CORRESPONDENCE: LETTER TO THE EDITOR
Reply
J. Stephen Jenkins, MD*
* Ochsner Medical Foundation, Interventional Cardiology Department, 1516 Jefferson Highway, New Orleans, Louisiana 70121 (Email: jsjenk{at}bellsouth.net).
We thank Dr. Gupta for his comments on our paper (1) describing our experience treating symptomatic patients in whom medical therapy had failed with vertebral artery stenting.
We are in complete agreement that this field will benefit from more data and larger clinical trials. Despite the fact that both vertebral arteries supply a single basilar artery, conventional wisdom has been that a single vertebral artery is adequate for posterior circulation perfusion. Clearly there are infrequent clinical exceptions to this rule. Clinical practice has been to preserve the dominant vertebral artery whenever possible.
In our series of patients, coexistent subclavian artery disease was demonstrated in 29.2% of patients, one-half of whom were treated concurrently with a vertebral stent and the other half of whom were hemodynamically insignificant.
There are several reasons for a lack of clinical trial data. One is the unwillingness of providers to pay for vertebral artery stenting or to reimburse for care performed as part of an investigational trial that has benefited carotid stenting significantly. The second issue is that the vertebral arteries are well treated with off-label balloons and stents, which diminish the enthusiasm of medical device manufacturers to support additional investigations.
As mentioned by Dr. Gupta, posterior circulation symptoms are more difficult to localize than anterior circulation symptoms. Patients with medically refractory vertebral basilar symptoms carry a 5-year stroke rate of 30%, and if the disease is intracranial in location, a 1-year stroke rate of 50% far exceeds the risk of anterior circulation disease (2). Posterior circulation strokes account for a minority of ischemic strokes (20% to 25%) (3), making it more difficult to enroll a sufficient number of patients in a clinical trial.
The effect of drug-eluting stents on vertebral artery restenosis and the utility of emboli protection devices have not been studied in the vertebral circulation. Going forward, these are important questions that will need to be answered. Until then, we must do our best to treat patients using the best available data.
The encouraging results of our current series of vertebral stenting, along with those of other single-center series (4,5), strongly support a strategy of percutaneous catheter–based therapy for medically refractory symptomatic patients with posterior circulation ischemia related to vertebral artery disease.
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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. Crawley F, Brown MM. Percutaneous transluminal angioplasty and stenting for vertebral artery stenosis Cochrane Database Syst Rev 2000CD000516. 3. Savitz SI, Caplan LR. Vertebrobasilar disease N Engl J Med 2005;352:2618-2626.[CrossRef][Web of Science][Medline] 4. Albuquerque FC, Fiorella D, Han P, Spetzler RF, McDougall CG. A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis Neurosurgery 2003;53:607-614discussion 614–6.[CrossRef][Web of Science][Medline] 5. Henry M, Polydorou A, Henry I, Ad Polydorou I, Hugel IM, Anagnostopoulou S. Angioplasty and stenting of extracranial vertebral artery stenosis Int Angiol 2005;24:311-324.[Web of Science][Medline]
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