Tamunoinemi Bob-Manuel and James S. Jenkins Department of Cardiovascular Diseases, John Ochsner Heart & Vascular Institute, The Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA Endovascular treatment of the ostial and proximal portion of the vertebral artery is a safe and effective technique for alleviating symptoms and improving cerebral blood flow to the posterior circulation [1–3]. Vertebral artery angioplasty can be performed with high technical and clinical success rates, low complication rates, and durable long‐term results [4]. Although restenosis rates vary widely, the durability of vertebral artery angioplasty is evidenced by low restenosis rates in several large series reported in the literature using multiple treatment options, including balloon angioplasty alone, bare‐metal stents, and drug‐coated stents [5]. Endovascular stenting of vertebral artery atherosclerotic disease in patients who fail medical therapy should be considered first‐line therapy despite the absence of randomized trials demonstrating superiority of endovascular therapy. Defining the anatomy of the vertebral artery, including proximal inflow and collateral pathways, is necessary to determine the appropriate vessel that provides the best revascularization to the posterior circulation [6]. The use of coronary angioplasty equipment and proper guide selection will allow safe and effective treatment of complex vertebral lesions. Although off‐label, EPD should be considered to prevent distal embolic complications if vertebral artery anatomy is suitable. Endovascular treatment of the vertebral artery is a less invasive alternative than open surgery and should become the preferred therapy for symptomatic vertebral artery atherosclerotic obstructive disease not responsive to medical therapy. All patients should be loaded with aspirin (325 mg) and an antiplatelet preferably clopidogrel (300–600 mg) at least one day prior to the procedure. Minimal or no sedation should be used during the procedure, and continuous neurological monitoring is encouraged to quickly identify any complications. As is routine in all institutions, care should be taken to explain the risks, which include death, ischemic or hemorrhagic stroke, access site bleeding requiring transfusion, paralysis, or potential worsening of symptoms weighed against resolution of symptoms by intervention. Low‐dose weight‐adjusted heparin to maintain an activated clotting time greater than 200 seconds is the procedural anticoagulant of choice for vertebral artery intervention. Bivalirudin is an acceptable alternative in patients with heparin‐induced thrombocytopenia. Using ultrasound guidance, access the femoral artery with a micropuncture needle and 0.018 wire employing the Seldinger technique [7]. Connect the manifold to the micropuncture 4 Fr sheath and perform a femoral angiogram to ensure proper access without complication (optional) or, alternatively, upsize to a 6 Fr femoral sheath over a diagnostic J‐wire or Hi‐Torque Supra Core guidewire (Abbott vascular, Santa Clara, CA, USA) and perform a femoral angiogram. Insert a 5 Fr or 6 Fr pigtail catheter via a diagnostic J‐wire or exchange‐length J‐wire to perform an aortic arch angiogram in the LAO view (Figure 3.1). The pigtail should be placed in the ascending aorta just proximal to the innominate artery. This view is performed to rule out anomalous vertebral artery origin. Using a 0.035 glidewire or J‐wire, insert a 5 Fr Berenstein catheter via the femoral access sheath (alternatively, a 5 Fr or 6 Fr Judkins right, internal mammary, or Vitek curve catheters are acceptable). If brachial or radial access is obtained, a multipurpose or Judkins right catheter is used instead. Carefully engage the vertebral artery ostium, while monitoring continuous pressure. Perform high‐quality angiograms of all four supra‐aortic main vessels, laying out vertebral artery anatomy (Figure 3.2), especially the target lesion (Figure 3.3). Proceed to image the cervical carotid and vertebral arteries and intracranial arteries (Figure 3.4). Digital subtraction techniques are essential when imaging intracranial anatomy. A minimum image intensifier size of 12 in. is necessary to adequately image the intracranial vessels. A complete angiographic evaluation includes an aortic arch and four‐vessel study with selective angiography of bilateral carotid and vertebral arteries including intracranial imaging to ensure collateral blood supply and define the circle of Willis. Nonionic, iso‐osmolar contrast is used for intracranial angiography. Importantly, femoral access is used 80% of the time. Ipsilateral brachial or radial artery access is used 20% of the time if the proximal vertebral artery is acutely angulated when imaged from the femoral access. A combination of femoral and upper extremity access is used in complex cases involving subclavian artery atherosclerotic disease. Figure 3.1 Aortic arch angiography showing main supra‐aortic vessels. Figure 3.2 Vertebral artery anatomy. Source: From Jenkins and Collins (2011).
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Vertebral Artery Intervention: Catheter‐Based Therapy
Introduction
Preprocedural Considerations
Step 1. Procedural Planning with Diagnostic Angiography
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