the vertebral artery a forgotten vessel - mac conference...
TRANSCRIPT
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 ?