34 Management of Vertebral Artery Origin Stenosis

Pouya Entezami and John C. Dalfino

Abstract

The vertebral artery origin is a common site of posterior circulation atherosclerosis. Ischemia in the posterior fossa is typically secondary to emboli from the plaque, rather than hemodynamic compromise. Common risk factors include hypertension, smoking, and coronary artery disease. However, data of this disease are limited due to the difficulty of imaging this area with noninvasive methods. Evidence suggests that asymptomatic vertebral artery origin stenosis (VAOS) generally follows a benign natural history. In patients with symptoms of posterior fossa hypoperfusion—which is itself a difficult diagnosis to make—the VAOS can be addressed via medical therapies, including blood pressure management, statins, and antiplatelet or anticoagulant medications. For patients with high-grade lesions or those with VAOS refractory to medical therapy, surgical revascularization remains an option. Both open surgical bypass (by either transposition or endarterectomy) and endovascular therapy (angioplasty with or without stent placement) are options. The percutaneous options are often difficult due to the lack of dedicated endovascular devices for the posterior circulation, relying on tools designed for the carotid or cardiac circulations to perform these procedures. Nevertheless, VAOS remains a common manifestation of peripheral arterial disease, with a relative paucity of data surrounding it as compared to stenosis of the anterior circulation vasculature.

Key words

angioplasty - endovascular therapy - posterior circulation - stent placement - vertebral artery stenosis

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