CORRESPONDENCE: LETTER TO THE EDITOR
Vertebral Artery StentingNot Quite Ready for Prime Time!
Kamal Gupta, MD*
* University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, Kansas 66160 (Email: kamal.gupta{at}sbcglobal.net).
Atherosclerotic vertebral artery (VA) stenosis is a significant cause of vertebrobasilar ischemia. However, vertebral artery stenting (VAS) has not received the detailed scientific study that has been accorded to carotid artery stenting (CAS).
In their series, Jenkins et al. (1) show excellent results. These results add to the growing body of nonrandomized studies that demonstrate the feasibility and relative safety of VAS (2). Based on their outcomes, the authors recommend a more liberal use of VAS. However, several issues remain unresolved that beg for a more cautious approach.
No recent study of sufficient size has investigated the impact of optimal medical regimen on the natural history of VA disease or compared it with VAS (3). Further, there are several unresolved issues regarding optimal endovascular strategy. Bilateral VA stenosis presents a clinical challenge. Unlike anterior circulation ischemia, vertebrobasilar ischemia symptoms are difficult to lateralize to one side. It is not known whether unilateral VAS will resolve the symptoms or whether bilateral VAS is indicated. The authors report that 54.3% patients had bilateral VA disease, although only 6.3% of the subjects received bilateral stents. It is unclear how the stented side was chosen and whether symptoms resolved completely.
Subclavian artery stenosis without coexistent VA stenosis can cause vertebrobasilar ischemia (4). In the current study, 29.2% of the subjects had concurrent subclavian artery disease. It will be useful to know whether the subclavian artery was also stented concomitantly.
The present study did not use distal embolic protection, although this is the standard in CAS. This is an important issue in VAS with only limited data available (5).
Another important issue is restenosis. Unlike CAS, which has a low risk of restenosis, VAS has a significantly higher restenosis rate (6,7). Little information is available regarding the use of drug-eluting stents, although initial reports indicate a lower restenosis rate (8).
Jenkins et al. (1) demonstrate that VAS is relatively safe and feasible. However, before more widespread use, VAS should undergo the same meticulous investigation as CAS has been accorded. This will involve a direct comparison with optimal medical therapy and use of current endovascular standards (distal embolic protection and perhaps drug-eluting stents).
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References
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1. Jenkins JS, Patel SN, White CJ, et al. Endovascular stenting for vertebral artery stenosis J Am Coll Cardiol 2010;55:538-542.[Abstract/Free Full Text]2. Taylor RA, Siddiq F, Memon MZ, et al. Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results Neuroradiology 2009;51:531-539.[CrossRef][Web of Science][Medline] 3. Coward LJ, McCabe DJ, Ederle J, Featherstone RL, Clifton A, Brown MM. Long-term outcome after angioplasty and stenting for symptomatic vertebral artery stenosis compared with medical treatment in the Carotid And Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomized trial Stroke 2007;38:1526-1530.[Abstract/Free Full Text] 4. Gosselin C, Walker PM. Subclavian steal syndrome: existence, clinical features, diagnosis and management Semin Vasc Surg 1996;9:93-97.[Medline] 5. Qureshi AI, Kirmani JF, Harris-Lane P, et al. Vertebral artery origin stent placement with distal protection: technical and clinical results AJNR Am J Neuroradiol 2006;27:1140-1145.[Abstract/Free Full Text] 6. Younis GA, Gupta K, Mortazavi A, et al. Predictors of carotid stent restenosis Catheter Cardiovasc Interv 2007;69:673-682.[CrossRef][Web of Science][Medline] 7. Dabus G, Gerstle RJ, Derdeyn CP, Cross 3rd DT, Moran CJ. Endovascular treatment of the vertebral artery origin in patients with symptoms of vertebrobasilar ischemia Neuroradiology 2006;48:917-923.[CrossRef][Web of Science][Medline] 8. Gupta R, Al-Ali F, Thomas AJ, et al. Safety, feasibility, and short-term follow-up of drug-eluting stent placement in the intracranial and extracranial circulation Stroke 2006;37:2562-2566.[Abstract/Free Full Text]
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