Vertebral Artery Stenosis Management

Initial Assessment and Diagnosis

• The American Heart Association recommends evaluating patients for symptoms suggesting posterior circulation ischemia, including vertigo, diplopia, ataxia, bilateral sensory deficits, and syncope 3
• The American College of Cardiology recommends MRA or CTA rather than ultrasound for evaluation of vertebral arteries in patients with suspected posterior cerebral or cerebellar ischemia 4
• Catheter-based contrast angiography can be useful when noninvasive imaging fails to define the location or severity of stenosis in patients who may be candidates for revascularization, according to the American Heart Association 4

Medical Management

• The American College of Cardiology recommends antiplatelet therapy as the cornerstone of management for vertebral artery stenosis, with aspirin (75-325 mg daily) as first-line therapy 1, 2, 5
• For patients with aspirin contraindications, the American Heart Association suggests clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) as reasonable alternatives 4
• The combination of aspirin plus extended-release dipyridamole has shown benefit in reducing vertebrobasilar territory stroke or TIA compared to placebo, according to the American Heart Association 1, 6
• Anticoagulation is generally recommended for at least 3 months for patients with acute ischemic syndromes involving the vertebral artery territory with angiographic evidence of thrombus in the extracranial portion, according to the American College of Cardiology 1, 6, 7

Revascularization Considerations

• Revascularization (surgical or endovascular) should be considered only when medical therapy fails to control symptoms, according to the American Heart Association 6
• Endovascular treatment (angioplasty and stenting) has associated risks, including death (0.3%), periprocedural neurological complications (5.5%), and posterior stroke (0.7%), as reported by the American College of Cardiology 6, 7
• Restenosis occurs in approximately 26% of proximal vertebral artery interventions, according to the American Heart Association 1, 2
• Surgical options include trans-subclavian vertebral endarterectomy, transposition of the vertebral artery to the ipsilateral common carotid artery, and reimplantation of the vertebral artery, as suggested by the American College of Cardiology 1, 6

Special Considerations

• For subclavian steal syndrome, the American College of Cardiology recommends extra-anatomic carotid-subclavian bypass in the absence of clinical factors predisposing to surgical morbidity or mortality, and percutaneous endovascular angioplasty and stenting for patients at high risk of surgical complications 5
• Monitoring for recurrent symptoms and considering serial noninvasive imaging to assess progression of atherosclerotic disease is recommended by the American Heart Association 4