In patients with symptomatic vertebral artery stenosis, is there enough evidence to recommend endovascular intervention over medical treatment? Leon Lai Evidence-Based Surgery Presentation
P Vertebrobasilar insufficiency I Balloon angioplasty stent C Medical Therapy (Antiplatelets, Anticoagulants, Heparin, Warfarin) O Treatment outcome Morbidity/Mortality
Article Title Journal Rank Coward 2007 Long term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) Stroke 3 Lutsep 2004 Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results Stroke 3 Coward 2000 Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis Cochrane Review 3 Binning 2010 Vascular disease: Endovascular treatment of vertebral artery stenosis Nature Reviews Cardiology 3 Ralea 2008 Stenting of symptomatic basilar and vertebral artery stenosis in patients resistant to optimal medical prevention: the Lyon stroke unit experience European Neurology 2 Hatano 2005 Stenting for vertebrobasilar artery stenosis Acta Neurochirurgica (Sup) 2 Eckert 2005 Aggressive therapy with iv abciximab and intra-arterial rtPA and additional PTA/stenting improves clinical outcome in acute vertebrobasilar occlusion: combined local fibrinolysis and iv abciximab in acute vertebrobasilar stroke treatment (FAST): results of a multicener study Stroke 2 Jovin 2007 Managment of symptomatic intracranial atherosclerotic disease Current Cardiology Reports 2 Yu 2005 Long-term outcome of endovascular stenting for symptomatic basilar artery stenosis. Neurology 2 Ogilvy 2010 Restenosis rates following vertebral artery origin stenting: does stent type make a difference? Journal of Invasive Cardiology 1
Medical Therapy Search
Article Title Journal Rank Macleod 2005 Results of a multicentre, randomised controlled trial of intra-arterial urokinase in the treatment of acute posterior circulation ischaemic stroke Cerebrovascular diseases 2 Montavont2004 Intravenous r-TPA in vertebrobasilar acute infarcts Neurology 2 Sivenius 1991 The European Stroke Prevention Study (ESPS): results by arterial distribution Annals of Neurology 2 Eckert 2005 Aggressive therapy with iv abciximab and intra-arterial rtPA and additional PTA/stenting improves clinical outcome in acute vertebrobasilar occlusion: combined local fibrinolysis and iv abciximab in acute vertebrobasilar stroke treatment (FAST): results of a multicener study Stroke 2 Eckert 2002 Acute basilar artery occlusion treated with combined iv Abciximab and intra-arterial tissue plasminogen activator – report of 3 cases. Stroke 1 Sivenius 1991 Antiplatelet therapy is effective in the prevention of stroke or death in women: subgroup analysis of the European Stroke Prevention Study (ESPS) Acta Neurologica Scandinavica 1 Hofferberth 1986 Calcium entry blockers in the treatment of vertebrobasilar insufficiency European Neurology 1 Ralea 2008 Stenting of symptomatic basilar and vertebral artery stenosis in patients resistant to optimal medical prevention: the Lyon stroke unit experience European Neurology 1 Engelter 2005 Antithrombotic therapy for cervical artery dissection Frontiers of Neurology & Neuroscience 1 Guzzo 2010 Preoperative thrombolysis and venoplasty affords no benefit in patency following first rib resection and scalenotomy for subacute and chronic subclavian vein thrombosis Journal of vascular surgery 1
Scopus Google Scholar Article Title Journal Rank Steinfort 2007 Midterm outcomes of paclitaxel-eluting stents for the treatment of intracranial posterior circulation stenoses Journal of Neurosurgery 3 Barakate 2001 Angioplasty and stenting in the posterior cerebral circulation Journal of Endovascular Therapy 2 Amin-Hanjani 2010 Vertebrobasilar Flow Evaluation and risk of transient ischaemic attach and stroke study (VERiTAS): Rationale and design International Journal of Stroke 3 Compter 2008 Vertebral artery stenting trial. Protocol for randomised safety and feasibility trial Trials 3 Article Title Journal Rank - The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial - -
Key Results from Search
To date, the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) is the only prospective randomized study comparing best medical therapy vs endovascular stenting for patients with symptomatic vertebral artery stenosis.
16 patients – 8 in medical vs 8 in endovascular stenting
Of 8 assigned to stenting only 2 had stents; 6 underwent angioplasty
Study failed to show an advantage for endovascular treatment of vertebral artery stenosis because
None of the patients in either group had experienced a posterior circulation stroke by 8 yr follow up.
Medical therapy was loosely defined in CAVATAS – could consist of antiplatelet agents or anticoagulation with warfarin.
Jenkins et al
105 patients with symptomatic vertebral artery stenosis – underwent stenting
100% radiographic improvement in stenosis (residual stenosis <30%)
All were placed on dual antiplatelet therapy for at least 1 month after the procedure
Ceasation of clopidogrel at discretion of interventionalist
At 1 yr follow up
6 patients died, 5 experienced a vertebrobasilar stroke
At 2.5yr follow up
70% remained symptom free; 13% had restenosis requiring retreatment
Stenting could be performed safely and effectively
Rate of in-stent stenosis lower than other published series
SSYLVIA trial – restenosis at 6 months were
50% for intracranial vertebral arteries
43% for extracranial vertebral arteries
Vertebral Artery Stenting Trial (VAST)
currently enrolling patients for stenting of intracranial and extracranial vertebral artery stenosis
Medical treatment is at discretion of neurologist, but a statin + at least one antiplatelet agent are recommended.
Type of stent at discretion of interventionalist.
Stenting & Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)
Just stopped enrolment
Comparing best medical therapy with vascular stenting for symptomatic intracranial atherosclerostic disease
Medical therapy is standardized (dual antiplatelet medication + statin)
Use of Wingspan stent is consistent.
At present, there is not enough evidence to recommend endovascular stenting over medical therapy.
If the aforementioned studies show that stenting is superior to medical management, then this may help to establish endovascular stenting as the standard of care for patients with symptomatic vertebral artery stenosis.
So in the mean time, maximal medical therapy should be trialled first.
For medically refractory patients, endovascular stenting is recommended.