Abstract
Objective: To report a single-center experience using drug-eluting balloon mounted stents (DES) for endovascular treatment of atherosclerotic ostial vertebral artery stenosis (OVAS).Background: Posterior circulation is affected in up to 25% of strokes, 20% of them resulting from atherosclerotic OVAS. The optimal management of symptomatic OVAS remains controversial. DES have been introduced to improve restenosis rates.Methods: We retrospectively analyzed prospectively collected data from patients with dominant OVAS who underwent endovascular treatment with second-generation DES placement. Patient demographics, clinical presentation, comorbidities, stenosis severity, stent features, technical success, complications, and imaging follow-up were assessed.Results: Thirty patients were treated, predominantly male (86.6%). Sixteen patients presented with an acute stroke or TIA and fourteen were treated on an elective basis due to symptomatic chronic stenosis and contralateral occlusion. Comorbidities included hyperlipidemia (83%), hypertension (70%) and prior stroke (63.3%). Mean ostial stenosis at presentation was 80 ± 14.8%. Twenty-one patients had contralateral VA involvement. DES deployment was technically successful in all patients using everolimus eluting stents in 30 lesions and zotarolimus eluting stents in two. One technical complication (stent migration) and three (10%) minor peri-procedural complications occurred. Complications included one asymptomatic ischemic infarct in the posterior circulation, one femoral artery thrombosis and one post-procedure altered mental status secondary to contrast induced neurotoxicity. Mean imaging follow-up was 8.8 months. Two (7.6%) patients had in-stent restenosis and underwent retreatment with angioplasty. There were no procedure-related mortalities.Conclusion: Our study confirms the feasibility of deploying DES for the treatment of ostial vertebral artery stenosis with low peri-procedural risk and low medium-term rates of re-stenosis.
Highlights
Posterior circulation strokes represent ∼25% of all strokes
Our study confirms the feasibility of deploying drug-eluting stents (DES) for the treatment of ostial vertebral artery stenosis with low peri-procedural risk and low medium-term rates of re-stenosis
Low stroke (1.9%) and death (0.6%) rates have been reported with the use of open surgical bypass or endarterectomy for extracranial artery disease (3), significant complication rates approaching 20% were described when applied for ostial vertebral stenosis (OVAS) (3, 4)
Summary
Posterior circulation strokes represent ∼25% of all strokes. Of those, up to 20% result from atherosclerotic ostial vertebral stenosis (OVAS) (1, 2). A high restenosis rate has been observed with OVAS when bare metal stents (BMS) are used (6). Antiproliferative drug-eluting stents (DES) for treatment of coronary vascular disease has led to reduced rates of restenosis in this vascular bed (7, 8), leading neurointerventionalists to adopt this technology in the treatment for OVAS. First-generation DES, such as sirolimus and paclitaxeleluting stents, have shown superior results when compared with BMS (bare metal stents) in some case series, with no improvement in others (10, 11). Debate continues on their safety and efficacy given their association with delayed vascular healing and late stent thrombosis, especially after discontinuation of dual antiplatelet therapy (7).
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