AUTHOR=Wang Xuan , Tong Xiaoguang 

TITLE=Vascular reconstruction related to the extracranial vertebral artery: the presentation of the concept and the basis for the establishment of the bypass system

JOURNAL=Frontiers in Neurology

VOLUME=Volume 14 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1202257

DOI=10.3389/fneur.2023.1202257

ISSN=1664-2295

ABSTRACT=The intracranial vertebrobasilar artery system possesses a unique hemodynamic pattern (vessel trunk converged bilateral flow with three groups of perforators directly arising from it), embedded within intense osseous constraints and located far from conventional donor vessels. Two major traditional modalities of posterior circulation revascularization encompass the superficial temporal artery to the superior cerebellar artery and the occipital artery to the posteroinferior cerebellar artery anastomosis, which are extracranial-intracranial low-flow bypass with donor arteries belonging to the anterior circulation and supply mainly for focal perforators and distal vascular territories. As our understanding of flow hemodynamics has improved, extracranial vertebral artery-related bypass has further evolved to improve the cerebral revascularization system. In this article, we proposed the concept of “vascular reconstruction related to the extracranial vertebral artery” and reviewed the design philosophy of the available innovative modalities of the respective segments. V1 transposition overcomes the high rates of in-stent restenosis and provides a durable complementary alternative to endovascular treatment. V2 bypass serves as an extracranial communication pathway between the anterior and posterior circulation, providing the advantages of high-flow, short interposition grafts, orthograde flow in the vertebrobasilar system and avoiding complex skull base manipulation. V3 bypass is characterized by profound and simultaneous vascular reconstruction of the posterior circulation, achieved by intracranial-intracranial or multiple bypasses in conjunction with skull base techniques. These posterior circulation vessels not only play a pivotal role in bypass modalities design for vertebrobasilar lesions but also can be implemented to revascularize the anterior circulation, hence becoming a systematic methodology.