Author + information
- Received August 2, 2018
- Revision received August 20, 2018
- Accepted September 4, 2018
- Published online December 3, 2018.
- Parham Sadeghipour, MDa,b,
- Omid Shafe, MDa,b,
- Hamidreza Pouraliakbar, MDa and
- Jamal Moosavi, MDa,b,∗ ()
- aRajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- bCardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- ↵∗Address for correspondence:
Dr. Jamal Moosavi, Rajaie Cardiovascular, Medical, and Research Center, Vali-Asr Street, adjacent to Mellat Park, Tehran, 1996911151, Iran.
- aberrant vertebral artery
- aortic coarctation
- atypical bow hunter’s syndrome
- late complication
- vertebrobasilar insufficiency
A 24-year-old female patient, who had undergone stenting for aortic coarctation 4 years previously, referred to our clinic. She described some episodes of syncope and dizziness in the preceding 6 months, for which her treating neurologist had prescribed antiepileptic agents for a diagnosis of seizure.
Follow-up aortic computed tomography (CT) angiography demonstrated a juxta-stent pseudoaneurysm at the coarctation site (Figure 1).
The first challenge was whether to choose the surgical or the endovascular approach for the exclusion of the pseudoaneurysm. The patient refused the choice of the surgical approach, which would entail a subcostal incision or probably a median sternotomy to access the complex anatomy of this region. The second challenge was the aberrant location of her large left vertebral artery, between the left carotid and subclavian arteries.
The day before the main procedure, we created a carotid–subclavian graft and clamped the subclavian artery proximally, thus averting the predictable hand ischemia in the absence of a retrograde flow from the vertebral artery (Figure 2).
The following day, we resolved the proximal–distal aortic diameter mismatch by using a custom-made device (26 to 22 × 110 mm). Our major concern vis-à-vis the endovascular approach was the possible consequences of covering such a large vertebral artery by the graft. Our fears were allayed after 4-vessel CT angiography illustrated a complete posterior cerebral artery supply and an acceptable size of the right vertebral artery. After the deployment of the custom-made graft device, we coiled the aberrant vertebral artery close to the pseudoaneurysm cavity using a jailed catheter to preclude the risk of coil migration (Figure 3).
The final angiography (Figure 4) and follow-up CT angiography (Figure 5) did not show any endoleak, especially from the vertebral or subclavian arteries. The striking clinical consequence of the procedure was the nonrecurrence of the patient’s syncopal attacks despite the discontinuation of the antiepileptic agents after about 9 months.
Following coarctation repair, whether endovascularly or surgically, patients should be kept under regular surveillance to prevent untoward situations and even emergent bleedings (1) in the wake of pseudoaneurysm formation in the pathologically affected portion of the aorta. It is not an out-of-the-ordinary event to encounter variations in the aortic arch requiring intervention (2). The good news is, however, that we now live in the era of endovascular solutions to aorta pathologies.
Bow hunter’s syndrome, also known as rotational vertebral artery occlusion syndrome, is a rare form of vertebrobasilar insufficiency resulting from dynamic mechanical occlusion or stenosis of the vertebral artery during head and neck rotation or extension. Abnormal bony structures such as osteophyte, lateral disc herniation, or rarely, tumor compression are some of underlying pathologies, and the condition is manifested by symptoms including vertigo, nausea, syncope, or drop attacks (3). It appears that our patient’s case was a rare presentation of vertebrobasilar insufficiency due to vertebral artery compression syndrome, which we wish to term the “atypical bow hunter’s syndrome.”
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 2, 2018.
- Revision received August 20, 2018.
- Accepted September 4, 2018.
- 2018 American College of Cardiology Foundation
- Shafe O.,
- Sadeghipour P.,
- Moosavi J.
- Yuan S.M.
- Duan G.,
- Xu J.,
- Shi J.,
- Cao Y.