Vertebral artery revascularization
- Mark D Morasch, MD, FACS, RPVI
Mark D Morasch, MD, FACS, RPVI
- Director, Division of Vascular Surgery
- Billings Clinic
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Many pathologic processes, including atherosclerosis, trauma, fibromuscular dysplasia, dissections, and aneurysm, among others, can lead to symptoms referable to the vertebral artery. Atherosclerotic vertebral artery disease is often under-diagnosed as a cause of posterior circulation ischemia because of the frequently vague nature of patient presentation. Clinicians may be reluctant to pursue pathologic diagnosis or to recommend treatment, but revascularization of the vertebral artery should be considered in symptomatic patients for whom medical therapy has failed. Intervention is not indicated in asymptomatic patients.
Both surgical and endoluminal approaches are options for treating vertebral artery pathology, with the choice between the two often determined by the anatomic location of the lesion. Clinicians must carefully balance the risks of surgery versus the limitations of endoluminal intervention before proceeding. Open techniques for revascularization of the vertebral artery have proven clinical durability and acceptable surgical morbidity in experienced hands. Endovascular techniques, which have gained momentum over the past decade, are clinically feasible but have yet to deliver on durability benchmarks set by open surgical revascularization. As such, vertebral artery stenting should be reserved for select centers with high-volume experience that have established acceptable outcomes in both clinical success and safety.
The indications for, evaluation and preparation of, and methods of vertebral artery revascularization are reviewed here.
The vascular supply to the brain is divided into the anterior and posterior circulations originating from the carotid and vertebral arteries, respectively (figure 1). The circle of Willis connects the anterior and posterior circulations, but is completely intact and symmetric in only about 20 percent of individuals . The anatomic variability of the collateral circulation helps explain the variability of clinical presentations of patients with vertebral artery disease.
The vertebral arteries most commonly originate from the subclavian arteries. They originate directly from the aortic arch in 3 to 5 percent of individuals . The vertebral arteries are commonly asymmetric in diameter and it is not uncommon for one vertebral artery to be atretic, a finding that is slightly more common on the left than the right . In some patients, an atretic vertebral artery can perfuse an isolated ipsilateral posterior inferior cerebellar artery.
- Fabian TC. Blunt cerebrovascular injuries: anatomic and pathologic heterogeneity create management enigmas. J Am Coll Surg 2013; 216:873.
- Cavdar S, Arisan E. Variations in the extracranial origin of the human vertebral artery. Acta Anat (Basel) 1989; 135:236.
- Biffl WL, Moore EE, Elliott JP, et al. Blunt cerebrovascular injuries. Curr Probl Surg 1999; 36:505.
- Morasch MD, Phade SV, Naughton P, et al. Primary extracranial vertebral artery aneurysms. Ann Vasc Surg 2013; 27:418.
- Greer LT, Kuehn RB, Gillespie DL, et al. Contemporary management of combat-related vertebral artery injuries. J Trauma Acute Care Surg 2013; 74:818.
- Flossmann E, Rothwell PM. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain 2003; 126:1940.
- Cartlidge NE, Whisnant JP, Elveback LR. Carotid and vertebral-basilar transient cerebral ischemic attacks. A community study, Rochester, Minnesota. Mayo Clin Proc 1977; 52:117.
- Heyman A, Wilkinson WE, Hurwitz BJ, et al. Clinical and epidemiologic aspects of vertebrobasilar and nonfocal cerebral ischemia. In: Vertebrobasilar Arterial Occlusive Disease, Berguer R, Bauer RB (Eds), Raven Press, New York 1984. p.27.
- Whisnant JP, Cartlidge NE, Elveback LR. Carotid and vertebral-basilar transient ischemic attacks: effect of anticoagulants, hypertension, and cardiac disorders on survival and stroke occurrence--a population study. Ann Neurol 1978; 3:107.
- Jones HR Jr, Millikan CH, Sandok BA. Temporal profile (clinical course) of acute vertebrobasilar system cerebral infarction. Stroke 1980; 11:173.
- MCDOWELL FH, POTES J, GROCH S. The natural history of internal carotid and vertebral-basilar artery occlusion. Neurology 1961; 11(4)Pt2:153.
- Patrick BK, Ramirez-Lassepas M, Synder BD. Temporal profile of vertebrobasilar territory infarction. Prognostic implications. Stroke 1980; 11:643.
- Caplan LR, Wityk RJ, Glass TA, et al. New England Medical Center Posterior Circulation registry. Ann Neurol 2004; 56:389.
- Bauer R.. Mechanical compression of the vertebral arteries. In: Vertebrobasilar Arterial Occlusive Disease: Medical and Surgical Management, Berguer R, Bauer R (Eds), Raven Press, New York 1984. p.45.
- Ruotolo C, Hazan H, Rancurel G, Kieffer E. Dynamic arteriography. In: Vertebrobasilar Arterial Disease, Berguer R, Caplan L (Eds), Quality Medical, St. Louis 1992. p.116.
- Berguer R, Higgins R, Nelson R. Noninvasive diagnosis of reversal of vertebral-artery blood flow. N Engl J Med 1980; 302:1349.
- Ramirez CA, Febrer G, Gaudric J, et al. Open repair of vertebral artery: a 7-year single-center report. Ann Vasc Surg 2012; 26:79.
- Berguer R. Complex Carotid and Vertebral Revascularizations. In: Vascular Surgery in the Endovascular Era, Pearce WH, Matsumura JS, Yao JST (Eds), Greenwood Academic, Evanston 2008. p.344.
- Berguer R, Morasch MD, Kline RA. A review of 100 consecutive reconstructions of the distal vertebral artery for embolic and hemodynamic disease. J Vasc Surg 1998; 27:852.
- Berguer R, Flynn LM, Kline RA, Caplan L. Surgical reconstruction of the extracranial vertebral artery: management and outcome. J Vasc Surg 2000; 31:9.
- Stayman AN, Nogueira RG, Gupta R. A systematic review of stenting and angioplasty of symptomatic extracranial vertebral artery stenosis. Stroke 2011; 42:2212.
- Radak D, Babic S, Sagic D, et al. Endovascular treatment of symptomatic high-grade vertebral artery stenosis. J Vasc Surg 2014; 60:92.
- Antoniou GA, Murray D, Georgiadis GS, et al. Percutaneous transluminal angioplasty and stenting in patients with proximal vertebral artery stenosis. J Vasc Surg 2012; 55:1167.
- Henry M, Polydorou A, Henry I, et al. Angioplasty and stenting of extracranial vertebral artery stenosis. Int Angiol 2005; 24:311.
- Stone GW, Ellis SG, Cox DA, et al. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med 2004; 350:221.
- Vajda Z, Miloslavski E, Güthe T, et al. Treatment of stenoses of vertebral artery origin using short drug-eluting coronary stents: improved follow-up results. AJNR Am J Neuroradiol 2009; 30:1653.
- Ogilvy CS, Yang X, Natarajan SK, et al. Restenosis rates following vertebral artery origin stenting: does stent type make a difference? J Invasive Cardiol 2010; 22:119.
- Langwieser N, Buyer D, Schuster T, et al. Bare metal vs. drug-eluting stents for extracranial vertebral artery disease: a meta-analysis of nonrandomized comparative studies. J Endovasc Ther 2014; 21:683.
- Werner M, Bräunlich S, Ulrich M, et al. Drug-eluting stents for the treatment of vertebral artery origin stenosis. J Endovasc Ther 2010; 17:232.
- Fields JD, Petersen BD, Lutsep HL, et al. Drug eluting stents for symptomatic intracranial and vertebral artery stenosis. Interv Neuroradiol 2011; 17:241.
- Chen X, Huang Q, Hong B, et al. Drug-eluting stent for the treatment of symptomatic vertebral origin stenosis: Long-term results. J Clin Neurosci 2011; 18:47.
- Park MS, Fiorella D, Stiefel MF, et al. Vertebral artery origin stents revisited: improved results with paclitaxel-eluting stents. Neurosurgery 2010; 67:41.
- Edgell RC, Yavagal DR, Drazin D, et al. Treatment of vertebral artery origin stenosis with anti-proliferative drug-eluting stents. J Neuroimaging 2010; 20:175.
- Lin YH, Hung CS, Tseng WY, et al. Safety and feasibility of drug-eluting stent implantation at vertebral artery origin: the first case series in Asians. J Formos Med Assoc 2008; 107:253.
- Akins PT, Kerber CW, Pakbaz RS. Stenting of vertebral artery origin atherosclerosis in high-risk patients: bare or coated? A single-center consecutive case series. J Invasive Cardiol 2008; 20:14.
- Boulos AS, Agner C, Deshaies EM. Preliminary evidence supporting the safety of drug-eluting stents in neurovascular disease. Neurol Res 2005; 27 Suppl 1:S95.
- Steinfort B, Ng PP, Faulder K, et al. Midterm outcomes of paclitaxel-eluting stents for the treatment of intracranial posterior circulation stenoses. J Neurosurg 2007; 106:222.
- Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet 2001; 357:1729.
- Compter A, van der Worp HB, Schonewille WJ, et al. VAST: Vertebral Artery Stenting Trial. Protocol for a randomised safety and feasibility trial. Trials 2008; 9:65.
- Coward LJ, Featherstone RL, Brown MM. Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis. Cochrane Database Syst Rev 2005; :CD000516.
- Jenkins JS, Patel SN, White CJ, et al. Endovascular stenting for vertebral artery stenosis. J Am Coll Cardiol 2010; 55:538.
- SSYLVIA Study Investigators. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke 2004; 35:1388.
- Compter A, van der Worp HB, Schonewille WJ, et al. Stenting versus medical treatment in patients with symptomatic vertebral artery stenosis: a randomised open-label phase 2 trial. Lancet Neurol 2015; 14:606.
- CRAWFORD ES, DE BAKEY ME, FIELDS WS. Roentgenographic diagnosis and surgical treatment of basilar artery insufficiency. J Am Med Assoc 1958; 168:509.
- Berguer R, Andaya LV, Bauer RB. Vertebral artery bypass. Arch Surg 1976; 111:976.
- Clark K, Perry MO. Carotid vertebral anastomosis: an alternate technic for repair of the subclavian steal syndrome. Ann Surg 1966; 163:414.
- Roon AJ, Ehrenfeld WK, Cooke PB, Wylie EJ. Vertebral artery reconstruction. Am J Surg 1979; 138:29.
- Berguer R. Distal vertebral artery bypass: technique, the "occipital connection," and potential uses. J Vasc Surg 1985; 2:621.
- Berguer R. Suboccipital approach to the distal vertebral artery. J Vasc Surg 1999; 30:344.
- Carney A, Anderson E. Carotid distal vertebral bypass for carotid artery occlusion. Clin Electroencephalogr 1978; 9:105.
- Corkill G, French BN, Michas C, et al. External carotid-vertebral artery anastomosis for vertebrobasilar insufficiency. Surg Neurol 1977; 7:109.
- Geng X, Hussain M, Du H, et al. Comparison of self-expanding stents with distal embolic protection to balloon-expandable stents without a protection device in the treatment of symptomatic vertebral artery origin stenosis: a prospective randomized trial. J Endovasc Ther 2015; 22:436.
- He Y, Bai W, Li T, et al. Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion. Ann Vasc Surg 2014; 28:386.
- Coleman DM, Obi A, Criado E, et al. Contemporary outcomes after distal vertebral reconstruction. J Vasc Surg 2013; 58:152.
- Lin YH, Liu YC, Tseng WY, et al. The impact of lesion length on angiographic restenosis after vertebral artery origin stenting. Eur J Vasc Endovasc Surg 2006; 32:379.
- Kim SR, Baik MW, Yoo SH, et al. Stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery origin and treatment with the stent-in-stent technique. Report of two cases. J Neurosurg 2007; 106:907.
- ANATOMIC CONSIDERATIONS
- VERTEBROBASILAR DISEASE
- Mechanisms of ischemia
- - Hemodynamic
- - Embolism
- INDICATIONS FOR REVASCULARIZATION
- History and physical
- - Vascular imaging
- - Cerebral imaging
- Cardiac evaluation
- - Open surgery versus endovascular treatment
- - Approach by segment
- Open surgical repair
- - Vertebral artery transposition
- - Distal vertebral artery bypass
- Endovascular treatment
- SUMMARY AND RECOMMENDATIONS