Endovascular Treatment for Vertebrobasilar Insufficiency

Endovascular management of supra-aortic atherosclerotic vascular disease is becoming relatively common in the innominate, subclavian, and carotid arteries. However, revascularization of vertebral artery disease is an infrequently used treatment option due to several reasons: 1) stroke etiology and prevention is generally considered with respect to carotid disease as posterior circulation ischemia is poorly defined; 2) the limited success and excessive morbidity have made surgery an unattractive option for vertebral artery revascularization; 3) routine screening for posterior circulation disease as an etiology for stroke is rarely performed; and 4) endovascular treatment of vertebrobasilar insufficiency is not routinely performed in peripheral interventional programs. Randomized data comparing medical therapy, endovascular treatment, or surgical treatment do not exist. Due to infrequent identification of vertebral artery disease as the etiology of posterior circulation symptomatology, randomized comparisons will be difficult to obtain. Balloon angioplasty alone, provisional stenting, or primary stent placement for the treatment of vertebral artery stenosis is associated with low restenosis rates and high success rates. The available literature demonstrates angioplasty with stent placement of posterior circulation, symptomatic, vertebrobasilar atherosclerotic disease is a safe and effective approach that avoids the morbidity associated with major surgery. We believe primary stent placement is the treatment of choice for vertebral artery revascularization due to the high technical success rate, low incidence of morbidity and mortality, and long-term durability.