Hybrid Recanalization for Symptomatic Long-Segmental Occlusion Post Vertebral Artery Stenting

A novel angiographic classification for the endovascular recanalization of symptomatic nonacute extracranial vertebral artery occlusion

BACKGROUND

There remains major uncertainty regarding the optimal therapy for symptomatic nonacute extracranial vertebral artery occlusion (EVAO). Endovascular recanalization for EVAO is technically challenging, and limited data are available. This research aimed to report a multicenter clinical experience of endovascular recanalization for symptomatic nonacute EVAO and establish a novel angiographic classification.

METHODS

From June 2011 to December 2019, 50 symptomatic nonacute EVAO patients treated with endovascular recanalization in three regional referral stroke centers were retrospectively analyzed. All patients were categorized into four groups based on the angiographic classification. The rates of technical success, periprocedural complications, any stroke or death within 1 month, and follow-up data were assessed.

RESULTS

The rates of technical success, periprocedural complications, and any stroke or death within 1 month were 86.0% (43/50), 12.0% (6/50), and 4.0% (2/50), respectively. The recanalization rates gradually decreased from Type A to Type D (100%, 94.7%, 80%, and 63.6%, respectively; P=0.007). The EVAO patients in the Type A group with tapered stump and short-segment occlusions showed excellent recanalization effects, with 100% technical success rates and no complications. Conversely, the lowest recanalization rate of 63.6% (7/11) and the highest periprocedural complication rate of 27.3% (3/11) were observed for the Type D group.

CONCLUSIONS

Endovascular recanalization for symptomatic nonacute EVAO is technically feasible, especially Type A EVAO patients, which can provide an alternative treatment option for recurrent vertebrobasilar ischemia despite optimal medical therapy. The angiographic categorization established in this study is conducive to the selection of suitable patients prior to treatment decision.

Hybrid Recanalization for the Treatment of Carotid/Vertebral In-stent Restenosis or Occlusion: Pilot Surgery Experiences From One Single Center

Background : The hybrid recanalization of internal carotid artery (ICA) and vertebral artery (VA) in-stent restenosis or occlusion using a combination of endarterectomy and endovascular intervention has achieved technical success. We present our surgical experiences to further evaluate the safety and efficacy of the hybrid technique for the treatment of in-stent restenosis and occlusion. Methods : A cohort of 12 refractory patients with in-stent restenosis or occlusion who underwent hybrid recanalization, a combination of endarterectomy and endovascular intervention, were retrospectively analyzed. Medical records, including presenting symptoms, comorbidities, contralateral ICA/VA findings, use of antiplatelet drugs, postoperative complications, and angiographic outcomes, were collected. Results : Among 415 consecutive patients with ICA, common carotid artery, and V1 segment lesions, 12 refractory patients (2.89%) with 13 cases were enrolled in our study (1 female and 11 male). All patients underwent successful hybrid recanalization. There were no cases of postoperative stroke or death. Only two patients sustained hoarseness, but it resolved within 2 weeks after surgery. Three patients were treated with dual antiplatelet (aspirin and clopidogrel), seven with single antiplatelet (aspirin), one with single antiplatelet (clopidogrel), and one with single antiplatelet (ticagrelor). All patients were followed up in the outpatient department according to the protocol, with a mean follow-up period of 13 months (range, 6-24 months). No death or recurrent symptoms occurred during the regular follow-up period. Conclusion : The hybrid technique maybe a safe and feasible treatment option to recanalize in-stent restenosis or occlusion with acceptable complications.

Safety and Blood-Flow Outcomes for Hybrid Recanalization in Symptomatic Refractory Long-Segmental Vertebral Artery Occlusion-Results of a Pilot Study

Objective: Hybrid recanalization for vertebral artery (VA) long-segmental occlusion using a combination of ostial vertebral endarterectomy and distal endovascular stenting has achieved technical success. The safety and efficacy of the hybrid technique should be further evaluated.

Methods: We examined a cohort of refractory patients with long-segmental occlusion in the VA and low flow in the basilar artery (BA). The hybrid technique was performed to achieve the recanalization of VA. Angiograms were analyzed for occlusive length, contralateral VA status and collaterals. Clinical variables, including 30-days outcomes and blood-flow changes within 6 months based on quantitative magnetic resonance angiography (qMRA) with non-invasive optimal vessel analysis (NOVA), were collected pre- and post-operatively.

Results: Among 290 consecutive cases with VA initial segment stenosis or occlusion, 14 patients (13 male and 1 female) with symptomatic long-segmental VA occlusion and low flow in the BA were refractory to the best standard medical therapy. The hybrid technique was successful in obtaining recanalization in all but one patient. The mean follow-up period was 17.2 ± 9.2 months. One patient had new ischemic deficits within seven days of the operation. Four patients suffered from transient Horner syndrome postoperatively, but had recovered completely by the 6-months follow-up. Within this period, all revascularization was visible with computed tomography angiography (CTA), and the blood-flow in the BA improved significantly (66.4 ± 15.3 ml/min vs. 104.0±12.9 ml/min, P < 0.05) within 6 months. No ischemic events recurred during follow-up.

Conclusions: The hybrid technique is potentially a safe and feasible method to achieve recanalization and improve hemodynamic compromise for long-segmental VA occlusion.