Treatment of posterior circulation ischemia with extracranial percutaneousballoon angioplasty and stent placement

Background and Purpose-Vertebrobasilar territory ischemia (VBI) leads to di sabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascu lar treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsiv e to medical therapy. Methods-Twenty-one patients (9 female, 12 male) with a mean age of 65.7 yea rs (range 47 to 81 years) underwent treatment with percutaneous endovascula r balloon angioplasty and stent placement. Sixteen patients (76.2%) had evi dence of contralateral involvement, and 9 (42.8%) demonstrated severe anter ior-circulation atherosclerosis. Nine patients had a previous infarct in th e occipital lobe, cerebellum, or pens before treatment. Follow-up was avail able for all patients. Results-Balloon angioplasty with intravascular stent placement was performe d in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segme nt) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 1 00%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patient s with proximal subclavian stenosis demonstrated angiographic evidence of s ubclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who develop ed a hemispheric stroke after thrombotic occlusion of an untreated cavernou s carotid artery stenosis (rate of major stroke and mortality = 4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and no ne had minor stroke. At long-term follow-up (mean = 20.7 +/- 3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had a t most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, a nd 2 (9.5%) had persistent symptoms. There were no clinically evident infar cts during the follow-up period. Conclusions-Endovascular treatment using balloon angioplasty with intravasc ular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-r isk subset of patients with poor collateral flow.