Review Article
Vertebral Artery Origin Stenosis and its Treatment

https://doi.org/10.1016/j.jstrokecerebrovasdis.2011.05.007Get rights and content

Vertebral artery origin stenosis (VAOS) is a common but underappreciated cause of stroke. It causes as many as 20% of posterior circulation stroke. This article reviews the epidemiology, natural history, and treatment of this condition. We focus on the emerging therapeutic endovascular options and their safety and durability. Finally, we discuss the gaps in the current understanding of VAOS and how best to explore them in the future.

Section snippets

Epidemiology and Pathology

Several influential autopsy and angiographic studies contributed significantly to our understanding of VAOS. Table 1 summarizes the epidemiologic and pathologic characteristics in comparison to carotid and intracranial stenosis. The New England Posterior Circulation Registry of 407 patients included 80 (20%) patients who had VAOS or occlusion. In 32 (9%) of these patients, there were no other causes of stroke.4 If this incidence is representative of the larger population of stroke patients in

Pathophysiology

There is a widespread perception that stroke in the setting of VAOS is caused by “vertebrobasilar insufficiency,” which is hypoperfusion of the posterior circulation. However, the literature points to artery to artery embolism as the cause of most strokes in this setting.

The New England Posterior Circulation Registry classified stroke in the setting of VAOS according to presumed pathophysiology: 49% was probable or possible artery-to-artery embolism; only 16% was thought to be “hemodynamic” in

Natural History

VAOS has long been an underrecognized cause of stroke. This misperception may have arisen in part from early work claiming that vertebral artery occlusion was not only benign, but in certain circumstances, therapeutic for conditions such as refractory epilepsy.14 In 1970, Fisher1 published an article describing 5 patients with bilateral vertebral artery occlusion and recurrent nonspecific symptoms (eg, dizziness and double vision). He concluded that because none of these patients had actually

Open Surgical Treatment

The first surgical correction of vertebral artery stenosis was published by Crawford and De Bakey in 1958.16 The 2 most commonly used surgical techniques are transposition to the common carotid artery and endarterectomy. Other described procedures include: subclavian to V1 bypass grafting, transposition of the V1 to the subclavian or thyrocervical trunk, and carotid to V1 bypass grafts. Intracranial bypass procedures have also been performed by connecting the occipital or superficial temporal

Endovascular Treatment

In 1981, Motarjeme et al18 published the first case of vertebral artery origin angioplasty. Several small case series describing angioplasty of the vertebral artery origin have been published.19, 20, 21, 22

The largest angioplasty-only series was reported by Higashida et al9 in 1993. In this series, 41 patients were treated, 34 of whom had V1 stenosis. There was postangioplasty spasm responding to nitroglycerin in 2 patients, and in 1 patient there was a <30-minute worsening of symptoms. At 6

Technical Description of Endovascular Vertebral Artery Origin Stenosis Treatment

Most procedures are performed using conscious sedation under the supervision of the interventionalist. All patients should be pretreated with dual antiplatelet therapy (aspirin and clopidogrel) according to local protocols. Vascular access (ie, transfemoral, transradial, or transbrachial) varies, but is most commonly transfemoral. Heparin is administered to obtain an activated clotting time 1.5 to 2.0 times the baseline value. A 6F guide catheter is then positioned in the subclavian artery in

Natural History

The natural history of medically treated symptomatic VAOS has not been adequately studied. The few published, medically treated case series and CAVATAS suggest that the risk of recurrent stroke is low, calling into question the need of any intervention. However, the role of contralateral vertebral artery occlusion or hypoplasia and the impact of current, more aggressive medical treatment is not known.8, 15 Therefore, there is a need for prospective evaluation of these patients, ideally in a

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