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

Abstract

SES with EPD in the treatment of symptomatic VAOS is technically feasible and safe, with low rates of ISR and significantly reduced thromboembolic events on imaging when compared to BES without EPD.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting

“…Posterior circulation strokes comprise up to 20–25% of all ischemic strokes, with an associated mortality rate as high as 30% (5, 6). It is estimated that ~20% of these cases involve atherosclerosis of the VA, frequently occurring proximally as it arises from the subclavian artery (7).…”

“…This is due in part to the tortuosity, diameter, and resulting altered hemodynamic flow through the proximal VA (8). VA atherosclerotic disease is often asymptomatic due to the vast collateral blood supply, but distal lodging of atherosclerotic emboli with resulting stroke can be catastrophic (5, 9). Arterio-arterial embolism is the potential mechanism for stroke in 14 to 20% of patients who have occlusive vertebral or basilar artery disease (10).…”

“…EPD use is well described in the endovascular treatment of carotid artery stenosis and is currently mandated by the Centers for Medicare and Medicaid (CMS) for reimbursement in conjunction with carotid artery stenting (3). EPDs have been shown to reduce intraoperative intracranial debris embolization and stroke (3, 5, 13). Cremonesi et al demonstrated successful EPD use in 440 of 442 patients who underwent carotid artery stenting with no peri-procedural deaths reported and an overall complication rate of 3.4% (13).…”

“…While their results showed a technical success rate of 95.5% (63/66 patients) in the EPD group vs. 100% (70/70 patients) without EPD use at 30 days ( p = 0.072), a mean 18-month follow-up yielded a clinical success rate of 93.9% (62/66 patients) in the EPD group vs. 85.7% (60/70 patients) without EPD use ( p = 0.115). Additionally, diffusion weighted imaging at 42 h post-stenting showed two hyperintense lesions in two patients (3.3%) with EPD use vs. 15 lesions in 13 patients (18.6%) without EPD use ( p < 0.01) (5). Similar results and technical success of EPD use in VA stenting have been shown in multiple studies (6, 9, 14, 15).…”

Stenting of symptomatic extracranial vertebral artery stenosis: Is further testing indicated?

“…We included publications from 1999 to 2015 that presented data on the long-term outcomes of patients with significant symptomatic extracranial VA stenosis who underwent either stenting or medical management. [2][3][4][5] Studies with cohort size less than five were excluded. Perioperative complication risk, 30-day event rates, and long-term outcomes such as stroke incidence rate were calculated separately for the stenting and medical management group and compared per data availability.…”