Vertebral Artery Ostial Stenosis Research Articles

Analysis on the correlation between the occurrence of vertebral artery ostium stenosis and the severity of osteoporosis in elderly patients with atherosclerosis

To analyze the correlation between the occurrence of vertebral artery ostium stenosis (VAOS) and the severity of osteoporosis in elderly patients with atherosclerosis (AS), and disclose the physiopathologic mechanism of the correlation between VAOS and osteoporosis. 120 patients were divided into two groups. The baseline data of both groups were collected. The biochemical indicators of patients in both groups were collected. The EpiData database was established to enter all the data into the database for statistical analysis. There were significant differences in the incidence of dyslipidemia among risk factors of cardia-cerebrovascular disease (P<0.05). LDL-C, Apoa and Apob were significantly lower than the control group (P<0.05). BMD, T-value and Ca in the observation group were significantly lower than the control group, while BALP and serum phosphorus in the observation group were significantly higher than the control group (P<0.05). The more severe the VAOS stenosis, the higher the incidence of osteoporosis, and there was a statistical difference in the risk of osteoporosis among different VAOS stenosis degrees (P<0.05). Apolipoprotein A, B and LDL-C in blood lipids are important factors affecting the development of bone and artery diseases. There is a significant correlation between VAOS and the severity of osteoporosis. The pathological calcification process of VAOS has many similarities with the process of bone metabolism and osteogenesis, and shows preventable and reversible physiological characteristics.

Use of drug-eluting, balloon-expandable resolute onyx coronary stent as a novel treatment strategy for vertebral artery ostial stenosis: Case series.

Vertebral artery (VA) ostial stenosis is notoriously difficult to treat using bare-metal stents owing to high rates of restenosis and stent kinking and breakage. We investigated the safety and effectiveness of treatment with a drug-eluting, balloon-expandable coronary stent (Resolute Onyx, Medtronic). Our prospectively maintained database was retrospectively searched for consecutive patients diagnosed with VA ostial stenosis who underwent Resolute Onyx stenting with/without angioplasty between January 1, 2015 and January 1, 2022. Patient demographics and clinical and radiographic presentations were recorded. Occlusion location, stenosis severity, contralateral disease, devices used, and intraprocedural and postprocedural complications were noted. Outcomes were assessed based on new or recurrent stroke, transient ischemic attack (TIA), or intracranial hemorrhage (ICH). Patients were followed up clinically and with radiographic imaging for in-stent stenosis. Twenty-six patients were included in our study (21 men [80.8%]; mean age 70.3 ± 9.8 years). Symptomatic patients presented with TIA (11/26, 42.3%) and stroke (10/26; 38.5%). Mean stenosis in the study cohort was 74.9 ± 13.0%. One (3.8%) intraprocedural complication was encountered whereby the stent failed to open despite several attempts and was exchanged with a new one without issues. No in-hospital postprocedure stroke, TIA, or mortality was reported. During a mean 16.2 ± 13.6 months' follow up, two patients developed symptomatic in-stent restenosis that was treated with balloon angioplasty. We report the first case series of Resolute Onyx drug-eluting stenting including 30-day postprocedure stroke/TIA rates and clinical/radiographic follow up and demonstrate safe and effective treatment of symptomatic and asymptomatic VA ostial stenosis.

Surgical exposure of the vertebral artery for endovascular access in a hybrid operating room.

Endovascular procedures are a desirable treatment option for neurovascular lesions in posterior circulation. However, endovascular access occasionally fails due to tortuosity of the proximal vertebral artery (VA), aortic arch, and/or VA ostium stenosis. We aimed to describe the creation of endovascular access via surgical exposure of the VA in a hybrid operating room to overcome anatomical difficulties hampering distal access to the VA through the transfemoral or transradial approach. We present six patients with seven posterior circulation lesions in whom distal access via the conventional approach to the VA was impossible. Surgical exposure of the VA was performed to provide endovascular access to these patients. Radiographic characteristics, operative techniques, and outcomes were reviewed. Surgical exposure of the VA was performed in six patients with cerebral aneurysm (n = 4) and symptomatic stenosis of the VA ostium (n = 3). There were four female and two male patients, aged 73-82years. Surgical exposure was usually performed beyond the tortuous segments of the VA. After endovascular access was provided, coil embolization was performed for cerebral aneurysms and/or balloon angioplasty and stenting was performed to treat the VA ostium stenosis. All puncture sites were closed by direct suture using a 7-0 Prolene suture. All procedures were completed without adverse events. Endovascular access via surgical exposure of the VA is a feasible and safe alternative for patients in whom the femoral or radial route does not allow the navigation and stabilization of the guiding catheter into the proximal segment of the VA.

Outcomes of Endovascular Stenting in Symptomatic Vertebral Artery Ostial Stenosis.

Vertebral artery ostial stenosis is implicated in one-fifth of all posterior circulation cerebrovascular accidents. However, uniform treatment guidelines and data on the different treatment modalities are still lacking. Endovascular stenting is an emerging therapy for symptomatic vertebral artery ostial stenosis when medical management fails. This manuscript will examine the safety and efficacy of endovascular revascularization with drug-eluting stents in a series of ten consecutive patients that had failed medical management. We also report the rate of complications and in-stent restenosis, as well as the rate of recurrent cerebrovascular accidents.

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.

Effects of the Vertebral Artery Ostium/Subclavian Artery Angle on In-Stent Restenosis after Vertebral Artery Ostium Stenting

Methods Between January 2016 and October 2018, sixty-four consecutive patients who underwent a total of 66 stenting procedures were screened for symptomatic and asymptomatic atherosclerotic VAOS. Of these patients, 57 had complete follow-up data. The baseline patient demographics and morphological features of the VAO were recorded. Potential factors influencing ISR, including conventional cerebrovascular disease risk factors, were assessed, together with outcome events including recurrent transient ischemic attack (TIA), stroke, and vascular-related mortality. Results The average follow-up period was 13.2 ± 4.6 months. Technical success was achieved in all interventions. The degree of stenosis was reduced from 77.2 ± 6.1% to 13.7 ± 8.9% after the procedure. ISR was detected in eight treated vessels (14.0%) and occlusion in two (5.3%) arteries. Of the 57 patients, one had an ischemic stroke and 5 had TIAs. The angle of the VAO at the subclavian artery was associated with the risk of restenosis (preoperative, P = 0.04; postoperative, P = 0.02). Conclusions Stenting is a feasible and effective treatment for VAOS. The angle of the VAO at the subclavian artery may contribute to the development of ISR.

In-Stent Restenosis of Carotid and Vertebral Arteries Treated by Angioplasty Using a Cutting Balloon: A Case Report.

We treated a patient with internal carotid artery and vertebral artery ostium in-stent restenosis (ISR) treated by cutting balloon (CB) angioplasty. A 79-year-old man developed dizziness and right homonymous upper quadrantanopia. On arrival, magnetic resonance imaging (MRI) revealed acute-stage brain infarction. Angiography demonstrated left internal carotid artery and vertebral artery ostium stenosis (VAOS), which was thought to be related to the infarction. We performed stenting for both lesions, but 5 months later, restenosis occurred. The patient was successfully retreated by CB angioplasty for both lesions. When treating carotid or vertebral artery ISR, plain balloon (PB) and stent-in-stent (SIS) procedures may induce insufficient dilatation, and hamper re-retreatment because of neointimal hyperplasia. Using CB should be considered as an option in such cases.

Optimization technique for stenting of ostial vertebral artery stenosis

Objective ‒ to develop a technique for endovascular treatment of symptomatic ostial stenosis of the vertebral arteries, which allows to minimize risks of delayed stent breakage and restenosis. Materials and methods. This is analysis of prospectively collected data from patients presenting from 2016 to 2019 in the endovascular center of the Dnepropetrovsk Regional Clinical Hospital named after I.I. Mechnikov. One hundred four stents were placed in 99 patients using the author’s complex method, which is based on our modification of Szabo technique. The principles of the method were developed based on a literature review and in vitro tests using 7 silicone models of the initial segments of the subclavian and vertebral arteries with different angles of divergence of the vertebral arteries (30, 45, 60, 90, 120, 135, 150°) and 9 balloon mounted drug-eluting stents with open-cell design Resolute (Medtronic).Results. There were no cases of displacement of the stent proximally or distally during implantation. In all cases, stents were implanted in the affected segment exactly and did not prolapse more than 1 mm beyond the ostium of the vertebral artery into the subclavian artery. There were no «clinical» ischemic complications in the early postoperative period. In 5 cases, isolated subclinical ischemic lessions in the carotid circulation were revealed during one-session stenting of ostial stenosis of the vertebral arteries and carotid stenting. In the posterior circulation, ischemic lessions on MRI in the early postoperative period were not detected in any observations.Conclusions. Developed complex stenting method based on our modification of Szabo technique allows us to achieve optimal long-term results of stenting of symptomatic ostial stenosis of the vertebral arteries.

Minimally Invasive Surgical Repair of Vertebral Artery Ostium Stenosis in Patients with Ischemic Stroke: A Single-Center Case Series

Ischemic stroke is the second leading cause of death in North Macedonia. Posterior circulation disease, caused by vertebral artery (VA) ostium (VAo) stenosis, is a common cause of ischemic stroke. We established a treatment approach using surgical revascularization of posterior circulation disease. In the present observational study, we assessed the outcome after surgical revascularization of the posterior circulation ischemia caused by VAo stenosis. A retrospective analysis of 20 consecutive patients who had undergone surgery from January 2017 to December 2019. The VA was accessed through a 3-cm incision in the upper medial clavicle. The corrective procedures consisted of resection and anastomosis (15 of 20), VA to subclavian artery transposition (16 of 20), endarterectomy (10 of 20), vein graft interposition techniques (4 of 20), and vein graft bypass (1 of 20). The cohort included 9 acute cases. The mean patient age was 66.5 years (range 46-77). Of the 20 patients, 8 were women and 12 were men. Left-sided VA pathology was present in 75% of the cases. We observed rapid clinical improvement in 19 patients (95%). The total study period was 321 patient-months, with a median follow-up of 18 months (interquartile range, 5-24 months). One patient had died of an unknown cause after 12 months. During the follow-up period, 15 patients (75%) had reported permanent clinical improvement with no significant relapse of symptoms. Minimally invasive surgical revascularization of the posterior brain circulation is a clinically effective therapeutic approach to manage ischemia caused by VAo stenosis. It can be performed safely, promote long-lasting symptom relief, and prevent recurrent strokes.

Angioplasty Using Drug-Coated Balloons in Ostial Vertebral Artery Stenosis

Ostial vertebral artery stenosis (OVAS) is a relevant cause of acute ischemic posterior circulation stroke. Percutaneous trans-luminal angioplasty (PTA) might offer a promising treatment modality, but restenosis rate is high. So far, little is known about recanalization using drug-coated balloons (DCB) in OVAS. We aimed to show feasibility and safety of DCB-PTA in OVAS. Retrospective, monocenter case series of 12 patients with ostial vertebral artery stenosis (≥50%) treated with PTA using a drug-coated balloon. Median age was 69.5years (IQR 57-78.5) with a female rate of 41%. Patients were treated either with a SeQuent Please NEO or Neuro Elutax SV DEB. Median preinterventional stenosis degree was 75% (IQR 70-85) with a median lesion length of 4.5mm (IQR 4-7.5). Median postinterventional stenosis degree was 40% (IQR 27-50). All treated vessels remained patent. No major complications such as dissection, vessel perforation, hemorrhage, or ischemic events occurred. Moreover, we did not detect any restenosis during a median follow-up period of 6.1months. The clinical outcome was excellent with median mRS scale of 0 (IQR 0-1). PTA using drug-coated balloons is feasible and safe in patients with ostial vertebral artery stenosis.

Second Generation Drug-Eluting Stents for Endovascular Treatment of Ostial Vertebral Artery Stenosis: A Single Center Experience.

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.

椎骨動脈起始部狭窄に対してSelf-expanding Stent を留置した2 例

椎骨動脈起始部狭窄に対してSelf-expanding Stent を留置した2 例

Arterial occlusions increase the risk of in-stent restenosis after vertebral artery ostium stenting

ObjectiveThe study was designed to investigate if vascular occlusion in the internal carotid artery (ICA) or the contralateral vertebral artery (VA) contribute to developing in-stent restenosis (ISR) in patients with...

Progress of In-stent Restenosis after Vertebral Artery Ostium Stenosis and Imaging Assessments

Progress of In-stent Restenosis after Vertebral Artery Ostium Stenosis and Imaging Assessments

Endovascular therapy for complex ostial vertebral artery stenosis

Objective To investigate the characteristics of endovascular intervention to treat complex ostial vertebral artery stenosis. Methods The 56 patients of complex ostial vertebral artery stenosis were summarized with endovascular treatment by vascular surgery at Xuanwu Hospital of Capital Medical University from 2013 Jun to 2015 Jun. The lesion features of the cases, the success rate of endovascular treatment, relief of postoperative symptoms, and the patency rate were analyzed. Results The complex of vertebral artery lesion was divided into three types: Type Ⅰwas the almost occlude lesion of vertebral artery, Type Ⅱ was the stenting of ostial vertebral artery need upper limb artery approach, and Type Ⅲ was the ostial vertebral artery lesion combined with the subclavian artery stenosis or occlusion. The success rate of endovascular treatment was 92.9%. Postoperative symptom improvement rate was 56.5%. The patency rate was 88.5% after 1 year. Conclusions Predilation could improve the stent success rate to the almost occlude lesion of vertebral artery. Upper limb artery approach could improve the stent success rate of vertebral artery. The vertebral artery should be protected during the procedure of the subclavian artery stenting. Key words: Vertebrobasilar insufficiency/SU; Angioplasty; Vascular surgical procedures; Stents

Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations—Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke

Patients suffering from acute atherothrombotic occlusion of the proximal vertebral artery (VA) and concomitant basilar artery (BA) occlusion present a grim prognosis. We describe our experience in the endovascular recanalization of tandem vertebrobasilar occlusions using endovascular techniques. The BA was accessed through the normal VA (clean-road) or the occluded, thrombotic VA (dirty-road), and stentriever-based thrombectomy was performed using antegrade or reverse revascularization variants. Seven patients underwent successful stentriever-assisted mechanical thrombectomy of the BA and five sustained concomitant VA revascularization. Stroke onset to endovascular intervention initiation (time-to-treatment) ranged from 4.5–13hours (mean 8.6). In two of seven patients, the BA occlusion was approached with a ‘clean-road’ approach via the contralateral VA; in five of seven patients, a ‘dirty-road’ approach via the occluded VA was used. Mean time-to-recanalization was 66minutes (range 55–82). There were no perforations, iatrogenic vessel dissections, or other technical complications. Four patients presented mild-to-moderate disability (modified Rankin Scale [mRS] 0–3) at 3months, one remained with moderate-to-severe disability (mRS 4), and two patients died on days 9 and 23 after their strokes. Follow-up ranged from 6–45months (mean 24months). In selected patients with acute VA-BA occlusion, stentriever-based thrombectomy performed through either the patent or the occluded VA, may be feasible, effective, and safe. Clinical outcomes in these patients seem to equipoise the neurological outcome of patients with successful revascularization for isolated BA occlusion. This unique pair of occlusions confirms the role of VA ostium stenosis as a cause of vertebrobasilar stroke.

Hemodynamics in stented vertebral artery ostial stenosis based on computational fluid dynamics simulations

Hemodynamic factors may affect the potential occurrence of in-stent restenosis (ISR) after intervention procedure of vertebral artery ostial stenosis (VAOS). The purpose of the present study is to investigate the influence of stent protrusion length in implantation strategy on the local hemodynamics of the VAOS. CTA images of a 58-year-old female patient with posterior circulation transient ischemic attack were used to perform a 3D reconstruction of the vertebral artery. Five models of the vertebral artery before and after the stent implantation were established. Model 1 was without stent implantation, Model 2–5 was with stent protruding into the subclavian artery for 0, 1, 2, 3 mm, respectively. Computational fluid dynamics simulations based on finite element analysis were employed to mimic the blood flow in arteries and to assess hemodynamic conditions, particularly the blood flow velocity and wall shear stress (WSS). The WSS and the blood flow velocity at the vertebral artery ostium were reduced by 85.33 and 35.36% respectively after stents implantation. The phenomenon of helical flow disappeared. Hemodynamics comparison showed that stent struts that protruded 1 mm into the subclavian artery induced the least decrease in blood speed and WSS. The results suggest that stent implantation can improve the hemodynamics of VAOS, while stent struts that had protruded 1 mm into the subclavian artery would result in less thrombogenesis and neointimal hyperplasia and most likely decrease the risk of ISR.

Bilateral Occipital Arteries of Internal Carotid Origin: Report of a Case and Review of the Literature.

The present report describes a patient with bilateral occipital arteries of internal carotid origin, which is an extremely rare variation, and left vertebral artery ostial stenosis diagnosed by selective catheterization and digital subtraction angiography.

Commentary: Vertebral Artery Ostial Stenosis Stenting Technique

Commentary: Vertebral Artery Ostial Stenosis Stenting Technique

Comparison of Self-Expanding Stents With Distal Embolic Protection to Balloon-Expandable Stents Without a Protection Device in the Treatment of Symptomatic Vertebral Artery Origin Stenosis

Purpose: To compare the angiographic and clinical outcomes of self-expanding stents (SES) with distal embolic protection devices (EPD) vs balloon-expandable stents (BES) without EPD in the treatment of symptomatic atherosclerotic vertebral artery ostial stenosis (VAOS). Methods: Between July 2011 and March 2013, a prospective randomized trial was conducted involving 127 patients (mean age 67.3±10.2 years; 94 men) with symptomatic VAOS randomly assigned to treatment with SES + EPD (Precise RX or RX Acculink stent + Spider FX EPD; n=61) or BES (Palmaz Blue or Resolute RX; n=66) without EPD. In-stent restenosis (ISR) >50% detected by duplex ultrasound was the primary endpoint. Technical success, clinical success, complications within 30 days, and signal intensity abnormalities on diffusion weighted imaging (DWI) after stenting were compared. Results: The 30-day technical success rate was 95.5% (63/66) for SES+EPD vs 100% (70/70) for BES without EPD (p=0.072). DWI at 24 hours poststenting showed 2 hyperintense lesions in 2 (3.3%) SES + EPD cases and 15 hyperintense lesions in 13 (18.6%) BES patients (p<0.01). At a mean 18-month follow-up, the clinical success rate was 93.9% (62/66) for the SES + EPD group vs 85.7% (60/70) for the BES group (p=0.115). The ISR was seen in 16/70 (22.9%) arteries in the BES group and 2/66 (3.1%) arteries in SES + EPD group (p<0.01). Target vessel revascularization was performed in 7 (10.0%) BES arteries vs none in the SES + EPD group (p<0.01). Conclusion: SES with EPD in the treatment of symptomatic VAOS is technically feasible and safe, with low rates of ISR and significantly reduced thromboembolic events on imaging when compared to BES without EPD.