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Stenting of vertebral artery origin atherosclerosis in high-risk patients: bare or coated? A single-center
Paul T Akins1, Charles W Kerber, Ramin S Pakbaz
1Department of Neurosurgery, Kaiser Permanente, 2025 Morse Avenue, Sacramento, CA, 95825, USA. akins@surewest.net
Insights
Vertebral artery stenting effectively treated high-risk patients with posterior circulation infarction. Drug-eluting stents showed promise in reducing restenosis, offering good long-term outcomes for stroke prevention.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Interventional Radiology
Background:
- Atherosclerotic disease of vertebrobasilar vessels is a significant cause of posterior circulation infarction.
- Atheroma commonly originates at the vertebral arteries, leading to stenosis and ischemic events.
Purpose of the Study:
- To evaluate the technique and outcomes of dilatation and stenting for symptomatic vertebral-origin disease in high-risk patients.
- To assess the safety and efficacy of stenting in preventing stroke in this patient population.
Main Methods:
- Retrospective review of 12 high-risk patients who underwent proximal vertebral artery stenting between 1999-2005.
- Patients had high-grade stenoses, ischemic symptoms, and significant vascular risk factors, including contralateral vertebral or carotid occlusions.
- Post-treatment monitoring included ultrasound and angiography, with aggressive management of risk factors; drug-eluting stents were used in later cases.
Main Results:
- No deaths or procedural complications occurred during neurointerventional procedures.
- Restenosis occurred in 3 of 7 patients treated with uncoated stents, while none of the 5 patients treated with drug-eluting stents experienced restenosis (p = 0.08).
- Long-term outcomes included good patency and stroke-free survival, with two late deaths from unrelated cancers.
Conclusions:
- Vertebral artery stenting is a safe procedure with a low complication rate in high-risk patients.
- Stenting offers moderate restenosis rates but good long-term patency and stroke-free survival.
- Drug-eluting stents may significantly reduce in-stent restenosis compared to bare-metal stents.
Unlabelled:
Atherosclerotic disease of the vertebrobasilar vessels is an important cause of posterior circulation infarction. Commonly, the primary atheroma forms at the origin of the vertebral arteries. We have recently treated 12 high-risk patients with dilatation and stenting of symptomatic vertebral-origin disease and report our technique and results.
Methods:
Twelve patients with proximal vertebral stents placed between 1999-2005 were identified from a computerized registry of 3,046 records. All patients had high-grade origin stenoses, symptoms of cerebral ischemia and the following additional risk factors: 6 had contralateral vertebral occlusions; 1 had bilateral carotid occlusion; 2 had combined subclavian/vertebral-origin disease. After treatment, all patients were monitored with ultrasound and angiography and were aggressively managed for vascular disease risk factors.
Results:
Patients had: hyperlipidemia, 90%; hypertension, 80%; tobacco use, 70%; homocysteine > 10, 50%; coronary disease, 40%; diabetes mellitus, 20%. No deaths or procedural complications occurred during the neurointerventional procedures. Drug-eluting stents (tacrolimus) were used in the last 5 cases. Three of the 7 patients treated with uncoated stents developed restenosis. Angioplasty for restenosis was durable in 2. One patient developed asymptomatic occlusion of her bare-metal stent. None of the patients treated with tacrolimus stents had recurrence of stenosis (p = 0.08). One patient died from pharyngeal cancer at 8 months, and 1 from lung cancer at 17 months.
Conclusions:
In high-risk patients with vertebralorigin disease, stenting demonstrated a low procedural complication rate, a moderate restenosis rate, good long-term patency and good longterm stroke-free survival. Placement of drug-eluting stents appears to reduce in-stent restenosis.
