Management of symptomatic vertebral artery stenosis

Report
MANAGEMENT OF SYMPTOMATIC
VERTEBRAL ARTERY STENOSIS
Dr Sulaiman AL Shamsi
Sr.consultant Vascular Surgeon
Royal Hospital
Oman International Vascular Coneferenec
ANDREW L. CARNEY
« My concern for the VA began with my first
patient, an elderly woman who might have been
simply bypassed as another senile patient, but
the esteem she commanded from her large and
illustrious family bespoke a remarkable woman.
Although she was incontinent, agitated, and
unable to remember even the names of her own
children, she lamented with great anguish her
inability to care for her own needs and to walk
with pride among her people. After vertebral
artery reconstruction, she regained all her
faculties and all her self-respect. »
(Advances in Neurology, Vol. 30: Diagnosis and Treatment of Brain Ischemia,edited by
A. L. Carney and E. M. Anderson. Raven Press, New York © 1981.)
ANATOMY OF THE VERTEBRAL ARTERY
4 segments.
 Anatomic variants, VA > carotid.
 Lt, 5% directly from the aortic arch
 diameter left > in 50% or
equal to in 25% of individuals

EPIDEMIOLOGY
Difficult to visualize the origins of VA.
 20% of posterior circulation stroke

(Cloud and Markus, 2003)
Recent studies have shown that the early risk of
recurrent stroke after TIA and minor stroke is as
high as 8–10% in the first week. (Rothwell et al., 2006)
 New England Medical Center Posterior
Circulation Registry:
- 82 of 407 patients with ischemia affecting the
posterior circulation had >50% stenosis ECVA.
 Annual stroke rates = 8 %

CLINICAL PRESENTATION
dizziness,
 vertigo,
 diplopia,
 perioral numbness,
 blurred vision,
 tinnitus,
 ataxia,
 bilateral sensory deficits,
 syncope,

EVALUATION

Based on the 2011
ASA/ACCF/AHA/AANN/AANS/ACR/
CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS
Guideline on the Management of Patients With
Extracranial Carotid and Vertebral Artery
DiseaseDeveloped in Collaboration With the
American Academy of Neurology and Society of
Cardiovascular Computed Tomography
January 2011
EVALUATION
Vertebral Artery Imaging
Class I
1.
Noninvasive imaging by CTA or MRA for
detection of vertebral artery disease
o
should be part of the initial evaluation of
patients with neurological symptoms referable
to the posterior circulation and those with
subclavian steal syndrome. (Level of Evidence:
C)

o
o
should be performed in patients with asymptomatic
bilateral carotid occlusions or unilateral carotid artery
occlusion and incomplete circle of Willis. (Level of
Evidence: C)
is recommended over ultrasound imaging for
evaluation of the vertebral arteries in patients whose
symptoms suggest posterior cerebral or cerebellar
ischemia. (Level of Evidence: C)
Class IIa
1.
In patients with symptoms of posterior cerebral or
cerebellar ischemia
1.
In patients with posterior cerebral or cerebellar
ischemic symptoms who may be candidates for
revascularization, catheter-based contrast
angiography can be useful to define vertebral artery
pathoanatomy when noninvasive imaging fails to
define the location or severity of stenosis. ( Level of
Evidence: C )
3- In patients who have undergone vertebral artery
revascularization, serial noninvasive imaging of the
extracranial vertebral arteries is reasonable at
intervals similar to those for carotid
revascularization. ( Level of Evidence: C )

CTA and MRA were associated with higher
sensitivity (94%) and specificity (95%) than duplex
ultrasonography (sensitivity 70%), and CTA had
slightly superior accuracy .
MEDICAL THERAPY
1.
Medical therapy and lifestyle modification (
Level of Evidence: B )
1.
Patients with atherosclerotic VA should receive
antiplatelet therapy with aspirin (75 to 325 mg
daily) to prevent MI and other ischemic events .
( Level of Evidence: B )
1.
Antiplatelet drug therapy is recommended for
patients who sustain ischemic stroke or TIA
associated with extracranial vertebral
atherosclerosis. ( Level of Evidence: B )
SURGICAL MANAGMENT
SURGICAL MANAGEMENT
Indications for surgery on the first part of the
vertebral artery are relatively rare.
 No randomized trials.
 Surgical options: endarterectomy, bypass, or
transposition.
 The feasibility of endarterectomy and vessel
reconstruction with favorable outcomes .

( Ramon Bergeur, Presented at the Forty-seventh Scientific Meeting of
theInternational Society for Cardiovascular Surgery, NorthAmerican Chapter,
Washington, DC, Jun 8–9, 1999.
SURGICAL MX CONT……
Proximal vertebral artery reconstruction, early
complication rates of 2.5% to 25% and
perioperative mortality rates of 0% to 4%.
 Distal vertebral artery reconstruction, mortality
rates 2% to 8%
 Cumulative Kaplan-Meier survival rate was
89.0% at 5 years and 75.4% at 10 years
 Significant vertebrobasilar symptom-free rate
was 94.0% at 5 years and 92.8% at 10 years.

( Edouard Kieffer Distal vertebral artery reconstruction: Long-term outcome 2002 )
ENDOVASCULAR INTERVENTIONS FOR
VERTEBRAL ARTERY DISEASE
ENDOVASCULAR INTERVENTIONS FOR
VERTEBRAL ARTERY DISEASE
There is insufficient evidence from randomized
trials.
 In a review of 300 interventions for proximal
vertebral artery stenosis
 Death 0.3%
 The risk of periprocedural neurological
complications 5.5%
 Risk of posterior stroke 0.7% at a mean follow-up
of 14.2 months



Restenosis in 26% of cases (0% to 43% after a mean of
12 months (3 to 25 months)
Among 170 angioplasty with distal vertebrobasilar
disease, neurological complications developed in 24%,
but the rate approached 80% in cases of urgent
vertebrobasilar revascularization.
( Eberhardt et al 2006,JVS )


The annual stroke risk after angioplasty for distal
vertebrobasilar disease is approximately 3%.
Drug Eluting Stents ?
The restenosis rate was 21% at the VO in 14 months.
( Fields JD Interv Neuroradiol.2011)

CAVATAS , the only randomized study to date to
compare outcomes after endovascular and medical
treatment for patients with vertebral artery stenosis,
included only 16 such patients, and because no patient
in either arm had recurrent vertebral basilar territory
stroke by 8 years after randomization, there was no
difference in outcomes among those treated by stenting
or medical therapy.
WHAT IS NEW ?
VAST :
 The primary aim is to assess whether stenting
for symptomatic vertebral artery stenosis ≥ 50%
is feasible and safe.
 Secondary aim is to assess the rate of new
vascular events in the territory of the
vertebrobasilar arteries in patients with
symptomatic vertebral stenosis ≥ 50% on best
medical therapy with or without stenting.
 Awaited

CONCLUSION
Vertebral artery stenosis is an important
aetiology of posterior circulation stroke.
 At present, there is not enough evidence to
recommend endovascular stenting over medical
therapy.
 If the above studies show that stenting is
superior to medical management, they may help
to establish endovascular stenting as the
standard of care for symptomatic VA stenosis.
 In the mean time, maximal medical therapy
should be tried first.
 For medically refractory patients, endovascular
stenting is recommended.

Thank You

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