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Lesion location, stability, and pretreatment management: factors affecting outcomes of endovascular treatment for vertebrobasilar atherosclerosis
  1. Matthew D Alexander1,
  2. Jeffrey M Rebhun2,
  3. Steven W Hetts3,
  4. Anthony S Kim4,
  5. Jeffrey Nelson5,
  6. Helen Kim5,
  7. Matthew R Amans3,
  8. Fabio Settecase3,
  9. Christopher F Dowd3,
  10. Van V Halbach3,
  11. Randall T Higashida3,
  12. Daniel L Cooke3
  1. 1Department of Radiology, University of Washington, Seattle, Washington, USA
  2. 2University of California, Berkeley, California, USA
  3. 3Department of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
  4. 4Department of Neurology, University of California San Francisco, San Francisco, California, USA
  5. 5Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr D L Cooke, Department of Radiology and Biomedical Imaging, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, USA; daniel.cooke{at}ucsf.edu

Abstract

Background and purpose The proper role of endovascular treatment of cervicocerebral atherosclerosis is unclear. Posterior circulation disease has not been investigated as extensively as disease in the anterior circulation. In this study, we characterized the rates of technical success, transient ischemic attack, stroke, and death or disability, for both acute and elective endovascular treatment of atherosclerosis in the vertebrobasilar system.

Methods We identified patients with atherosclerosis of the vertebrobasilar circulation who underwent endovascular intervention at our hospital through retrospective medical record review, and evaluated the association between lesion and treatment features and subsequent stroke, death, or disability at 30 days and 1 year.

Results We identified 136 lesions in 122 patients, including 13 interventions for acute strokes. Technical success was achieved in 123 of 136 cases (90.4%). Elective procedures had higher rates of technical success (6.5% vs 15.4%, p=0.21) and better clinical outcomes. In multivariate analysis, intracranial lesions were associated with more disability (modified Rankin Scale score >2) at 30 days (OR 7.1, p=0.01) and 1 year (OR 10, p=0.03). Patients with non-hypoperfusion related symptoms had fewer strokes at follow-up at 1 year when treated after an asymptomatic interval of >10 days compared with those treated within 10 days of the presenting symptoms (OR 0.2, p=0.03). Statin treatment prior to intervention was associated with favorable outcomes across several examined endpoints. Preoperative antiplatelet treatment was associated with lower rates of disability at 30 days and 1 year (OR 0.1, p<0.01 and OR 0.07, p=0.01, respectively), and preoperative anticoagulation treatment was associated with higher rates of death at 30 days, particularly when prescribed for reasons other than atrial fibrillation (OR 6.4, p=0.01).

Conclusions Endovascular treatment of symptomatic vertebrobasilar atherosclerosis can be performed safely and with good outcomes. Technical results were better for those with extracranial disease while clinical outcomes were more favorable in those patients with non-progressive symptoms in the subacute period and those receiving statin therapy.

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