Bare Metal vs. Drug-Eluting Stents for Extracranial Vertebral Artery Disease: A Meta-Analysis of Nonrandomized Comparative Studies

Percutaneous Transluminal Angioplasty for Atherosclerotic Stenosis of Vertebral Artery Origin

Background: In patients with vertebral artery origin (VAO) stenosis and concomitant stenoses of other cerebral feeding arteries, data on the risk of percutaneous transluminal angioplasty (PTA) alone and with stent placement (PTAS) for VAO stenosis are limited. We aimed to determine how the presence of polystenotic lesions in other cerebral feeding arteries and concomitant carotid artery stenting (CAS) affect the periprocedural risk and long-term effect of PTA/S for atherosclerotic VAO stenosis. Methods: In a retrospective descriptive study, consecutive patients treated with PTA/S for ≥70% VAO stenosis were divided into groups with isolated VAO stenosis and multiple stenoses. We investigated the rate of periprocedural complications in the first 72 h and the risk of restenosis and ischemic stroke (IS)/transient ischemic attack (TIA) during the follow-up period. Results: In a set of 66 patients aged 66.1 ± 9.1 years, polystenotic lesions were present in 56 (84.8%) patients. 21 (31.8%) patients underwent endovascular treatment for stenosis of one or more other arteries in addition to VAO stenosis (15 underwent CAS). During the periprocedural period, no patient suffered from an IS or died, and, in the polystenotic group with concomitant CAS, there was one case of TIA (1.6%). During a mean follow-up period of 36 months, we identified 8 cases (16.3%) of ≥50% asymptomatic VA restenosis, and, in the polystenotic group, 4 (8.9%) cases of IS. Conclusion: The presence of severe polystenotic lesions or concomitant CAS had no adverse effect on the overall low periprocedural risk of PTA/S of VAO stenosis or the risk of restenosis during the follow-up period.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

The morphology of occlusion stump for endovascular recanalization in non-acute vertebral ostial occlusion

PURPOSE

Non-acute vertebral ostial occlusion (VOO) is a debilitating condition with significant mortality and morbidity rates. However, currently, there is no consensus on the optimal treatment strategy for VOO. This study aims to examine the feasibility, effectiveness, and safety of endovascular recanalization in patients with VOO.

METHODS

We conducted a retrospective review of data from 21 consecutive patients with VOO who underwent endovascular recanalization between May 2018 and August 2023. The patients were divided into two groups based on a new angiographic classification proposed by Gao et al. Type I (tapered stump group) included patients with non-acute extracranial vertebral artery ostial occlusion presenting a tapered occlusion stump. Type II (nontapered stump group) consisted of patients with a nontapered occlusion stump. We collected data on recanalization rates, perioperative complications, and follow-up outcomes.

RESULTS

Our analysis included data from a total of 21 patients (22 lesions) with a mean age of 64.6 ± 10.6 years. The technical success rate was 66.7 % (14/21), and the rate of periprocedural complications was 14.3 % (3/21). The success rate of transitioning from the tapered stump group to the nontapered stump group was 90.9 % (10/11) and 40 % (4/10), respectively (P = 0.024). The perioperative complication rate for type I and type II patients was 18.2 % (2/11) and 10 % (1/10), respectively. Among these patients, 18 cases underwent endovascular recanalization using transfemoral access, while 3 patients underwent transradial access after failed transfemoral access, with successful outcomes for two patients.

CONCLUSIONS

This study suggests that endovascular recanalization may offer a safe, effective, and feasible treatment option for VOO patients. Additionally, the proposed angiographic classification may serve as a useful guide in selecting suitable candidates for surgery.

Using drug-coated balloons for symptomatic vertebral artery origin stenosis: A systematic review and meta-Analysis

BACKGROUND

Endovascular stenting has emerged as an effective treatment for patients with symptomatic vertebral artery origin stenosis (VAOS), but the incidence of severe restenosis is concerning. Angioplasty alone with a drug-coated balloon (DCB) is a potential treatment for VAOS. The purpose of this systematic review and meta-analysis was to assess the utility of DCB angioplasty for VAOS.

METHODS

A systematic search of the Medline (PubMed), Embase, CNKI, and Cochrane databases for studies on the treatment of VAOS by DCB angioplasty published in English and Chinese before June 15, 2022 was conducted. Data were extracted using standardized methods. The incidence rates of restenosis, technical success, and perioperative complication in the follow-up period were pooled using Freeman-Tukey double arcsine transformation with random or fixed-effect models. Tests for heterogeneity and publication bias were performed.

RESULTS

A total of seven studies containing 159 patients were included in this review and meta-analysis. The pre-treatment stenosis rate of the vertebral artery in the DCB group ranged from 70.0 % to 86.3 %, and the median follow-up time ranged from 6.0 to 14.1 months. The pooled restenosis incidence was 11.9 % (95 % CI: 3.4 %-23.4 %; I² = 59 %, p = 0.02) during the follow-up period. The pooled technical success rate was 96.6 % (95 % CI: 91.4 %-99.7 %; I² = 37 %, p = 0.14). The overall perioperative complication rate was 2.9 % (95 % CI: 0.3 %-6.9 %; I² = 0 %, p = 0.64). According to the funnel diagram and Egger's test, there was no evidence of publication bias.

CONCLUSION

It is suggested in this review and meta-analysis that angioplasty with DCB may be a potential treatment for VAOS. However, randomized studies including a large representative sample of VAOS patients are needed to validate our findings.

Vertebral Artery Interventions: A Comprehensive Updated Review

Patients with posterior circulation ischemia due to vertebral artery stenosis account for 20 to 25% of ischemic strokes and have an increased risk of recurrent stroke. In patients treated with medical therapy alone, the risk of recurrence is particularly increased in the first few weeks after symptoms occur, with an annual stroke rate of 10 to 15%. Additionally, obstructive disease of the vertebrobasilar system carries a worse prognosis, with a 30% mortality at 2-years if managed medically without additional surgical or endovascular intervention. Percutaneous transluminal angioplasty and stenting of symptomatic vertebral artery stenosis are promising options widely used in clinical practice with good technical results; however, the improved clinical outcome has been examined in various clinical trials without a sufficient sample size to conclusively determine whether stenting is better than medical therapy. Surgical revascularization is an alternative approach for the treatment of symptomatic vertebral artery stenosis that carries a 10-20% mortality rate. Despite the advances in medical therapy and endovascular and surgical options, symptomatic vertebral artery stenosis continues to impose a high risk of stroke recurrence with associated high morbidity and mortality. This review aims to provide a focused update on the percutaneous treatment of vertebral artery stenosis, its appropriate diagnostic approach, and advances in medical therapies.

Effect of a Drug-Eluting Stent vs. Bare Metal Stent for the Treatment of Symptomatic Intracranial and Vertebral Artery Stenosis

Background

For patients with symptomatic intracranial and vertebral artery stenosis who receive endovascular treatment, in-stent restenosis (ISR) is associated with the recurrence of ischemic stroke. This study evaluated a drug-eluting stent (DES) vs. bare metal stent (BMS) for the treatment of symptomatic intracranial and vertebral artery stenosis.

Methods

The trial was a multicenter, 1:1 randomized, prospective feasibility clinical trial with 10 participating centers in China from March 2014 to October 2015. Eligible patients had symptomatic intracranial and vertebral artery stenosis (70%−99%) and had medical drug treatment failure. The primary endpoint was the rate of in-stent restenosis at 180 days of randomization. The secondary endpoint was a composite of the following two outcomes: (1) ischemic stroke or transient cerebral ischemia (TIA) in the same territory as the presenting event (distal to the target lesion) between 30 days and 1 year after randomization and (2) successful stent implantation. The safety outcome was the presence of stroke in any territory and death within 30 days of randomization or adverse events. Group t-tests or Wilcoxon rank-sum tests were used for the intergroup comparison of quantitative data according to the data distribution. The chi-square test or exact probability method was used for the classification data. The Wilcoxon rank-sum test or CMH test was used for the categorical data.

Results

We enrolled 188 patients at 10 medical centers in China (92 assigned to the DES group and 96 to the BMS group). The mean age of the 188 study participants was 61.6 years (range, 38–75 years); 152 participants (80.9%) were male. There were 28 patients (43.8%) with an ISR at 180 days in the BMS group and 10 patients (14.5%) in the DES group [risk difference, 29.3% (95% CI, 14.5%−44.0%); P = 0.001]. The percent of patients with ischemic stroke or TIA in the same territory between 30 days and 1 year was 5.2% (5/96) in the BMS group and 2.2% (2/92) in the DES group [risk difference, 3.0%; (95% CI, −2.3% to 8.2%); P = 0.354]. The percent of patients with successful stent implantation was 99.0% (95/96) in the BMS group and 97.8% (90/92) in the DES group [risk difference, 1.1%; (95% CI, −1.7% to 3.9%); P = 0.584]. In total, five patients (5.2%) in the BMS group and three patients (3.3%) in the DES group [risk difference, 1.9%; (95% CI, −2.3% to 6.1%); P = 0.721] had stroke in any territory and death within the 30-day follow-up. Total adverse events occurred 167 times in 72 patients (75.0%) in the BMS group compared with 114 times in 59 patients (64.1%) in the DES group [risk difference, 10.9%; (95% CI, −0.1% to 21.7%); P = 0.115].

Conclusions

Among patients with symptomatic intracranial arterial stenosis and vertebral artery stenosis, the use of a drug-eluting stent compared with a bare metal stent resulted in a decreased risk of ISR, similar successful stent implantation, and similar adverse events. These findings support the use of a drug-eluting stent for patients with symptomatic intracranial arterial stenosis and vertebral artery stenosis.

Clinical Trial Registration

http://www.chictr.org.cn/showproj.aspx?proj=148272, identifier: ChiCTR2200055925.

Risk factors for in-stent restenosis after vertebral artery stenting of V1 segment: A systematic review and meta-analysis

OBJECTIVE

In-stent restenosis (ISR) remains a challenge in the treatment of vertebral artery V1 segment stenosis. The aim of this meta-analysis is to identify the risk factors of ISR.

METHODS

Studies eligible for inclusion criteria were found in PubMed, Embase, and Cochrane Library databases. Data related to risk factors of ISR were extracted from the included studies, and pooled analysis was performed when data of the same factor were available in ≥2 studies. Dichotomous outcomes were analyzed with odds ratios (OR) and continuous outcomes were analyzed with a weighted mean difference (WMD). The Stata 14.0 program was used for the meta-analysis.

RESULTS

A total of 11 studies involving 1356 patients were included in our analysis. Pooled analyses showed that younger age (p = 0.01; WMD= -1.958; 95% confidence interval [CI], -3.453 to -0.463) and V1 tortuosity (p = 0.004; OR = 4.145; 95% CI, 1.56-11.012) significantly associated with higher risk of ISR in V1 segment stenting. While bare-metal stents, stent diameter and length, diabetes mellitus, coronary artery disease, and smoking were not found to increase ISR rates.

CONCLUSIONS

This meta-analysis showed that young age and V1 tortuosity increase the ISR rates after vertebral V1 segment stenting.

A Comparison of Different Endovascular Treatment for Vertebral Artery Origin Stenosis

OBJECTIVE

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 did not respond to aggressive medical management.

METHODS

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.

RESULTS

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 1 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).

CONCLUSIONS

In patients with symptomatic VAOS who did not respond to aggressive medical management, 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.

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.

Vertebral artery stenosis

Symptomatic vertebral artery stenosis is associated with high risk of early recurrent stroke. Vertebral artery stenosis can be treated with angioplasty and stenting with good technical results. In this review we outline the framework for the diagnosis and management of vertebral artery disease with focus on the emerging benefits of angiography and endovascular interventions.

Validation and comparison of drug eluting stent to bare metal stent for restenosis rates following vertebral artery ostium stenting: A single-center real-world study

BACKGROUND AND PURPOSE

While drug-eluting stents (DES) have been widely applicated in coronary stenosis, uncertainty persists concerning the relative performance and clinical benefit in patients undergoing vertebral artery stenting when compared with a bare metal stent (BMS). We sought to compare in-stent restenosis (ISR) rates of DES and BMS in the treatment of vertebral artery ostium (VAO) stenosis.

MATERIALS AND METHODS

This study analyzed a single-center prospective cohort. Over 1.5-year period (January 2014-June 2015), 137 consecutive patients underwent VAO stenting involving deployment of 76 DES and 74 BMS. Patient demographics, comorbidities, stenosis severity, stent diameters and lengths, periprocedural complications, imaging and duplex ultrasonography follow-up and recurrent symptoms were assessed.

RESULTS

Technical success was achieved in all patients. Mean VAO stenosis at presentation were 82.4 ± 7.2% in the DES group and 83.3 ± 7.5% in the BMS group and were reduced to 12.5 ± 4.5% and 11.3 ± 4.0%. Mean stent diameter was 3.53 ± 0.40 mm in DES and 5.05 ± 0.40 mm in BMS (p < 0.0001). Mean follow-up was 12.3 months for DES and 11.7 months for BMS. The use of DES was associated with significant lower ISR rates compared with BMS (18.4% vs. 31.1%; OR = 2.628, p = 0.021). Recurrent symptoms rates were similar in DES vs. BMS (2.6% vs 2.7%, p = 0.680). Stent type and stent diameter were independent risk factors for ISR (P = 0.026).

CONCLUSION

Our results suggest superior efficacy of deploying DES for the treatment of VAO stenosis with lower ISR rates as compared to BMS, but do not support significant differences in periprocedural risk and recurrent symptoms rate.

Endovascular therapy of subclavian artery occlusive disease involving the vertebral artery origin

Background: While the majority of subclavian artery (SA) lesions are localized in the proximal segment, the evidence in patients with medial SA disease involving the vertebral artery (VA) origin are scarce.

PATIENTS AND METHODS

We retrospectively analyzed all patients who underwent percutaneous revascularization of the SA at our institution.

RESULTS

A total of 196 patients were retrospectively analyzed. The majority of SA lesions (n = 163, 83 %) were located in the proximal segment, whereas 28 lesions (14 %) were located in the medial segment, and only 5 lesions (3 %) involved the distal segment. Procedural success was high for both stenosis (96 %) and occlusion (89 %) and did not differ depending on lesion location. Revascularization techniques in the medial segment included stenting of the SA only (13 patients), additional VA balloon-dilatation (6 patients), and bifurcation stenting of the SA and VA using T-stenting technique (9 patients). Outcome after a median of 12 months showed no significant differences in freedom from restenosis between proximal and medial lesions (90 % vs. 95 %; p = 0.67).

CONCLUSIONS

Endovascular revascularization of SA disease with medial segments involving the VA origin required more complex techniques and showed long-term patency rates comparable to those in lesions located within the proximal SA.

Endovascular Recanalization of Nonacute Symptomatic Vertebral Ostial Occlusion Performed Using a Distal Embolic Protection Device

OBJECTIVE

Endovascular recanalization of symptomatic vertebral ostial occlusion in the nonacute phase has not been well documented. Distal thromboembolic events negatively affect the success of endovascular treatment. We aimed to investigate the feasibility, safety, and outcomes of stenting performed with the use of a distal embolic protection device for patients with symptomatic vertebral ostial occlusion in the nonacute phase.

METHODS

We retrospectively reviewed the data of 7 patients with symptomatic vertebral ostial occlusion despite medical management who underwent stenting performed using a distal embolic protection device between January 2015 and February 2019. The occlusive lesions were predilated with small balloons, followed by placement of distal embolic protection devices and stents sequentially. At last, the protection devices were retrieved. The rate of successful recanalization, perioperative complications, and clinical and angiographic outcomes were analyzed.

RESULTS

The rate of successful recanalization was 100% with all distal embolic protection devices deployed and retrieved. Poststenting angiography showed no significant residual stenosis. There were no major acute thromboembolic events during and after the procedure. There were no recurrent ischemic symptoms after a mean clinical follow-up of 20.6 ± 16.3 months. At 6-month imaging follow-up, repeat vascular images from 5 patients showed asymptomatic restenosis in 1 artery.

CONCLUSIONS

Our single-center preliminary experience indicated that performing stent placement for vertebral ostial occlusion using a distal protection device may be feasible with a high rate of procedural success. However, this strategy should be confirmed in future prospective randomized studies with larger patient numbers.

Angioplasty Using Drug-Coated Balloons in Ostial Vertebral Artery Stenosis

BACKGROUND

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.

METHODS

Retrospective, monocenter case series of 12 patients with ostial vertebral artery stenosis (≥50%) treated with PTA using a drug-coated balloon.

RESULTS

Median age was 69.5 years (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 4.5 mm (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 6.1 months. The clinical outcome was excellent with median mRS scale of 0 (IQR 0-1).

CONCLUSIONS

PTA using drug-coated balloons is feasible and safe in patients with ostial vertebral artery stenosis.

Comparison of drug-eluting and bare metal stents for extracranial vertebral artery stenting

Introduction

Drug-eluting stents of the first (DES I) and second generation (DES II) proved superior to bare metal stents (BMS) in the coronary territory. However, there are limited data on whether they have any advantage over BMS in vertebral artery stenosis (VAS).

Aim

To compare outcomes of DES (DES I, DES II) and BMS in the treatment of symptomatic extracranial VAS.

Material and methods

During 13-year study period (2003–2016), 392 consecutive patients underwent VAS angioplasty in 428 arteries, including implantation of 148 DES (DES I: 21; DES II: 127 lesions), and 280 BMS.

Results

The technical success rates for DES and BMS groups were 96.7% and 94.6% (p = 0.103), with similar periprocedural complication rates (1.4% vs. 2.2%; p = 0.565). VAS degree was reduced from 86 ±9.7 to 2.7 ±5.0% in DES (p < 0.001) and from 84.1 ±9.4 to 4.3 ±6.9% in BMS (p < 0.001). Angiography confirmed in-stent restenosis/occlusion (ISR/ISO) 50–99% in 53 (14.2%) and 21 (5.6%) out of 373 patients (409 arteries) with at least 6-month follow-up. ISR/ISO rates were similar in DES vs. BMS (22.8% vs. 19.4%; p = 0.635), as well as in DES I vs. DES II (6/19; 31.6% vs. 25/92; 27.2%, p = 0.325). Stainless steel (24/135; 17.8%) and cobalt-chromium (23/121;19%) BMS had significantly lower incidence of ISR/ISO, as compared to platinum-chromium (7/18; 38.9%), p = 0.034. ISR/ISO was associated with age (p = 0.01) and CRP level > 5 mg/l (p = 0.043), while greater stent length was associated with ISR only in the DES group (p = 0.024).

Conclusions

Our results do not support significant differences in ISR/ISO rates between DES and BMS, although differences between particular stent types and ISR rates require further investigation.

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.

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

OBJECTIVE

The 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 vertebral artery ostium stenosis (VAOS).

METHODS

420 consecutive patients treated with VAOS stents (from a population of 8145 patients with VAOS) from January 2013 to December 2014 were analyzed in this retrospective study; 216 with drug eluted stents and 204 with bare metal stents. Based on pre-stent DSA findings, patients were divided into four groups: both carotid and vertebral arteries patent (PAT), ICA occlusion (ICA-OCC), contralateral VA occlusion (CVA-OCC), and combined occlusions (C-OCC). The incidence of ISR (stenosis >50%) was compared between groups using Cox regression analysis.

RESULTS

Of the 420 patients, the mean incidence of ISR was 36.4%, with a median 12 months of follow-up (IQR 3-12). Logistic regression analysis showed that drug eluting stent had less ISR than bare metal stent (OR=0.38, 95% CI 0.19 to 0.75, P=0.01). Cox regression analysis showed that CVA-OCC (HR=1.63, P=0.02) and C-OCC (HR=3.30, P=0.001) were risk factors for ISR but not ICA-OCC (P=0.31). In the CVA-OCC and C-OCC groups, in-stent peak systolic velocity (PSV) ≥140 cm/s, 1 day after successful stenting, was associated with subsequent development of ISR (OR=2.81, 95% CI 1.06 to 7.43, P=0.04).

CONCLUSION

Contralateral VA occlusion at the time of stenting increased the risk of ISR, especially if stent PSV on day 1 was >140 cm/s. Bare metal stents had more ISR than drug eluting stents.

Clinical outcomes and influencing factors of in-stent restenosis after stenting for symptomatic stenosis of the vertebral V1 segment

OBJECTIVE

The objective of this study was to evaluate 30-day and long-term clinical outcomes and influencing factors of in-stent restenosis (ISR) after stenting for symptomatic stenosis of the vertebral V1 segment.

METHODS

The clinical and follow-up data of 301 consecutive patients (mean age, 64 ± 8 years; 252 men) with symptomatic V1 stenosis who underwent stenting at the Fuwai Hospital between January 2010 and June 2016 were collected retrospectively. The 30-day and long-term follow-up of stroke and death after stenting and the recurrence of symptoms, ISR, and repeated revascularization were assessed.

RESULTS

Technical success was 100%. The mean stenosis of lesions was reduced from 82.8% ± 7.6% to 4.4% ± 4.0% immediately after 312 stents (165 bare-metal stents [BMSs] and 147 drug-eluting stents) were implanted. The overall risk of combined any stroke and death was 1.0% (3/301) within 30 days after stenting. The rates of freedom from any stroke and death were 98.2%, 96.8%, and 91.4% at 1 year, 3 years, and 5 years, respectively. After a mean follow-up of 2.9 ± 1.5 years, 46 (15.8%) patients developed ISR, of whom 19 (6.5%) were symptomatic. Twenty-two (7.6%) patients with ISR underwent repeated revascularization. The primary and assisted patency rates were 90.0% and 95.4%, 82.6% and 90.3%, and 80.3% and 87.9% at 1 year, 3 years, and 5 years, respectively. BMS (hazard ratio, 2.02; 95% confidence interval, 1.01-4.06; P < .05) and diabetes (hazard ratio, 1.87; 95% confidence interval, 1.04-3.37; P = .04) were independently associated with an increased risk of ISR.

CONCLUSIONS

Percutaneous stent placement for symptomatic V1 stenosis is safe and associated with a good long-term patency rate. BMS and diabetes are independent predictive factors of ISR.

Simultaneous vertebral and subclavian artery stenting

Introduction

Vertebrobasilar territory ischemia leads to disabling neurological symptoms and may be caused both by vertebral artery (VA) and subclavian artery (SA) stenosis. The coexisting symptomatic ipsilateral VA and proximal SA stenosis should be considered as a true bifurcation lesion for percutaneous treatment.

Aim

To evaluate the safety and efficacy of simultaneous angioplasty of vertebral and subclavian stenosis.

Material and methods

Fifteen patients (age 69.5 years, 46.7% men, all symptomatic from posterior circulation (history of stroke, transient ischemic attack, chronic ischemia symptoms)) were scheduled for simultaneous SA/VA angioplasty. Clinical and duplex ultrasound follow-up was conducted 1, 6 and 12 months after the procedure.

Results

The technical success rate was 100%. Single balloon-mounted stent angioplasty was performed for all VAs and for 13 (86.7%) SAs. In 4 cases a simultaneous radial and femoral approach was required. The mean North American Symptomatic Carotid Endarterectomy Trial (NASCET) VA stenosis was reduced from 88.7 ±9.7% to 5.7 ±6.8% and SA stenosis from 80 ±12.2% to 11 ±12.3% (p < 0.01). No periprocedural death, stroke, myocardial infarction or transient ischemic attack occurred. During follow-up (range: 6–107 months) in 10 of 15 (66.7%) patients relief of chronic ischemic symptoms was observed. No stroke/TIA occurred. One cardiovascular and 2 non-cardiovascular deaths were recorded. There was 1 symptomatic vertebral and 1 subclavian in-stent restenosis, and 2 cases of asymptomatic VA in-stent occlusion occurred.

Conclusions

Simultaneous vertebral and subclavian artery stenting is safe and effective. The restenosis rate remains at an acceptable level and it may be treated successfully with drug-eluting balloon angioplasty. In selected patients a dual radial and femoral approach may facilitate the procedure.

Experience with vertebral artery origin stenting and ostium dilatation: results of treatment and clinical outcomes

Background

The vertebral artery (VA) ostium (VAO) is a common stenosis site. Most patients with VAO stenosis refractory to medical treatment are treated endovascularly using stenting. To optimally cover the ostial plaque, which frequently extends into the adjacent subclavian artery, part of the stent must overhang in the subclavian artery. This configuration makes subsequent VA access very challenging in cases of in-stent or distal vertebrobasilar pathology; it also obstructs the distal subclavian artery.

Objective

To determine whether angioplasty at the ostium with a dual balloon (Flash Ostial) specially designed to allow the subclavian end of the stent to flare might circumvent these problems and, most importantly, provide optimal plaque coverage around the vertebral ostium.

Methods

Between June 2012 and July 2014, 11 patients with symptomatic VAO stenosis refractory to best medical therapy were treated with stenting and dual balloon Flash angioplasty. Demographics, results, and outcomes were reviewed.

Results

A total of 12 VAO stenting–dual balloon angioplasty procedures were performed (mean stenosis, 83.6%; range, 78–90%). Nine patients had mild-to-moderate (40–60%) contralateral VAO stenosis. The initial average modified Rankin Scale (mRS) score was 1.25. In all cases, immediate postangioplasty angiography showed excellent stent apposition against the VA and around the ostium in the subclavian artery. No permanent perioperative complications or deaths occurred. At a mean follow-up of 10.8 months (range 2–24), all patients had symptom resolution and no evidence of symptomatic restenosis on neuroimaging/Doppler studies; the average mRS score was 0.66. Three patients continued to have previously diagnosed mid-cervical VA stenosis; one of them had postprocedure dissection and an asymptomatic in-stent stenosis at 8 months.

Conclusions

Safety and feasibility were demonstrated using the Ostial Flash system for VAO stenting and angioplasty. No permanent perioperative complications were seen.