From the Guidelines
Vertebral artery stenosis should be managed with lifestyle modifications and medical therapy, including antiplatelet agents and statins, as the initial treatment approach, with consideration of endovascular stenting or surgical bypass for symptomatic patients who fail medical therapy. This recommendation is based on the most recent guidelines, which emphasize the importance of overall cardiovascular risk reduction in patients with vertebral artery stenosis 1. The use of preventive strategies and antithrombotic agents is also reasonable in the presence of other cardiovascular risk factors, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Medical Management
Medical management typically includes:
- Antiplatelet therapy, such as aspirin 81-325mg daily or clopidogrel 75mg daily
- Statins, such as atorvastatin 40-80mg daily
- Aggressive control of vascular risk factors, including hypertension, diabetes, and smoking cessation This approach is supported by guidelines from the American Heart Association/American Stroke Association, which recommend optimal medical therapy for all patients with vertebral artery stenosis and a history of transient ischemic attack or stroke 1.
Revascularization Options
For symptomatic patients with significant stenosis (>50%) who fail medical therapy, revascularization may be considered. Options include:
- Endovascular stenting
- Surgical bypass, such as transposition to the common carotid artery or trans-subclavian vertebral endarterectomy The decision between these approaches depends on the patient's anatomy, comorbidities, and local expertise, as well as the availability of experienced centers with low stroke and death rates for these procedures 1.
Monitoring and Follow-up
Monitoring typically involves regular clinical assessments and periodic imaging with ultrasound, CT angiography, or MR angiography every 6-12 months to assess the severity of stenosis and the effectiveness of treatment. This approach allows for early detection of restenosis or progression of disease, and prompt adjustment of treatment as needed.
From the Research
Vertebral Artery Stenosis Overview
- Vertebral artery stenosis is associated with a high risk of early recurrent stroke, accounting for 20 to 25% of ischemic strokes 2.
- The annual stroke rate for patients treated with medical therapy alone is 10 to 15%, with a 30% mortality rate at 2-years if managed medically without additional surgical or endovascular intervention 2.
Treatment Options
- Angioplasty and stenting are promising options for treating symptomatic vertebral artery stenosis, with good technical results 3, 2.
- Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis have been shown to be safe and effective, particularly for extracranial stenosis 4, 5, 6.
- Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis, but carries a 10-20% mortality rate 2.
Clinical Trials
- The Vertebral Artery Ischaemia Stenting Trial (VIST) compared the risks and benefits of vertebral angioplasty and stenting with best medical treatment alone for symptomatic vertebral artery stenosis, and found a trend towards reduced stroke risk with stenting, particularly for extracranial stenosis 4, 5, 6.
- The VIST trial was underpowered and had limitations, including a high rate of non-confirmation of stenosis in the stented group, and further studies are required to confirm the findings 4, 5.
- The SAMMPRIS trial showed that intensive medical therapy was more effective than stenting for intracranial vertebral stenosis, highlighting the need for individualized treatment approaches 6.
Risks and Complications
- The risk of recurrent stroke is high for patients with symptomatic vertebral artery stenosis, particularly in the first few weeks after symptoms occur 2.
- Stenting of intracranial stenosis carries a higher operative risk compared to extracranial stenosis, with a higher rate of perioperative stroke 4, 5, 6.