• Xia Lu, Yan Ma, Bin Yang, Peng Gao, Yabing Wang, and Liqun Jiao.
• Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.
• World Neurosurg. 2017 Nov 1; 107: 1051.e13-1051.e17.

BackgroundTortuous or occluded vertebral arteries (VAs) can make the endovascular treatment of vertebrobasilar insufficiency impractical. Bypass surgery is an option, but a craniotomy of the posterior fossa is complicated when physiologic vessels must be abandoned. We report 3 cases of refractory vertebrobasilar insufficiency with different presentations requiring problematic approaches in which the patients were treated by different hybrid strategies.Case DescriptionPatient 1 had severe stenosis of right VA ostium with right V1 segment tortuosity and was treated by right VA ostium transposition during which the proximal subclavian artery was blocked by a balloon guide catheter. Patient 2 had severe stenosis of the basilar artery and bilateral VA tortuosity. The V1 segment was exposed and cut open so that an available approach for endovascular procedures was created. Patient 3 had bilateral VA occlusion. After exposure of the left V1 segment, recanalization of the left VA was performed by an interventional radiologist and surgeon working together. All patients had improved hemodynamics and symptoms alleviated without major complications.ConclusionsFor refractory vertebrobasilar insufficiencies, hybrid operations that combine surgical manipulation of the V1 segment and endovascular techniques can be safe and effective.Copyright © 2017. Published by Elsevier Inc.

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