Vertebral Artery Origin Stenosis Research Articles

Abstract Number ‐ 75: Simultaneous Extracranial‐Intracranial Management of Tandem Lesion (Seimless Technique) in Posterior Circulation Stroke

Introduction Simultaneous extracranial‐intracranial management of Tandem lesion in stroke (Seimless technique) is well published and important technique in treating tandem lesions in anterior circulation. However, this technique has been rarely used in the posterior circulation. We present the case of a 70 year‐old male presented with coma and was found to have right vertebral artery origin stenosis with super‐imposed thrombus and tandem occlusion of the basilar artery. We used endovascular Seimless technique successfully with TICI‐3 reperfusion score and good clinical outcome. To our knowledge, this is the first case report for endovascularSeimless technique used in the post circulation. Methods We reviewed our endovascular mechanical thrombectomy data from May 2019 to July 2022 and those with post circulation tandem occlusion were selected. Baseline demographics and clinical presentation were obtained including clinical outcome. Results 70 year‐old male with history of high blood pressure presented with state of coma was found to have right vertebral artery origin stenosis with superimposed pedunculated thrombus and tandem distal third Basilar artery occlusion. Patient underwent simultaneous extracranial‐intracranial management of tandem lesions (Seimless technique) through right trans radial basilar artery thrombectomy with stent retriever and aspiration as well as right vertebral artery origin aspiration and balloon angioplasty over the wire of the stent retriever. Following day, the patient underwent right trans‐radial vertebral artery origin stenosis stenting. Patient’s neurological exam was improved from NIHSS 30 to 0 at the time of discharge. We performed Basilar artery thrombectomy using Rist catheter, Red 62 reperfusion catheter, Rebar microcatheter and Solitaire stent retriever4 mm x 41 mm. After deploying the stent retriever, we advanced sterling balloon 4 mm x 20 mm over the stent retrieverwire and performed optimal balloon angioplasty. Conclusions This particular technique of treating intracranial and extracranial lesion simultaneously for posterior circulation hasn’t been reported in the literature. By presenting this case, we want to conclude that in selective posterior circulation tandem occlusion strokes “Seimless technique” can be used effectively and safely without many complications.

In-stent restenosis after vertebral artery origin stenosis stenting: a nomogram for risk assessment

ObjectiveTo propose a nomogram for individual risk assessment of in-stent restenosis (ISR) after vertebral artery origin stenosis (VAOS) stenting.MethodsWe included 793 patients with VAOS treated with stenting from October 2006...

A Comparison of Different Endovascular Treatment for Vertebral Artery Origin Stenosis

To compare the safety and efficacy of stenting with drug-eluting stent (DES), stenting with bare mental stent (BMS), and angioplasty alone with drug-coated balloon (DCB) in patients with symptomatic vertebral artery origin stenosis (VAOS) who failed aggressive medical management (AMM). We performed a retrospective analysis of consecutive patients with symptomatic VAOS who underwent endovascular treatment between December 2018 and November 2021 at our institution. The main outcome compared were technical success, perioperative complications, residual stenosis, stroke recurrence, progression of residual stenosis, and restenosis. A total of 46 patients were included: 29 were stented with DES, 12 were stented with BMS and 5 received angioplasty alone with DCB. Technical success was achieved in 100%, 100%, and 60%, respectively (P = 0.008). Residual stenosis was 10.8%, 20.2%, and 51.2%, respectively (P < 0.001). Perioperative complications occurred only in one case in the DES group (P = 1.00). During a mean follow-up of 14.1 months, stroke recurrence rate was 6.9%, 16.7%, and 0% respectively (P = 0.73). Absolute progression of residual stenosis was 10.1%, 34.9%, and -8.0%, respectively (P < 0.001). Restenosis rate was 6.9%, 50.0%, and 20.0%, respectively (P = 0.007). In patients with symptomatic VAOS who failed AMM, stenting with DES shows superiority in the lowering the restenosis rate compared with stenting with BMS. Angioplasty alone with DCB is associated with the slowest progression of stenosis in spite of moderate residual stenosis.

A retrospective study of drug-coated balloon angioplasty for vertebral artery origin stenosis.

Angioplasty using drug-coated balloon (DCB) for treatment of symptomatic vertebral artery origin stenosis (VAOS) is promising, but of uncertain benefit. This study aimed to evaluate the feasibility, safety, and effectiveness of using DCB in the treatment of severe VAOS. This study included 20 patients with severe VAOS treated with DCB alone between April 2018 and December 2019. Vascular death, transient ischemic attack (TIA), and stroke related to the responsible artery within 30days after procedure were recorded as primary endpoints. Restenosis, late TIA, and stroke related to VAOS and satisfied clinical outcome [modified Rankin Scale (mRS) ≤ 2] were documented at follow-up visit as secondary endpoints. Of 20 patients, 16 were performed DCB dilation successfully, and 4 were excluded due to further bailout stenting. After the procedure, no adverse event occurred within 30days. Ten of 16 patients achieved residual VAOS (rVAOS) < 50% (lower rVAOS group), and the remaining 6 patients achieved rVAOS ≥ 50% but < 70% (higher rVAOS group). During follow-up, vertebral artery origin restenosis was detected in 3 (18.8%) of 16 patients by ultrasound. Among the 3 patients with restenosis, 2 were belonged to the higher rVAOS group, which might indicate a tendency that the more severe the residual stenosis, the higher the restenosis rate. All patients had no complaint in the whole follow-up period (median, 7months; InterQuartile Range, 1-18months). Angioplasty using DCB for VAOS may be feasible, safe, and effective. The degree of residual stenosis after using DCB alone may affect the restenosis rate.

Comparison of Drug-Coated Balloons to Bare Metal Stents in the Treatment of Symptomatic Vertebral Artery-Origin Stenosis: A Prospective Randomized Trial

We sought to compare the angiographic and clinical outcomes of drug-coated balloon (DCB) with distal embolic protection devices (EPDs) versus bare metal stent (BMS) without EPD in the treatment of symptomatic vertebral artery origin stenosis (VAOS). Between January 2017 and December 2018, a prospective randomized trial was conducted involving 95 patients with symptomatic VAOS randomly assigned to treatment with DCB+ EPD (n= 49) or BMS without EPD (n= 46). Target vessel restenosis (RS) >50% detected by computed tomography angiography was the primary endpoint. Technical success, clinical success, and signal intensity abnormalities on diffusion-weighted imaging within 3 days after operation were compared. The 30-day technical success rate was 93.9% for DCB group versus 95.7% for the BMS group (P= 0.094). Diffusion-weighted imaging within 3 days postoperative showed asymptomatic embolization in 2 (4.1%) patients in the DCB group and 9 (19.6%) patients in the BMS group (P= 0.004). At a mean 16-month follow-up, the clinical success rate was 89.8% for the DCB group versus 91.3% (42/46) for the BMS group (P= 0.125). The RS was seen in 5/49 (10.2%) in the DCB group and 6/46 (13.0%) in the BMS group (P= 0.082). Target vessel revascularization was performed in 4 (8.7%) BMS group versus 3 (6.1%) in the DCB group (P= 0.091). DCB with EPD in the treatment of symptomatic VAOS is technically feasible and safe and significantly reduced thromboembolic events on imaging when compared with BMS without EPD. There was no significant difference between the 2 groups in the rate of RS during 12 months after surgery.

Editors' Note: Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor

In “Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor,” Teixeira et al. present a CT angiogram (CTA) obtained through right antecubital vein injection that shows intracranial vascular reflux in the cortical veins and pseudopathologic enhancement of the right brain parenchyma in a patient with a right-sided parotid gland tumor who had transient left hemiparesis but had a normal digital subtraction angiogram (DSA) and a normal repeat CTA obtained through left-sided vein injection. The authors initially described the enhancement as being in the distribution of the right middle cerebral artery territory, but they subsequently agreed with Chen et al. that the involvement of the occipital lobe suggests the enhancement pattern is more consistent with the drainage territory of the right superficial cerebral veins. Chen et al. note the mechanism for this finding is unclear and question (1) whether the DSA showed any anomalies in the venous sinuses; and (2) whether the pseudopathologic enhancement could have been related to the fact that the initial injection was performed through a right-sided vein, suggesting there could be severe stenosis of the right brachiocephalic vein. On further review, Teixeira et al. reported the DSA showed a hypoplastic right anterior cerebral artery, occlusion of the right internal jugular vein, and critical stenosis of the right vertebral artery origin. They suspect the patient's symptoms were the result of compression of the right internal carotid artery by the tumor in the setting of right vertebral artery stenosis, which led directly to either compensatory vasodilation or precipitated blood-brain barrier disruption. Although there was also occlusion of the right internal jugular vein, the patent right external jugular vein may have led to rapid spread of contrast into the right hemisphere and retrograde flow into the dilated capillary bed. They postulated that the CTA obtained through left-sided injection was normal because either the patent left internal jugular vein reduced the contrast velocity or vascular autoregulation was reestablished. In “Teaching NeuroImages: Pseudopathologic Brain Parenchymal Enhancement due to Vascular Compression in Parotid Tumor,” Teixeira et al. present a CT angiogram (CTA) obtained through right antecubital vein injection that shows intracranial vascular reflux in the cortical veins and pseudopathologic enhancement of the right brain parenchyma in a patient with a right-sided parotid gland tumor who had transient left hemiparesis but had a normal digital subtraction angiogram (DSA) and a normal repeat CTA obtained through left-sided vein injection. The authors initially described the enhancement as being in the distribution of the right middle cerebral artery territory, but they subsequently agreed with Chen et al. that the involvement of the occipital lobe suggests the enhancement pattern is more consistent with the drainage territory of the right superficial cerebral veins. Chen et al. note the mechanism for this finding is unclear and question (1) whether the DSA showed any anomalies in the venous sinuses; and (2) whether the pseudopathologic enhancement could have been related to the fact that the initial injection was performed through a right-sided vein, suggesting there could be severe stenosis of the right brachiocephalic vein. On further review, Teixeira et al. reported the DSA showed a hypoplastic right anterior cerebral artery, occlusion of the right internal jugular vein, and critical stenosis of the right vertebral artery origin. They suspect the patient's symptoms were the result of compression of the right internal carotid artery by the tumor in the setting of right vertebral artery stenosis, which led directly to either compensatory vasodilation or precipitated blood-brain barrier disruption. Although there was also occlusion of the right internal jugular vein, the patent right external jugular vein may have led to rapid spread of contrast into the right hemisphere and retrograde flow into the dilated capillary bed. They postulated that the CTA obtained through left-sided injection was normal because either the patent left internal jugular vein reduced the contrast velocity or vascular autoregulation was reestablished.

Usage and Efficiency of Drug Eluting Stents in Vertebral Ostial Stenosis

Objectives: Extracranial vertebral artery atherosclerosis is an insidious and hazardous disease. With technological development and accumulating experience, antiproliferative drug eluting stents became a viable option for reducing the instent restenosis of the origin of the vertebral artery. Here, we evaluated the technical success rates, efficiency, clinical and angiographic results of the usage of drug eluting stents in vertebral ostial stenosis. Patients and Methods: 28 stents were implanted in 24 patients with vertebral artery origin stenosis. Digital substraction angiographic or CT angiographic follow-up was made at 6, 12 and 24 months. Results: Paclitaxel eluting stents were placed with high technical success for the treatment of vertebral artery origin stenosis. There was no procedure related mortality. However one patient scummed to death due to aspiration pneumonia for a basiller artery stroke with successful stenting and thrombolysis procedure. There was only one limited subclavian artery dissection in a patient (%4.1) during the procedure which was managed conservatively. One stent (%3.7) had instent restenosis on early period (6th month) and one patient (%4.1) had recurrent neurological symptoms on follow-up (9th month). In a median follow-up of 13 months (6-25 months) none of the patients had late stent thrombosis. Conclusion: Vertebral artery ostial stenosis can be treated effectively and safely with high technical success and low instent restenosis rates with paclitaxel drug eluting stents. With low restenosis rates the antiproliferative drug eluting stents are an option for reducing the vertebral artery instent restenosis.

Paclitaxel Coated Balloon vs. Bare Metal Stent for Endovascular Treatment of Symptomatic Vertebral Artery Origin Stenosis Patients: Protocol for a Randomized Controlled Trial.

Background: Stenting treatment for refractory symptomatic patients with vertebral artery origin stenosis (VAOS) is safe; however, there is a high rate of in-stent restenosis. Although drug-eluting stents can reduce the incidence of restenosis to some extent, there is still a risk caused by stent fracture. Drug-coated balloon (DCB) has been proven to reduce the rate of restenosis in peripheral and coronary artery disease. DCB can prevent inflammation caused by extraneous material stimulation and allow the subsequent treatment that is characteristic of “leave nothing behind.” The purpose of this trial is to compare the efficacy and safety of DCB and bare metal stent (BMS) in the treatment of VAOS.Method/Design: This trial is a 1:1 randomized, controlled, multicenter, non-inferiority trial that compares the DCB to BMS in terms of angiographically assessed target lesion binary restenosis (≥50%) at 12 months in endovascular treatment of symptomatic patients with VAOS.Discussion: A total of 180 patients with symptomatic VAOS who match the trial eligibility criteria will be randomized 1:1 to treatment with DCB (n = 90) or BMS (n = 90). An angiographic core laboratory-adjudicated target lesion binary restenosis (≥50%) at 12 months of follow-up was selected as primary efficacy endpoint to assess the DCB treatment effect. A clinical events committee will assess the safety endpoints of all-cause death, target vessel related transient ischemic attack and ischemic or hemorrhagic stroke events. A data safety monitoring board will periodically review safety data for subject safety, the study conduct, and progress. In this trial, randomization is only allowed after successful pre-dilatation. We anticipate that this trial will provide rigorous data to clarify whether DCBs are beneficial in patients with symptomatic VAOS.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03910166.

Endovascular treatment of a saccular aneurysm associated with fenestrated basilar artery and proximal stenosis of vertebral artery origin - A treatment challenge

A 52-year-old woman had subarachnoid haemorrhage due to an aneurysm at a fenestration of the vertebrobasilar artery junction. The fenestration and aneurysm filled by the dominant left vertebral artery (VA). The left VA had a tight stenosis at its origin from the left subclavian artery. The patient underwent a stent-assisted coiling of the aneurysm after balloon dilatation of the proximal stenosis. The management of this unusual and rare entity is discussed. The relevant literature on the subject is presented.

Drug-coated balloon for vertebral artery origin stenosis: a pilot study

BackgroundDrug-coated balloon (DCB) is a potential treatment for patients with low restenosis risk in vertebral artery origin stenosis (VAOS). However, the clinical data of long-term outcome are limited.ObjectiveTo evaluate the...

Endovascular Treatment of the Vertebral Artery Origin Stenosis by Using the Closed-Cell, Self-Expandable Carotid Wallstent

Retrospective, single-center study between December 2006 and November 2018. There were 72 symptomatic patients refractory to medical management who were treated with a closed-cell, self-expandable carotid Wallstent (Boston Scientific, Marlborough, Mass) of the origin of the vertebral artery. Overall technical success was 100%. Procedure-related complications occurred in 11% (eight) of patients: acute stent thrombosis (three), minor stroke (three), sudden asystole (one), and stent shortening (one). There were no permanent neurologic complications. In-stent stenosis (one) or stent shortening (two) occurred in 6% (3/49) of patients at a mean follow-up of 1 year. Recurrent symptoms of vertebrobasilar insufficiency occurred in 5% (3/57) of patients. Endovascular treatment of symptomatic stenosis at the origin of the vertebral artery using the closed-cell, self-expandable carotid Wallstent is technically feasible and effective in alleviating patient symptoms.

Endovascular treatment of the vertebral artery origin stenosis by using the closed-cell, self-expandable Carotid Wallstent.

Endovascular treatment has been considered a good alternative to surgery for symptomatic vertebral artery origin stenosis (VAOS) due to the high risk of morbidity associated with surgery. The purpose of this study was to evaluate the feasibility and efficacy of insertion of the closed-cell, self-expandable Carotid Wallstent for the treatment of VAOS. The records of 72 patients with VAOS refractory to adequate medication who were treated by endovascular treatment with the Carotid Wallstent from December 2006 to November 2018 were retrospectively evaluated. Of the 72 patients, 43 presented with transient ischemic attacks. Forty-seven patients (65.3%) manifested other brachiocephalic stenoses; of these, 40 patients had occlusion, hypoplasia, or stenosis of the contralateral vertebral artery. Overall technical success (defined as 20% or less residual stenosis) was 100%. Procedure-related complications (n = 8, 11.1%) included sudden asystole (n = 1), acute in-stent thrombosis (n = 3), minor stroke (n = 3), and stent shortening (n = 1). All complications were resolved without permanent neurological deficit. Angiographic follow-up (mean, 13.0months) was achieved in 49 patients and revealed in-stent restenosis in 1 patient (2.0%) and stent malposition by shortening in 2 patients (4.1%). Follow-up records were available in 57 patients (mean 15.6months). Three of the 57 patients (n = 3, 5.3%) had recurrent symptoms of vertebrobasilar ischemia and none was retreated. Endovascular treatment of symptomatic VAOS using the closed-cell, self-expandable Carotid Wallstent is technically feasible and effective in alleviating patient symptoms and for improving vertebrobasilar blood flow.

Safety and Efficacy of Percutaneous Transluminal Angioplasty for Atherosclerotic Stenosis of Vertebral Artery Origin (4218)

Safety and Efficacy of Percutaneous Transluminal Angioplasty for Atherosclerotic Stenosis of Vertebral Artery Origin (4218)

Vertebral Artery to Common Carotid Artery Transposition: 2-Dimensional Operative Video.

Vertebral artery (V1 segment) transposition is a useful technique in the treatment of patients with either proximal subclavian artery stenosis with vertebral "steal" syndrome or severe vertebral artery origin stenosis. This patient required extracranial augmentation of right vertebral artery blood flow to treat proximal vertebral artery stenosis. This was achieved through a V1 to common carotid artery end-to-side anastomosis. The end-to-side anastomosis was performed with the first stitch after the heel stich placed to the inside of the vessel, and the back wall was run from the inside. The anastomosis was completed by running along the front wall from the external surface of the arteries. The anastomosis was flushed by temporary removal of the proximal carotid artery clamp. The anastomotic suture was then tied, and clamps were removed. The patient gave informed consent for surgery and video recording. Institutional review board approval was deemed unnecessary. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Internal Thoracic Artery to Vertebral Artery Bypass Surgery: A Cadaveric Feasibility Study

Posterior circulation strokes account for over one quarter of all ischemic strokes. The frequency of vertebral artery origin stenosis (VAOS) in patients with vertebrobasilar insufficiency (VBI) has been estimated to be as high 26%-32%, and VAOS is the direct cause of posterior circulation strokes in 9% of patients. This association could have a significant genetic component. This study examines the feasibility of the internal thoracic artery (ITA) as a donor vessel for revascularization in patients with VAOS. Ten sides from 5 fresh-frozen white cadaveric necks derived from 3 women and 2 men were used in this study. The mean age of the cadavers at death was 77.2 years (range, 68-88 years). The subclavian artery, vertebral artery, and ITA were dissected. The length and diameter (proximal and distal) of the V1 segment and the length and diameter of the ITA were recorded. Finally, the ITA was transposed to the V1 segment of the vertebral artery (VA1). The mean length of the VA1 and its diameter at the proximal and distal parts were 35.51 and 3.69 mm, respectively. The mean length and diameter of the ITA were 26.53 and 3.27 mm, respectively. Rerouting the ITA to the VA1 was feasible without tension on all sides. This study indicates that the ITA is anatomically and hemodynamically an excellent option for bypass surgery in a VAOS scenario. We present convincing and reproducible data to aid neurosurgeons in choosing the procedure best suited to their patients.

Interrater Agreement for Measurements of Vertebral Artery Origin Stenosis (P4.3-034)

Interrater Agreement for Measurements of Vertebral Artery Origin Stenosis (P4.3-034)

Risk Factors for Restenosis After Stenting or Angioplasty of Vertebral Artery Origin : Results of Short-term and Long-term Follow-up.

Endovascular treatment represents awell-established therapeutic option in patients with vertebral artery origin (VAO) stenosis. Our aim was to determine which factors affect short- and long-term restenosis rates after endovascular VAO therapy. We conducted asingle center analysis of 52patients (36men; age 64 ± 9.54 years) who underwent 55endovascular procedures (27balloon-assisted angioplasty [BAA], 28stent-assisted angioplasty [SAA]) between 2005-2015. We collected data on patients clinical characteristics, medication and post-interventional follow-up visits. Overall, 15of 55vessels (27%) showed ≥70% restenosis at 1year (short-term follow-up) and 18after amean follow-up of 52.9 ± 31.8months (long-term). BMI ≥ 25 kg/m2 was associated with ≥70% restenosis in short-term (P = 0.014) and long-term (P = 0.003) follow-up. Other risk factors, namely, hypertension, ischemic heart disease, smoking, diabetes mellitus, hypercholesterolemia, atrial fibrillation, CRP (>5 mg/l) or pre-treatment antiplatelet administration, statin intake and platelet count, were not associated with restenosis risk in the entire cohort or in patients in the BAA group (all P > 0.05). BMI (P = 0.003) and ischemic heart disease (P = 0.041) were, in turn, associated with restenosis risk in the long-term follow-up in the SAA group. Patients undergoing BAA developed less frequently (P = 0.032) restenosis (18%) during long-term follow-up as compared to patients treated by stenting (46%). BMI ≥ 25 kg/m2 increases the odds for ≥70% restenosis of VAO while ischemic heart disease represents an additional risk factor in stented patients. Further studies are required to established therapeutic strategies lowering the restenosis rates in overweight individuals after VAO therapy, especially ones undergoing stenting.

First Report of Drug-Coated Balloon Angioplasty for Vertebral Artery Origin Stenosis

A 65-year-old woman presented with a 2-month history of unexplained dizziness, vertigo, nausea, and vomiting. She had a more than 10-year history of essential hypertension with her blood pressure kept in a normal range by medications. Her neurological examination was unremarkable. Computed

Stroke due to large vessel atherosclerosis: Five new things.

Extracranial (EC) and intracranial (IC) large vessel atherosclerosis account for about 20% of ischemic stroke cases. In recent years, new treatments have emerged for treatment of both EC and IC disease. The stroke rate in patients with carotid stenosis is decreasing with modern medical therapy. For patients with asymptomatic stenosis, the stroke rate is likely <1% per year. Some subsets of patients with symptomatic carotid disease benefit less from revascularization, and medical management can be considered in these patients. A second clinical trial has confirmed that aggressive medical management is the treatment of choice for IC atherosclerotic disease. Vessel wall imaging may be useful to define pathophysiology in patients with IC stenosis and could ultimately help tailor therapy, but further studies are needed. Medical therapy is preferred to stenting for patients with vertebral artery-origin stenosis. Recent data and emerging concepts regarding large vessel atherosclerosis are provided.

Diagnostic ability of 3-dimensional contrast-enhanced MR angiography in identifying vertebral basilar artery stenosis

BackgroundVertebral-basilar artery stenosis is associated with posterior circulation infarction. So correct detection of vertebral basilar artery stenosis is very important. Studies concerning the sensitivity and specificity of 3-dimensional contrast enhanced MR angiography (3D-CE-MRA) in detecting vertebral basilar artery stenosis is generally lacking. MethodsRetrospectively reviewed the imagines of consecutive one hundred and forty-nine Chinese patients with ischemic stroke or vertigo/dizziness who underwent 3D-CE-MRA and DSA. DSA and CE-MRA images were studied separately and to determine the presence of mild, moderate, or severe stenosis of the vertebral-basilar arteries. Analysis combined with vascular origin image was applied when evaluating the vertebral artery origin stenosis. Sensitivity, specificity, positive and negative predictive values, and the accuracy of 3D-CE-MRA in detecting and grading of vertebral-basilar artery stenosis were calculated. ResultsCompared with DSA, sensitivity, specificity and accuracy of 3D-CE-MRA in detecting of vertebral artery origin ≥70% stenosis or occlusion was 97.1%, 77.4% and 81.9%, but diagnostic consistency was poor (K=0.59); Analysis combined with vascular origin images, the specificity (97.8%), accuracy (92.9%) and consistency (K=0.826) was significantly improved. Conclusions3D-CE-MRA is a sensitive and noninvasive technique for the detection of vertebral artery origin stenosis. Furthermore, analysis combined with vascular origin image would improve the diagnostic accuracy.