Account on Vertebrl Artery Insufficiency .pptx

Highlights on effects of vertebral artery insufficiency and its management

1. Vertebral Artery Insufficiency Rohan Jayawardena Senior Registrar in Vascular & Transplant Surgery National Hospital Galle

2. Blood Supply

3. Vertebrobasilar Insufficiency Compromised perfusion to posterior circulation V1 – segment is more common for atherosclerotic obstruction 20% of ischemic strokes

4. Clinical Presentation Dizziness – 47% Unilateral limb weakness – 41% Balance disorders Diplopia More common Dysphasia Drop attacks B/L Homonymous hemianopia Nystagmus, cortical blindness, nausea, vomiting, occipital headaches – Less common

5. Diagnosis MRA CTA DSA Complete angiographic evaluation – Aortic arch, 4 vessel study, B/L carotid & intracranial imaging

6. General principles of treatment Lifestyle & risk factor modification Antiplatelets Statins Surgical – Endarterectomy Reconstruction – VA transposition/ Bypass Endovascular

7. Asymptomatic VA Disease No RCTs Screening – Not recommended Antiplatelets Statins Interventions

8. Symptomatic VA Disease Optimal medical therapy – same as symptomatic CAS Revascularization SVS guidelines recommendation – low risk symptomatic patients with proximal VA stenosis – open surgery Stenting – Extracranial < Intracranial (Death/Stroke)

9. Open Surgical VA origin – transposition to ipsilateral CCA, VA reimplantation, vein bypass from SCA, trans-subclavian endarterectomy V2 or V3 segments – Distal VA reconstruction (experience is limited) V3 – transposition(using ECA/Occipital artery) & bypass

10. Endovascular APRx , statins & IV Heparin as CAS Access – CFA/ Transbrachial / Transradial Angioplasty Stenting – BES/SES DES/BMS – no difference in technical success & procedural complications - BMS – more recurrent symptoms

11. Complications – Open Surgery Experience is limited. Mostly single centre series Conclusion – 30 day death/Stroke rates – low in both proximal or distal (2-7%) Risk is high if combined with carotid procedures

12. Complications – Open Surgery Paralysis of spinal accessory nerve (7%) Horner’s syndrome – Temporary/Permanent (11.5%)

13. Complications - Endovascular Systemic review of 20 non-randomized studies Perioperative strokes – 0.3% Access complications – 0.7% Dissection – 0.5% In stent restenosis(ISR) – ~25% Stent fractures – in a single centre series majority are asymptomatic 1y – 5% 3y – 15% 5y – 30%

14. Risk factors for ISR Intracranial stenosis Ostial stenosis Stenosis >10mm Smaller stent size BMS vs DES Higher residual stenosis VA tortuosity Contralateral VA occlusion DM Smoking

15. Management of ISR BMT alone Redo stenting Balloon angioplasty 1y rate of stroke/TIA - No difference in BMT vs reinterventions Rate of recurrent ISR–Balloon AP alone (50%)>Redo stenting(22%) Recurrent VB symptoms – consider redo stenting Asymptomatic >70% restenosis – no data to guide practice

16. Surveillance after VA revascularisation Open reconstructions for proximal VA lesions – high rates of symptomatic improvement & low rates of restenosis Surveillance is challenging Recurrent VB stroke/TIA – should be investigated DSA surveillance – Angiographic stroke

17. Thank you