Percutaneous vertebral artery intervention: a necessary tool in every interventional cardiologist armamentarium

Invasive treatment in peripheral artery disease

Invasive treatment in peripheral artery disease (PAD) has evolved as a viable alternative to surgical treatment. However, beyond the common pathophysiological substrate, as far as treatment is concerned, each site of atherosclerotic disease (subclavian and vertebral arteries; carotid arteries; intracranial arterial tree; renal arteries; lower extremity arteries) features unique characteristics. Treatment options include medical treatment, endovascular management and/or surgery. Sound clinical evaluation is required as individual patient assessment often limits intervention options, while available data regarding benefits of invasive and surgical management are questioned by advances in medical treatment. In the present article, we aim to summarize existing evidence and guidance on the role of invasive procedures in PAD.

Evaluation of Interventional Therapy for Patients with Intracranial Vertebral Artery Stenosis by Transcranial Color-Coded Sonography

The aim of this study was to evaluate the efficacy of stenting for patients with intra-cranial vertebral artery stenosis by trans-cranial color-coded sonography and to analyze the risk factors of in-stent restenosis (ISR). In total, 121 patients with intra-cranial vertebral artery stenosis stents were included. The follow-up time was 3-12 mo (mean: 9.9 mo). The success rate was 92.6%. Peak systolic velocity and end-diastolic velocity decreased from 261 ± 63 to 109 ± 41 cm/s and from 133 ± 44 to 47 ± 18 cm/s, respectively (both p < 0.001). Peak systolic velocity (245 ± 47 cm/s) and end-diastolic velocity (121 ± 31 cm/s) of patients with ISR (18.9%, 20/106) were higher than those of patients without ISR (101 ± 38 and 44 ± 17 cm/s, respectively) at 12 mo post-procedure (p < 0.05). The length of the stent and residual stenosis were related to ISR. In conclusion, stenting is a feasible treatment method for intra-cranial vertebral artery stenosis. Trans-cranial color-coded sonography can be used for monitoring patients to identify ISR.

Angioplasty and stenting of symptomatic vertebral artery stenosis. Clinical and angiographic follow-up of 206 cases from Northwest Iran

Percutaneous transluminal angioplasty (PTA) has recently become a noteworthy treatment option for significant stenosis involving the vertebral artery (VA) in selected patients. We conducted a prospective study to evaluate the efficacy, safety and mid-term follow up results of 206 cases received PTA with or without stent implant to treat their symptomatic atherosclerotic VA stenosis in all segments (V1-V4). In a prospective mono-arm trial from October 2008 to July 2012 in a single center, 239 lesions affecting the intra or extracranial VA (171 in V1, 17 in V2, 14 in V3, 21 in V4 and 16 in combined segments) were treated by PTA with or without stent implant. Non-disabling stroke patients who had failed conservative medical treatment and had angiographic evidence of >50% stenosis in the dominant VA with clinical signs and symptoms of VB stenosis were included in this study. They were mean followed for 13.15±5.24 months after treatment. Overall, 206 patients underwent the procedure. A stent was implemented in 199 patients (96.6%). The periprocedural complication rate was 7.2%. The procedural (technical) success rate was 97.6%. Of the total 239 lesions, 223 were treated with stent implant. Clinical success was achieved in all 206 symptomatic patients after the procedure. Restenosis occurred in 15.9% after a mean 10.8 (6-24) months. Of those, 63.1% and 34.2% had mild and moderate stenosis that was treated medically, whereas one case (2.6%) with severe restenosis underwent balloon angioplasty. No deaths occurred during the follow-up period. The follow-up complication rate was 6.3%. TIA occurred in 4.4%, a minor stroke in 1.4% and a major stroke in one patient. The overall patient event-free survival was 92.4%. These results demonstrate the safety and feasibility of PTA with or without stent implant, with a high technical success rate, a low complication rate, a low restenosis rate and durable clinical success in patients with symptomatic VA stenosis. This approach seems to improve patients' immediate and mid-term clinical results. Randomized controlled trials are necessary to further validate this treatment option.

Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results

INTRODUCTION

The study's purpose is to report the technical and clinical outcomes of a patient cohort that underwent vertebral artery ostium stent placement for atherosclerotic stenosis.

METHODS

We retrospectively analyzed a prospectively collected database of neurointerventional procedures performed at a single center from 1999 to 2005. Outcome measures included recurrent transient neurological deficits (TNDs), stroke, and death. Kaplan-Meier analysis was used to estimate stroke- and/or death-free survival at 12 months. Cox proportional hazard was used to identify risk factors for recurrent vertebrobasilar ischemic events.

RESULTS

Seventy-two patients with 77 treated vertebral ostial lesions were included. The 30-day stroke and/or death rate was 5.2% (n = 4), although no event was directly related to the vertebral ostium stent placement. Three procedure-related strokes were secondary to attempted stent placement at other sites (one carotid artery and two basilar arteries), and the one death was secondary to the presenting stroke severity. The mean clinical follow-up time available for 66 patients was 9 months. There were 14 TNDs (21%), two strokes (3%), and two deaths (3%) recorded in the follow-up. Recurrent vertebrobasilar ischemic events occurred in nine patients (seven TNDs and two strokes). No recurrent stroke and/or deaths were related to the treated vertebral ostium. Stroke- and/or death-free survival rate (including periprocedural stroke and/or death) was 89 +/- 5% at 12 months. No vascular risk factor was significantly associated with recurrent vertebrobasilar ischemic events.

CONCLUSIONS

Vertebral artery ostium stent placement can be safely and effectively performed with a low rate of recurrent stroke in the territory of the treated vessel. Patients who also underwent attempted treatment of a tandem intracranial stenosis appeared to be at highest risk for periprocedure stroke.