Abstract：
Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.
摘要：
椎基底动脉夹层动脉瘤（VBDA）是手术最具挑战性的动脉瘤类型。脑血管重建术是复杂VBDA的最终治疗方法。我们回顾性分析了这些特征，2015-2022年21例接受脑血管重建术治疗复杂VBDA的患者的手术结果和随访数据.根据动脉瘤的位置以及VBDA和PICA之间的解剖关系，VBDA患者分为四组：位于VA的动脉瘤伴PICA受累（10例），位于VA无PICA受累的动脉瘤（1例），位于基底心尖段的动脉瘤（1例）和位于基底干段的动脉瘤（9例）。复杂VBDA的手术算法主要由动脉瘤的位置决定，动脉瘤的状态和逆行血流到达椎基底动脉近端的能力。参与PICA的VA动脉瘤患者的手术方式包括低流量（OA-PICA）旁路和动脉瘤捕获，动脉瘤切除或重建夹8例，STA-PCA旁路术联合PICA保存和动脉瘤捕获2例。在没有PICA参与的VA动脉瘤患者中，动脉瘤切除是在没有脑旁路的情况下进行的。在基底尖段动脉瘤患者中，进行了带动脉瘤捕获的高流量旁路(ECA-RA-P2).在基底干段动脉瘤患者中，手术方式包括6例患者的高流量旁路（ECA-RA-P2和LVA-RA-P2）和动脉瘤捕获或近端闭塞，1例患者的ECA-RA-P2旁路伴部分近端闭塞，1例患者仅接受ECA-RA-P2旁路手术，1例患者的STA-PCA旁路和R-VA狭窄。在21名患者中，20例临床改善或无变化，21例患者中有17例获得了良好的功能结局（mRS≤2）。然而,1例患者术后死于梗死和呼吸衰竭.13例患者的动脉瘤完全消失，5例患者缩小，2例患者稳定。中位随访期为32.5个月。在后续期间,所有旁路都是专利，11例患者的临床进一步改善。脑血管重建术对于治疗复杂的VBDAs似乎是安全有效的，脑血运重建可以作为补充治疗策略。
