Balancing Risk-Benefit for Non-Acute Vertebral Artery Occlusion Revascularization
María Gutiérrez, MD
Gao F, Sun X, Zhang H, Ma N, Mo D, Miao Z. Endovascular Recanalization for Nonacute Intracranial Vertebral Artery Occlusion According to a New Classification. Stroke. 2020;51:3340–3343.
Large vessel occlusion of the posterior circulation has devastating effects and carries high morbidity and mortality. One of the main causes for this stroke subtype is vertebral atherosclerosis. The optimal treatment for the non-acute intracranial vertebral artery occlusion (NA-ICVAO) in patients at high risk of stroke despite the best medical treatment remains unclear. Some case-report studies showed that endovascular recanalization (ER) is feasible. However, a large heterogeneity of perioperative outcomes and a high incidence of complications makes critical to identify which patients would benefit from intervention.
In this study, the authors aimed to define an angiographic classification to explore the feasibility and safety of endovascular recanalization for symptomatic atherosclerotic NA-ICVAO that might become a reference for patient selection and risk stratification in future trials. They retrospectively analyzed 50 patients with atherosclerotic NA-ICVAO that were treated with angioplasty and stenting. Patients were divided into 4 groups according to the following angiographic classification: type I (Figure 1A), the occlusion length is ≤15 mm; type II (Figure 1B), the occlusion length is >15 mm; type III (Figure 1C and 2), the occlusion length is >15 mm, and the tortuosity angle of the occluded segment is ≥45°; and type IV (Figure 1D), the occlusion extends to the epidural segment.
The median duration of occlusion was 45 days, and the median time from last symptom onset to endovascular treatment was 15 days. The overall technical success rate was 76%. The perioperative complication rate was 16% (8/50); vascular dissection occurred in 5 cases (4 asymptomatic and 1 mild stroke). One patient died of vascular perforation. Stroke or death beyond 30 days was 10.2% (5/49), 2 patients died (one for cerebral hemorrhage and another from ischemic stroke), 1 patient experienced severe ischemic stroke, and 2 patients had mild ischemic stroke. In angiographic follow-up, 4 patients developed in-stent restenosis and 3 developed reclusions.