising from the pDTA (Figure 1). Full-Text PDF Open Access

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