The Vertebral Artery

A Forgotten Vessel ?

MAC 6th Munich Vascular Conference ■ 2016

K. Mathias

Clinical and Interventional Angiology

Asklepios Klinik St. Georg Academic Teaching Hospital of Hamburg/ Germany

Disclosures

Nothing to disclose in regard

to this presentation.

• Prevalence of 20 to 40% in pts with CVD

Incidence of VA Disease

• May account to up to 20% of all

posterior circulation strokes

• 35% pts with VB TIAs will suffer

a stroke within 5y

• clinical symptoms less characteristic

• localization of stenosis more variable

• condition of contra-lateral VA important

• compensatory collaterals from the anterior

circulation and neck arteries

• hemodynamic or embolic problem?

• compression by bony spurs

• no standardized surgical procedure

Why is VA disease more complicated

than ICA disease?

Broad Spectrum of Vertebro-basilar Symptoms

Typical symptoms • tinnitus

• dysphagia

• dysarthria

• drop attacks

• ataxia

• homonymous

hemianopsia

• dizziness

• vertigo

• diplopia

• perioral numbness

• alternating paresthesia

• mental status changes

Two Main Mechanisms

• hemodynamic impairment:

stenosis of the VA associated with

occlusion, hypoplasia, stenosis or

absence of the contralateral VA

• artery-to-artery embolism:

cardiac sources excluded

New England Posterior Circulation

Registry (407 consecutive pts evaluated)

• artery-artery embolism 25%

• hemodynamic impairment 16%

Two Main Mechanisms

Wityk et al. Arch Neurol 1998

In patients with proven VBD with at least

50% stenosis

• pts without distal flow compromise

carry low risk of recurrent strokes on

medical treatment (2.5% vs 30% stroke/y)

Amin-Hanjani et al. Stroke 2005

Stroke Risk of VA Stenosis

Rarer Causes of Ischemia

• extrinsic compression

• repetitive trauma

• fibromuscular dysplasia

• aneurysm

• dissection

VA segments

Where is the lesion located?

• V1 prevertebral 70%*

• V2 intertransverse 5%

• V3 atlanto-axial 4%

• V4 intracranial 21%

*Own figures 1990-2012

Where is the lesion located?

44 yo man bilateral VA occlusion

right proximal

VA occluded left distal VA

occluded

hypoperfusion of brainstem,

cerebellum, and occipital lobes

What are Good Indications for Tx?

• only symptomatic pts

• contra-lateral VA compromised

hypoplasia

stenosis/occlusion

ending in PICA

• V1 stenosis = ostial stenosis

• V4 stenosis = intracranial stenosis

What are the tx options

• vascular surgery

• spine surgery

• endovascular intervention

E.B. f-79 y

left VA stenosis 80%

stent AVE

dilatation 4.0 mm

Left VA

Hemodynamic & Embolic Disease

P.P. m-55

brain stem symptoms

P.P. m-61

brain stem

symptoms

HercuLink 5.0 mm

Left VA

steep angle

between VA & SA stent protrusion

often unavoidable

Buddy Wire Technique

H.M. m-68

vertigo

Aberrant Origin of Left VA

High degree stenosis of left VA

and moderate stenosis of right VA

HercuLink Stent

B.F. f-56 y

smoker

hyperlipidemia

vertigo

TIA right hemisphere

right VA occluded?

More than one artery affected ...

Strategy in Multiple Vessel Disease

- Treating more than one lesion

at a time?

- Where to begin with?

- No rule

- Individual decision

- First symptomatic artery ?

Maverick 2.75 / 9 Neuroform 2x 4 / 15

V4- and Basilar Artery Stenosis

HercuLink 8x5 mm

First Step ...

B.F. f- 56 y

AccuLink 6-8x40 mm

B.F. f-56 y

Second Step ...

And again …

W.H. m-69

small cerebellar

& brainstem

infarction

W.H. m-69

small

cerebrellar &

brainstem

infarction

Right VA ends

at PICA

Dominant left

VA with V4

stenosis

And again …

Never over-dilate

Risk of rupture !!!

And again …

Are there limitations?

• type III aortic arch

• siphon at ostium

• spiral VA

• probing more difficult:

brachial access

• risk of spasm and

dissection

What is the Outcome

• technical success ~95%

• complications 5%

spasm, dissection, occlusion

rupture, stroke

• recurrence rate ~20%/y

• use DES - recurrence rate <10%

• Ogilvy et al. J Invasive Cardiol 2010

35 pts. recurrent stenosis 17%

• Chen et al. J Clin Neurosc 2011

47 pts. recurrent stenosis 5%

• Yu et al. Radiology 2009

10 pts. recurrent stenosis 0%

• Vajda et al. AJNR 2009

48 pts. recurrent stenosis 12%

Do we have DES data ?

Technical success rates 97 - 100%

Peri-procedural morbidity

and 12 months follow up 0.3% risk of death

0.7% risk of stroke

Published data of over 300 procedures

Eberhardt et al. J Vasc Surg 2006

What is the Outcome

Rates of post treatment VB strokes during

a mean f/u of 21 months 1.3%

Review of 993 patients

Stayman et al. Stroke 2011

What is the Outcome

What is still missing

• good registries

• prospective

randomized trials

• BMT is first choice

• VA angioplasty is effective

and safe

• Recurrent disease varies in

publications

• Better long term results with DES

• I treat only symptomatic patients.

Conclusions

Klinische und Interventionelle Angiologie AK St. Georg Hamburg

Metaanalysis 300 VAS*

• combined risk

• mortality 0.3%

• stroke 0.7%

within the first year

What does endovascular

therapy achieve ?

Eberhardt et al. J Vasc Surg 2006

• technical success >95%

• complications <5% - spasm - dissektion - occlusion - rupture - stroke

• recurrence rate ~20%/y

• DE-stents ~10%/y

• DC-balloons unkown

What does endovascular

therapy achieve ?