Percutaneous transluminal angioplasty for vertebral artery origin stenosis under the flow-reversal protection using Mo.MA(™) Ultra: A technical case report

BACKGROUND: Vertebral artery origin stenosis (VAOS) is a major cause of ischemic stroke of the posterior circulation. Aggressive medical treatment using dual antiplatelet therapy is the most common treatment approach to symptomatic VAOS; however, the effectiveness of endovascular treatment (EVT) for VAOS has recently been reported. Here, we report a case of VAOS treated with percutaneous transluminal angioplasty (PTA) under flow reversal protection using Mo.MA(™) Ultra. CASE DESCRIPTION: The patient was a 78-year-old man. He underwent mechanical thrombectomy for acute right posterior cerebral artery occlusion, and recanalization was achieved. Subsequently, artery-to-artery (A-to-A) embolism caused by the right VAOS was revealed as the etiology. PTA under the flow-reversal protection using Mo.MA(™) Ultra was performed electively, and the VAOS and antegrade flow of the right vertebral artery (VA) improved. CONCLUSION: In EVT for symptomatic VAOS, lesion cross for distal protection device placement is considered to create a high risk of distal embolism due to the anatomic and clinicopathological characteristics of VAOS lesions, especially in A-to-A embolism cases. The flow-reversal protection using Mo.MA(™) Ultra can be performed with EVT to prevent distal embolism with lesion cross by retrograde flow of the VA. This method is feasible, especially for cases in which antegrade flow to the basilar artery through the developed contralateral VA is anticipated during the Mo.MA(™) Ultra protection.