What is the treatment for vertebral artery stenosis?

Treatment of Vertebral Artery Stenosis

All patients with vertebral artery stenosis should receive optimal medical therapy as first-line treatment, consisting of antiplatelet therapy (aspirin 75-325 mg daily), high-intensity statin therapy, and aggressive risk factor modification, regardless of symptom status. 1

Medical Management (First-Line for All Patients)

Antiplatelet Therapy

• Aspirin 75-325 mg daily is mandatory for all patients with vertebral artery atherosclerosis to prevent myocardial infarction and other ischemic events 1
• For patients with recent stroke/TIA (within 30 days) and severe stenosis (70-99%): consider adding clopidogrel 75 mg daily to aspirin for up to 90 days 2
• Alternative regimens include aspirin plus extended-release dipyridamole or clopidogrel monotherapy 1

Lipid Management

• High-intensity statin therapy is required to reduce LDL cholesterol below 100 mg/dL 1, 3
• For patients who have sustained ischemic stroke, target LDL near or below 70 mg/dL 3
• Statins provide additional benefits beyond cholesterol reduction, including endothelial stabilization, increased nitric oxide bioavailability, and reduced vascular inflammation 3
• For statin-intolerant patients, use bile acid sequestrants and/or niacin 3

Blood Pressure Control

• Target systolic blood pressure <140 mmHg 2
• Long-term maintenance of BP <140/90 mmHg is reasonable for patients with 50-99% stenosis 1

Lifestyle Modifications

• Smoking cessation is mandatory 3
• At least moderate physical activity 2
• Diet and exercise modifications, particularly for patients with diabetes 3

Revascularization (Reserved for Refractory Cases Only)

When to Consider Intervention

Endovascular or surgical treatment may be considered ONLY when patients have recurrent symptoms despite optimal medical therapy (including antithrombotics, statins, and risk factor control) 1

Critical Caveat

• Angioplasty and stenting should NOT be used as initial treatment, even in patients with severe (70-99%) stenosis who were already on antiplatelet therapy when they had their stroke/TIA 2
• The evidence base is weak: the only randomized trial (CAVATAS) enrolled just 16 patients and showed no difference between endovascular therapy and medical management alone 1
• Medical therapy remains the mainstay due to high morbidity rates associated with surgical correction 1

Endovascular Options (Class IIb Evidence)

• Percutaneous angioplasty with or without stenting may be considered for patients with persistent symptoms despite maximal medical therapy 1
• Technical success rates are high (97%), but clinical superiority over medical management has not been proven 1
• Should only be performed in centers with extensive experience 4

Surgical Options

• Extra-anatomic bypass or direct reconstruction may be considered for highly selected patients with refractory symptoms 1
• Surgery is viable only in a few specialist centers due to technical complexity 4, 5

Diagnostic Imaging Requirements

Initial Evaluation

• MRA or CTA is required (not ultrasound) for patients with posterior circulation symptoms 1, 2
• MRA/CTA has 94% sensitivity and 95% specificity compared to ultrasound's 70% sensitivity 2
• Catheter-based angiography is reserved for cases where noninvasive imaging fails to define stenosis severity or location, particularly if revascularization is being considered 1, 2

Surveillance

• Serial noninvasive imaging is reasonable to assess disease progression and exclude new lesions 1, 2
• For patients who undergo revascularization, surveillance at 1 month, 6 months, then annually is reasonable 2

Special Considerations for Subclavian Steal Syndrome

• Extra-anatomic carotid-subclavian bypass is reasonable for symptomatic patients without surgical contraindications 1
• Percutaneous endovascular angioplasty and stenting is reasonable for high-risk surgical patients 1
• Asymptomatic patients with subclavian steal should NOT undergo revascularization unless the internal mammary artery is required for coronary bypass 1

Common Pitfalls to Avoid

• Do not rush to endovascular intervention: Despite technical feasibility, guidelines explicitly recommend against angioplasty/stenting as initial treatment 2
• Do not undertreat atherosclerotic risk factors: Vertebral artery disease indicates systemic atherosclerosis requiring aggressive medical management 1, 2
• Do not rely on ultrasound alone: MRA or CTA provides superior diagnostic accuracy 1, 2
• Do not assume anticoagulation is beneficial: There is no proven indication for anticoagulation in vertebral artery stenosis 4
• Do not ignore the high early recurrence risk: Symptomatic vertebral artery stenosis carries greater recurrent stroke risk in the first 7 days than carotid stenosis 1