Symptomatic Vertebral Artery Stenosis Research Articles

Percutaneous transluminal angioplasty and stenting of post-irradiation stenosis of the vertebral artery

BackgroundThe outcomes of percutaneous transluminal angioplasty and stenting (PTAS) in patients with medically refractory post-irradiation stenosis of the vertebral artery (PISVA) have not been clarified. AimThis retrospective study evaluated the safety and outcomes of PTAS in patients with severe PISVA compared with their radiation-naïve counterparts (non-RT group). MethodsPatients with medically refractory severe symptomatic vertebral artery stenosis and undergoing PTAS between 2000 and 2021 were classified as the PISVA group or the non-RT group. The periprocedural neurological complications, periprocedural brain magnetic resonance imaging, the extent of symptom relief, and long-term stent patency were compared. ResultsAs compared with the non-RT group (22 cases, 24 lesions), the PISVA group (10 cases, 10 lesions) was younger (62.0 ± 8.6 vs 72.4 ± 9.7 years, P = 0.006) and less frequently had hypertension (40.0% vs 86.4%, P = 0.013) and diabetes mellitus (10.0% vs 54.6%, P = 0.024). Periprocedural embolic infarction was not significantly different between the non-RT group and the PISVA group (37.5% vs 35.7%, P = 1.000). At a mean follow-up of 72.1 ± 58.7 (3–244) months, there was no significant between-group differences in the symptom recurrence rate (0.00% vs 4.55%, P = 1.000) and in-stent restenosis rate (10.0% vs 12.5%, P = 1.000). ConclusionPTAS of severe medically refractory PISVA is effective in the management of vertebrobasilar ischemic symptoms in head and neck cancer patients. Technical safety and outcome of the procedure were like those features in radiation-naïve patients.

A balloon-supported embolism protection technique during vertebral/subclavian artery angioplasty stenting.

A balloon-supported embolism protection technique during vertebral/subclavian artery angioplasty stenting.

Vertebral Artery Stenosis: A Narrative Review

Vertebral artery stenosis (VAS) is the cause of approximately 20% of ischemic strokes in the posterior circulation. There are several causes of vertebral artery stenosis, including atherosclerosis, calcification, dissections, fibromuscular dysplasia, giant cell arteritis, neurofibromatosis type 1, and bony compressions. The most common cause of VAS is atherosclerosis which is derived from the macrophage-induced oxidation of low-density lipoproteins (LDLs), alongside the accumulation of cholesterol. Calcification of the vertebral artery occurs when there is excess calcium and phosphate deposition in the vessel. Dissection of the vertebral artery can lead to the formation of a hematoma causing stenosis of the vertebral artery. Fibromuscular dysplasia can result in stenosis due to the deposition of collagen fibers in the tunica media, intima, or adventitia. Giant cell arteritis, an autoimmune disorder, causes inflammation of the internal elastic membrane resulting in eventual stenosis of the artery. Neurofibromatosis type 1, an autosomal dominant disorder, results in the stenosis of the vertebral artery due to the altered function of neurofibromin. Mechanical compression of the vertebral artery by bone can also cause stenosis of the vertebral artery. Digital subtraction angiography (DSA) is considered the current gold standard in diagnosing vertebral artery stenosis; however, its associated morbidity and mortality have led to increased use of non-invasive techniques such as duplex ultrasonography (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). Currently, asymptomatic and symptomatic vertebral artery stenoses are treated by risk factor modification and medical treatment. However, it is recommended that surgical (endarterectomy, reconstruction, and decompression) and endovascular (balloon coronary, bare-metal, and drug-eluting stents) treatments are also used for symptomatic vertebral artery stenosis.

Duplex Ultrasonography for the Evaluation of Extracranial Vertebral Artery: A Prospective Comparison With Digital Subtraction Angiography.

Background and ObjectivePatients with symptomatic vertebral artery stenosis are at high risk of stroke recurrence, especially ≥70% stenosis. Revascularization may be considered for extracranial vertebral artery stenosis in patients with recurrent ischemic events despite optimal medical management. Currently, there is a lack of consensus on the ultrasonic evaluation of extracranial vertebral artery stenosis in clinical practice. This study aimed to validate the efficiency of duplex ultrasonography and assess the optimal sonographic thresholds for predicting extracranial vertebral artery stenosis.MethodsThis is a prospective study of all patients with symptomatic posterior circulation stroke/transient ischemic attack who were scheduled to undergo digital subtraction angiography from April 2020 to October 2021. A total of 544 vertebral arteries with a normal lumen or extracranial stenosis confirmed with digital subtraction angiography were included in the study. The peak systolic velocity at the V1 segment (PSVv1) and the V2 segment (PSVv2) were measured and the PSVv1/PSVv2 and PSVv2/PSVv1 ratios were calculated. The cutoff values were determined using receiver operating characteristic analysis.ResultsThe areas under the receiver operating characteristic curve of all the velocity parameters to predict extracranial vertebral artery stenosis were >0.80. The cutoff values for predicting ≥50% and ≥70% V1 segment stenosis were PSVv1 ≥146 cm/s (sensitivity 76.2%, specificity 86.3%) and PSVv1/PSVv2 ratio ≥2.2 (sensitivity 84.3%, specificity 77.6%), and PSVv1 ≥184 cm/s (sensitivity 80.8%, specificity 87.1%) and PSVv1/PSVv2 ratio ≥3.5 (sensitivity 79.5%, specificity 90.5%), respectively. The cutoff values for predicting ≥50% and ≥70% V2 segment stenosis were PSVv2 ≥80 cm/s (sensitivity 75.0%, specificity 91.0%) and PSVv2/PSVv1 ratio ≥1.2 (sensitivity 75.0%, specificity 94.8%), and PSVv2 ≥111 cm/s (sensitivity 81.0%, specificity 95.0%) and PSVv2/PSVv1 ratio ≥1.7 (sensitivity 81.0%, specificity 96.6%), respectively.ConclusionSymptomatic patients with the ultrasonic parameters of PSVv1 ≥146 cm/s and PSVv1/PSVv2 ratio ≥2.2 at V1 segment or PSVv2 ≥80 cm/s and PSVv2/PSVv1 ratio ≥1.2 at V2 segment need to be considered for further verification by digital subtraction angiography to seek revascularization. If the parameters increase to PSVv1 ≥184 cm/s and PSVv1/PSVv2 ratio ≥3.5 at the V1 segment or PSVv2 ≥111 cm/s and PSVv2/PSVv1 ratio ≥1.7 at the V2 segment, these patients have an increased risk of recurrent stroke and are more likely to need revascularization. The results can be used as a reference for the assessment and long-term management of patients with extracranial VA stenosis.

Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis.

Vertebral artery stenosis (narrowing of the vertebral artery) is an important cause of posterior circulation ischaemic stroke. Medical treatment (MT) e.g. controlling risk-factors and drug treatment, surgery, and endovascular treatment (ET) are the prevailing treatment strategies for symptomatic vertebral artery stenosis. ET consist s of percutaneous transluminal angioplasty (balloon catheter through the skin), with or without stenting. However, optimal management of people with symptomatic vertebral artery stenosis has not yet been established. To assess the safety and efficacy of percutaneous transluminal angioplasty, with or without stenting, combined with MT, compared to MT alone, in people with episodes of cerebral ischaemia due to vertebral artery stenosis. We searched the Cochrane Stroke Group, MEDLINE, Embase, BIOSIS, and two other indexes in Web of Science, China Biological Medicine Database, Chinese Science and Technique Journals Database, China National Knowledge Infrastructure and Wanfang Data, as well as ClinicalTrials.gov trials register and the World Health Organization (WHO) International Clinical Trials Registry Platform to 23 July 2021. We included all randomised controlled trials (RCTs) that compared ET plus MT with MT alone in treating people aged 18 years or over with symptomatic vertebral artery stenosis. We included all types of ET modalities (e.g. angioplasty alone, balloon-mounted stenting, and angioplasty followed by placement of a self-expanding stent). MT included risk factor control, antiplatelet therapy, lipid-lowering therapy, and individualised management for people with hypertension or diabetes. Two review authors independently screened potentially eligible studies, extracted data, and assessed trial quality and risk of bias. We applied the GRADE approach to assess the certainty of evidence. The primary outcomes were 30-day post-randomisation death/stroke (short-term outcome) and fatal/non-fatal stroke after 30 days post-randomisation to completion of follow-up (long-term outcome). MAIN RESULTS: We included three RCTs with 349 participants with symptomatic vertebral artery stenosis with a mean age of 64.4 years. The included RCTs were at low risk of bias overall. However, all included studies had a high risk of performance bias because blinding of the ET was not feasible. There was no significant difference in 30-day post-randomisation deaths/strokes between ET plus MT and MT alone (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.77 to 7.07; 3 studies, 349 participants; low-certainty evidence). There were no significant differences between ET plus MT and MT alone in fatal/non-fatal strokes in the territory of the treated vertebral artery stenosis after 30 days post-randomisation to completion of follow-up (RR 0.51, 95% CI 0.26 to 1.01; 3 studies, 349 participants; moderate-certainty evidence), ischaemic or haemorrhagic stroke during the entire follow-up period (RR 0.77, 95% CI 0.44 to 1.32; 3 studies, 349 participants; moderate-certainty evidence), death during the entire follow-up period (RR 0.78, 95% CI 0.37 to 1.62; 3 studies, 349 participants; low-certainty evidence), and stroke or transient ischaemic attack (TIA) during the entire follow-up period (RR 0.65, 95% CI 0.39 to 1.06; 2 studies, 234 participants; moderate-certainty evidence). This Cochrane Review provides low- to moderate-certainty evidence indicating that there are no significant differences in either short- or long-term risks of stroke, death, or TIA between people with symptomatic vertebral artery stenosis treated with ET plus MT and those treated with MT alone.

Safety and Efficacy of Rapamycin-Eluting Vertebral Stents in Patients With Symptomatic Extracranial Vertebral Artery Stenosis

Background and Purpose: Drug-eluting stents generally have superior performance to bare metal stents in the treatment of vertebral artery stenosis (VAS). This prospective, multicenter, and single-arm clinical trial was initiated to assess in-stent restenosis (ISR) and midterm outcome after rapamycin-eluting stent placement in patients with symptomatic extracranial VAS.Methods: The subjects underwent angiographic follow-up at 6 months and final clinical follow-up at 12 months. The primary efficacy endpoint was ISR at 6 months. Secondary endpoints included technical success, target lesion-related transient ischemic attack (TIA), stroke, or death, and all-cause TIA, stroke, or death during the 12-month follow-up period.Results: A total of 104 stents were implanted in the 101 patients and 83 patients (82.2%) completed angiographic follow-up at 6 months. The technical success rate was 86.1% (87/101); mean in-stent stenosis rate was 25.1 ± 17.1% and ISR rate was 5.9% (95% CI: 0.8–10.9%). All the patients with ISR were completely asymptomatic and no stent fractures were observed during angiographic follow-up. At the 12-month clinical follow-up, target lesion-related TIA, stroke, or death had occurred in two (2.0%) patients and all-cause TIA, stroke, or death had occurred in six (6.1%) patients.Conclusion: The placement of rapamycin-eluting stents in patients with symptomatic extracranial VAS yields favorable ISR results and showed a trend of favorable safety outcomes including low rates of perioperative complications and late stroke. However, further study is needed to establish the long-term clinical benefits of this stent in the treatment of VA disease.

Transradial approach using a distal access catheter without guiding support for symptomatic intracranial vertebral artery and basilar artery stenosis: a multicenter experience and technical procedure

BackgroundThere is little consensus on endovascular treatment for symptomatic intracranial posterior circulation stenosis via the transradial approach (TRA). We report our multicenter experience and technical procedures that directly used a...

Stenting for Symptomatic Intracranial Vertebrobasilar Artery Stenosis in Northeast of China: A Single-Center Study.

Objective: We described the incidence of surgery-related complications to evaluate the safety of endovascular therapy for severe symptomatic intracranial vertebral basilar artery stenosis (IVBS) in our stroke center in Northeast of China.Methods: Consecutive patients with symptomatic IVBS caused by 70–99% stenosis despite standard medical treatment of antiplatelet agents plus statin were enrolled. Either balloon-mounted stent or balloon predilation plus self-expanding stent was performed. Clinical adverse events such as stroke, transient ischemic attack (TIA), and death after the surgery were documented. Radiological events such as in-stent thrombosis, dissection, and guide-wire perforation during the process were recorded as complications as well. The baseline characteristics and outcomes of patients among different Mori types were compared.Results: From January 2017 to December 2018, 97 patients with stroke or TIA due to intracranial IVBS were treated by stenting, including 30 patients with basilar artery (BA) stenosis, 55 patients with intracranial vertebral artery (V4) stenosis, and 12 patients with V4-BA stenosis. The primary events include two intracranial hemorrhage (2.1%, 2/97), seven ischemic events (7.2%, 7/97), and two death (2.1%, 2/97). The successful stent deployment rate was 98.9% (96/97). The Apollo stents were used more for Mori A lesions. Self-expanding stents were more used in Mori C lesions. Mori C lesions were more vulnerable to endovascular procedure and showed higher rate of complications than A (p = 0.008) and B type (p = 0.047).Conclusion: A high technical success rate of IVBS stenting could be achieved, and the safety was acceptable, whereas Mori C lesions were more vulnerable to endovascular procedure and showed a higher rate of complications than A and B types.

Vertebral Artery Stenosis

Vertebral artery stenosis is a common condition associated with a very high risk of stroke. The goal of this review is to summarize the pathophysiology and natural history of vertebral artery stenosis and to evaluate the efficacy of medical and endovascular therapies. Early and aggressive initiation of medical care combined with advancements in antithrombotic and lipid-lowering therapies has substantially reduced the risk of stroke due to vertebral artery stenosis. Endovascular therapy does not appear to be beneficial with extracranial vertebral artery stenosis and appears harmful with intracranial vertebral artery stenosis. Risk of stroke due to symptomatic vertebral artery stenosis can be significantly reduced with implementation of standardized best medical therapy protocols focusing on ultra-early dual antiplatelet therapy, high-intensity statin therapy + novel lipid-lowering agents, and aggressive risk factor control. Endovascular therapy with angioplasty and stenting is not likely to play a significant role in treatment.

The effect of stenting on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis.

This study aimed to evaluate the effect of stenting on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. Whether posterior circulation revascularization could reduce blood pressure in hypertensive patients with posterior circulation hypoperfusion has not been investigated in humans. A total of 48 patients with essential hypertension (33 males; mean age 63.0 ± 8.7 years) with symptomatic proximal subclavian or vertebral artery stenosis who underwent stenting successfully at the Fuwai Hospital were prospectively enrolled between January 2014 and December 2015. All 48 patients were followed up at 1, 3, and 6 months after the procedure. Blood pressure, use of antihypertensive agents, and complications were investigated. Baseline values included office blood pressure of 132/77 ± 10/8 mmHg, mean 24-hr blood pressure of 127/75 ± 12/9 mmHg, and mean antihypertensive agents used of 1.6 ± 0.8. Stenosis of the subclavian and vertebral arteries decreased from 88.9 ± 9.5% and 85.8 ± 7.4% to 5.5 ± 3.5% and 4.6 ± 3.7%, respectively, immediately after the procedure. Reductions in office blood pressure were - 7/-3 (SD 3/2), -9/-4 (5/3), and - 10/-5 (7/5) mmHg at 1, 3, and 6 months, respectively. While 24-hr blood pressures after the procedure reduced by -5/-3 mmHg at 6 months, the total number of antihypertensive agents used at the aforementioned time points was unchanged. This first prospective cohort study in humans showed that posterior circulation stenting is apparently effective in reducing blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis.

Endovascular treatment of symptomatic severe vertebral artery stenosis

About 25%-40% of ischemic stroke is in the posterior circulation, in which 20% of posterior circulation stroke is caused by vertebral artery stenosis. Patients with symptomatic vertebral artery stenosis have a high risk of recurrent stroke. At present, the treatments of vertebral artery stenosis include medication, open surgery and interventional therapy. In this paper, the endovascular treatment of vertebral artery stenosis is reviewed, especially the progress of endovascular treatment is expounded, in order to promote the development of its treatment. Key words: Brain ischemia; Vertebral artery stenosis; Angioplasty, balloon; Drug-eluting stents; Atherectomy

Vertebral artery stenting to prevent recurrent stroke in symptomatic vertebral artery stenosis: the VIST RCT.

Symptomatic vertebral artery (VA) stenosis has been associated with a markedly increased early risk of recurrent stroke. VA stenosis can be treated with stenting; however, there are few data from randomised controlled trials evaluating the efficacy of this treatment, and recent studies in intracranial stenosis have suggested that stenting may be associated with increased risk. The Vertebral artery Ischaemia Stenting Trial (VIST) was established to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for recently symptomatic VA stenosis. VIST was a prospective, randomised, open, parallel, blinded end-point clinical trial. The trial was performed in 14 hospitals in the UK. Recruitment began on 23 October 2008 and follow-up ended on 1 March 2016, by which time every patient had been followed up for at least 1 year. Participants had to have symptomatic vertebral stenosis of at least 50% resulting from presumed atheromatous disease. Both patients and clinicians were aware of treatment allocation; however, an independent adjudication committee, masked to treatment allocation, assessed all primary and secondary end points. Participants were randomly assigned (1 : 1) to either vertebral angioplasty/stenting plus BMT (n = 91) or BMT alone (n = 88). A total of 182 patients were initially enrolled; however, three patients (two who withdrew after randomisation and one who did not attend after the initial randomisation visit) did not contribute any follow-up data and were excluded. None of these three patients had outcome events. The primary end point was the occurrence of fatal or non-fatal stroke in any arterial territory during follow-up. The median follow-up was 3.5 (interquartile range 2.1-4.7) years. Of the 61 patients who were stented, 48 (78.7%) had extracranial stenosis and 13 (21.3%) had intracranial stenosis. No perioperative complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point occurred in five patients (including one fatal stroke) in the stent group and in 12 patients (including two fatal strokes) in the medical group (giving a hazard ratio of 0.40, 95% confidence interval 0.14 to 1.13; p = 0.08), with an absolute risk reduction of 25 strokes per 1000 person-years. The study was underpowered because it failed to reach target recruitment. The high rate of non-confirmation of stenosis in the stented group of the trial was a second limitation. The trial found no difference in risk of the primary end point between the two groups. Post hoc analysis suggested that stenting could be associated with a reduced recurrent stroke risk in symptomatic VA and further studies are now required to confirm these findings, particularly in extracranial VA stenosis where complication rates with stenting were confirmed to be very low. Current Controlled Trials ISRCTN95212240. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 41. See the NIHR Journals Library website for further project information. In addition, funding for the pilot phase was provided by the Stroke Association.

Stenting vs. Medical Management for Vertebral Artery Stenosis

Although patients with symptomatic vertebral artery stenosis have a high risk for recurrent stroke, and stenting of extracranial or intracranial

Stenting for symptomatic vertebral artery stenosis: a preplanned pooled individual patient data analysis

Symptomatic vertebral artery stenosis is associated with a high risk of recurrent stroke, with higher risks for intracranial than for extracranial stenosis. Vertebral artery stenosis can be treated with stenting with good technical results, but whether it results in improved clinical outcome is uncertain. We aimed to compare vertebral stenting with medical treatment for symptomatic vertebral stenosis. We did a preplanned pooled individual patient data analysis of three completed randomised controlled trials comparing stenting with medical treatment in patients with symptomatic vertebral stenosis. The primary outcome was any fatal or non-fatal stroke. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses. Data from the intention-to-treat analysis were used for all studies. We estimated hazard ratios (HRs) with 95% CIs using Cox proportional-hazards regression models stratified by trial. Data were from 354 individuals from three trials, including 179 patients from VIST (148 with extracranial stenosis and 31 with intracranial stenosis), 115 patients from VAST (96 with extracranial stenosis and 19 with intracranial stenosis), and 60 patients with intracranial stenosis from SAMMPRIS (no patients had extracranial stenosis). Across all trials, 168 participants (46 with intracranial stenosis and 122 with extracranial stenosis) were randomly assigned to medical treatment and 186 to stenting (64 with intracranial stenosis and 122 with extracranial stenosis). In the stenting group, the frequency of periprocedural stroke or death was higher for intracranial stenosis than for extracranial stenosis (ten (16%) of 64 patients vs one (1%) of 121 patients; p<0·0001). During 1036 person-years of follow-up, the hazard ratio (HR) for any stroke in the stenting group compared with the medical treatment group was 0·81% CI 0·45-1·44; p=0·47). For extracranial stenosis alone the HR was 0·63 (95% CI 0·27-1·46) and for intracranial stenosis alone it was 1·06 (0·46-2·42; pinteraction=0·395). Stenting for vertebral stenosis has a much higher risk for intracranial, compared with extracranial, stenosis. This pooled analysis did not show evidence of a benefit for stroke prevention for either treatment. There was no evidence of benefit of stenting for intracranial stenosis. Stenting for extracranial stenosis might be beneficial, but further larger trials are required to determine the treatment effect in this subgroup. None.

A12181 Effect of Stenting on Blood Pressure in Hypertensive Patients with Symptomatic Proximal Subclavian or Vertebral Artery Stenosis

Objectives: To evaluate the effect of posterior circulation revascularization on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. Methods: 48 patients with essential hypertension (33 males; mean age 63.0 ± 8.7 years) with symptomatic proximal subclavian or vertebral artery stenosis (diameter reduction≥70%), who underwent successful stenting on the lesions, were prospectively enrolled at Fuwai Hospital between January 2014 and December 2015. These were followed up at 1, 3 and 6 months after the procedure. During the study, antihypertensive agents and dosage were fixed, Blood pressure and complications were investigated. Results: Baseline office blood pressure (OBP) of 132/77 ± 10/8 mm Hg, 24-hour ambulatory blood pressure (ABP) of 127/75 ± 12/9 mm Hg, and mean of 1.6 ± 0.8 antihypertensive agents. The mean subclavian and vertebral artery stenosis decreased from 88.9 ± 9.5% and 85.8 ± 7.4% to5.5 ± 3.5% and 4.6 ± 3.7% immediately after stenting, respectively. Mean reductions in OBP were –7/–3 (95% CI 3/2), –9/–4 (5/3), and –10/–5 mm Hg (7/5) at 1, 3, and 6 months, respectively. 24-h ABP after the procedure were reduced by –5/–3 mm Hg at 6 months. No procedure related complications occurred. Conclusion: This first prospective cohort study in human showed posterior circulation revascularization appears to be effective in reducing blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. However, the finding should be confirmed further.

A11105 Effect of Posterior Circulation Revascularization on Blood Pressure in Hypertensive Patients

Objectives: To evaluate the effect of posterior circulation revascularization on blood pressure in hypertensive patients with symptomatic proximal subclavian or vertebral artery stenosis. Methods: A total of 48 patients with essential hypertension (33 males; mean age 63.0 ± 8.7 years) with symptomatic proximal subclavian or vertebral artery stenosis underwent stenting successfully at the Fuwai Hospital were prospectively enrolled in the study between January 2014 and June 2016. All 48 patients were followed up at 1, 3 and 6 months after the procedure. Blood pressure, use of antihypertensive agents, and complications were investigated. Results: Baseline values included mean office blood pressure of 132/77 ± 10/8 mm Hg, 24-hour mean blood pressure of 127/75 ± 12/9 mm Hg, and mean 1.6 ± 0.8 antihypertensive agents. The mean stenosis of subclavian and vertebral artery decreased from 88.9 ± 9.5% and 85.8 ± 7.4% to 5.5 ± 3.5% and 4.6 ± 3.7% immediately after the procedure, respectively. Mean reductions in office blood pressure were −7/−3 (95% CI 3/2), −9/−4 (5/3), and −10/−5 mm Hg (7/5) at 1, 3, and 6 months, respectively. 24-hour mean blood pressures after procedure were reduced by −5/−3 mm Hg at 6 months, and the total number of antihypertensive agents at the above corresponding time points essentially unchanged. Conclusion: This first prospective cohort study in human showed posterior circulation revascularization seems to be effective in reducing blood pressure in hypertensive patients. Our research outcome validates the results of previous animal experiments, suggesting the Cushing's mechanism play an important role in the long-term control of mean arterial pressure of human.

Effects of endovascular stent implantation and medical treatment on symptomatic vertebral artery stenosis

Objective To investigate the clinical effect of endovascular stent implantation and medical treatment in the treatment of symptomatic vertebral artery stenosis. Methods Eighty patients with symptomatic vertebral artery stenosis admitted from January 2013 to May 2015 in the Department of Neurology of Wuhan Puren Hospital were selected.The patients were randomly divided into the observation group and the control group, with 40 cases in each group.The control group was given aspirin enteric-coated tablets 100 mg/ time, 1 time /d, clopidogrel bisulfate bablets 75 mg/ time, 1 time /d, atorvastatin calcium 10 mg/ time, 1 time/d.The observation group was treated with intravascular stent implantation.After 1 years of follow-up, the degree of vascular stenosis, the occurrence of ischemic cerebrovascular time and the clinical effect of the two groups were compared. Results (1) The stenosis degree of the observation group and the control group before treatment was (72.81±11.99)% and (68.31±12.35)% respectively, after treatment, it was (24.58±1.24)% and (56.01±3.30)% respectively.There was no significant difference between the two groups before treatment (t=0.121, P>0.05). After treatment, vascular stenosis degree in two groups were significantly improved, compared with that before treatment, the differences were statistically significant (t=0.790, P<0.05; t=0.457, P<0.05); the degree of vascular stenosis after treatment in the observation group was significantly lower than that in the control group (t=0.842, P<0.05); (2) during follow-up, the total occurrence rate of ischemic cerebrovascular events in the observation group was 17.5% (7/40), compared to 37.5% (15/40) in the control group, the difference between the two groups was statistically significant (χ2=4.065, P<0.05). (3) At 1 years of follow-up, the total effective rate of the observation group was 97.5% (39/40), while that of the control group was 60% (24/40), and the difference between the two groups was statistically significant (P=0.017). Conclusion Endovascular stent implantation can effectively improve the clinical efficacy of symptomatic vertebral artery, reduce the incidence of ischemic cerebrovascular time, and improve the degree of vascular stenosis. Key words: Intravascular stent implantation; Symptomatic vertebral artery stenosis; Aspirin enteric-coated tablets; Clopidogrel sulfate; Atorvastatin calcium

Stenting for Symptomatic Vertebral Artery Stenosis: The Vertebral Artery Ischaemia Stenting Trial

Objective: To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. Methods: VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant. Results: Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05). Conclusions: Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk. ISRCTN.com identifier: ISRCTN95212240. Classification of evidence: This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

Recent advances in the management of symptomatic vertebral artery stenosis.

Vertebrobasilar stenosis accounts for 20% of posterior circulation strokes and is associated with high risk of early stroke recurrence. We review data from randomized controlled trials examining whether stenting may reduce this risk, including the recently published Vertebral Artery Ischaemia Stenting Trial (VIST). VIST and VAST (Vertebral Artery Stenting Trial), having recruited both intracranial and extracranial vertebral stenosis and showed a low rate of perioperative stroke for extracranial (0 and 2%, respectively), but a higher rate for intracranial stenosis (15 and 22%, respectively). In VIST, the primary endpoint of stroke occurred in five patients in the stent group vs. 12 in the medical group (hazard ratio 0.40; 95% confidence interval 0.14-1.13, P = 0.08), although when days from last symptoms were adjusted for, the hazard ratio was 0.34 (95% confidence interval 0.12-0.98; P = 0.046). SAMMPRIS (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis) recruited only intracranial vertebral stenosis and showed a better outcome with intensive medical therapy than stenting. Stenting of extracranial stenosis can be performed with a low operative risk. VIST suggests it may reduce longer term stroke risk, but this needs confirming in larger trials. For intracranial stenosis, due to a higher operative risk, current evidence favours medical treatment. SAMMPRIS have emphasized the need for intensive medical therapy whether or not stenting is performed.

Angioplasty and drug-eluting stent for vertebral artery stenosis

Objective To study the efficacy, safety, and feasibility of angioplasty and drug-eluting stents (DESs) in the treatment of vertebral artery stenosis. Patients and methods The study was carried out on 20 patients (17 patients with vertebral artery endovascular stenting and three patients with angioplasty alone). The success rate, perioperative complications, and long-term effectiveness were evaluated. Results A total of 17 DESs were implanted and three patients with angioplasty alone. The success rate was 100%. The degree of stenosis decreased from 78.25±10.17 to 11.50±7.45% (P Conclusion Angioplasty and DESs is a safe and effective strategy for the treatment of symptomatic vertebral artery stenosis.