What is the management of moderate to high-grade vertebral artery (VA) stenosis with preserved blood flow?

From the Guidelines

Management of moderate to high-grade vertebral artery stenosis with preserved flow primarily involves medical therapy with antiplatelet agents, risk factor modification, and close monitoring. The first-line treatment is antiplatelet therapy with aspirin 81-325 mg daily or clopidogrel 75 mg daily, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. Dual antiplatelet therapy with aspirin 81 mg and clopidogrel 75 mg daily may be considered for 3 months in patients with recent symptoms before transitioning to single antiplatelet therapy for long-term use. Aggressive risk factor modification is essential, including:

• Statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) to achieve LDL < 70 mg/dL
• Blood pressure control targeting < 130/80 mmHg
• Smoking cessation
• Diabetes management
• Lifestyle modifications Regular follow-up with vascular imaging every 6-12 months is recommended to monitor stenosis progression. Endovascular intervention (angioplasty with stenting) or surgical revascularization may be considered for patients with recurrent symptoms despite optimal medical therapy, progressive stenosis, or critical stenosis (>80-90%), as suggested by the 2024 ESC guidelines 1. This approach is based on the understanding that vertebrobasilar circulation has good collateral potential, and many stenoses remain stable with medical management. The benefit-to-risk ratio for intervention must be carefully assessed, as procedural risks can outweigh benefits in asymptomatic patients or those with stable symptoms and adequate flow. Key considerations in management include:
• Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with vertebral artery stenosis and a TIA or stroke, as outlined in the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1
• Endovascular and surgical treatment of patients with extracranial vertebral stenosis may be considered when patients are having symptoms despite optimal medical treatment, as recommended by the 2011 guidelines for the prevention of stroke in patients with stroke or transient ischemic attack 1
• Surgery on extracranial vertebral stenosis can be performed with low stroke/death rates in experienced centers, but with limited expertise in complex vertebral artery reconstructions, open surgery has been mostly replaced by endovascular interventions, as noted in the 2024 ESC guidelines 1.

From the Research

Management of Moderate-High Grade Vertebral Artery Stenosis with Preserved Flow

• The management of vertebral artery stenosis involves medical treatment, surgery, and endovascular treatment 2.
• Medical treatment includes risk factor control, antiplatelet therapy, lipid-lowering therapy, and individualized management for people with hypertension or diabetes 2.
• Endovascular treatment consists of percutaneous transluminal angioplasty, with or without stenting, and has shown good technical results 3, 2.
• Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis, but carries a 10-20% mortality rate 4.
• The optimal management of people with symptomatic vertebral artery stenosis has not yet been established, and further studies are needed to clarify the best treatment approach 2, 5, 4.

Diagnostic Approaches

• Digital subtraction angiography (DSA) is considered the current gold standard in diagnosing vertebral artery stenosis, but non-invasive techniques such as duplex ultrasonography (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) are also used 6.
• Diagnostic approaches are important in determining the severity of stenosis and guiding treatment decisions.

Treatment Outcomes

• Patients with symptomatic intracranial vertebral artery or basilar stenosis are at high risk of stroke, myocardial infarction, or sudden death 5.
• The risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15% 4.
• Endovascular treatment has shown promising results, but the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy 2, 4.