What is the management approach for focal stenosis of the vertebral artery?

Management of Focal Vertebral Artery Stenosis

Antiplatelet therapy is the cornerstone of medical management for focal vertebral artery stenosis, with revascularization reserved for patients with persistent symptoms despite optimal medical therapy. 1

Diagnostic Evaluation

• Preferred imaging methods:

  • CTA or contrast-enhanced MRA (sensitivity 94%, specificity 95%) 2, 1
  • Catheter-based angiography typically required before revascularization 2, 1
  • Ultrasound has lower sensitivity (70%) for vertebral artery stenosis 2

• Key assessment factors:

  • Location and severity of stenosis
  • Contralateral vertebral artery patency and dominance
  • Presence of posterior circulation symptoms

Medical Management

First-line Treatment

• Antiplatelet therapy options: 2, 1

  • Aspirin (75-325 mg daily)
  • Clopidogrel (75 mg daily)
  • Combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily)

• Risk factor modification: 1

  • Statin therapy (target total cholesterol <200 mg/dL)
  • Blood pressure control (target <140/90 mmHg)
  • Smoking cessation
  • Diabetes management

Special Circumstances

• For acute ischemic syndromes with angiographic evidence of thrombus:
  • Anticoagulation for at least 3 months regardless of initial thrombolytic therapy 1

Revascularization Indications

Revascularization should be considered when: 1

1. Patients experience persistent symptoms despite optimal medical therapy
2. Recurrent vertebrobasilar TIAs or strokes occur despite medical management

Revascularization Options

For Subclavian Steal Syndrome

• Extra-anatomic carotid-subclavian bypass for symptomatic posterior cerebral or cerebellar ischemia 2, 1
• Percutaneous endovascular angioplasty and stenting as an alternative, especially for high surgical risk patients 2, 1

For Vertebral Artery Stenosis

• Proximal vertebral artery reconstruction options: 1

  • Trans-subclavian vertebral endarterectomy
  • Transposition of vertebral artery to ipsilateral common carotid artery
  • Reimplantation of vertebral artery with vein graft extension

• Distal vertebral artery reconstruction: 1

  • Anastomosis of principal trunk of external carotid artery to vertebral artery

• Endovascular treatment: 3, 4

  • Angioplasty with or without stenting
  • Technical success rates are high with low complication rates
  • Restenosis rates vary (0-48%)

Follow-up

• Serial noninvasive imaging at intervals similar to carotid revascularization 1
• Annual assessment of neurological symptoms and cardiovascular risk factors 1

Outcomes and Complications

• Proximal vertebral artery reconstruction: 1

  • Early complication rates: 2.5-25%
  • Perioperative mortality: 0-4%

• Distal vertebral artery reconstruction: 1

  • Mortality rates: 2-8%

• Endovascular interventions for proximal stenosis: 1

  • Death risk: approximately 0.3%
  • Periprocedural neurological complications: 5.5%
  • Restenosis: 26% after mean of 12 months

• Endovascular interventions for distal disease: 1

  • Neurological complications: 24%
  • Restenosis: 10% after mean follow-up of 12.6 months
  • Annual stroke risk: approximately 3%

Important Considerations

• Symptomatic vertebral artery stenosis carries a high risk of early recurrent stroke 5, 6
• The natural history of untreated symptomatic vertebral artery stenosis includes stroke rates of 7.8-10.7 per 100 patient-years in the territory of the stenotic artery 6
• While endovascular interventions have largely replaced complex vertebral artery reconstructions due to limited surgical expertise, the benefit of stenting over optimal medical therapy remains unclear 1