Vertebral artery interventions: indication, techniques and outcomes

Atherosclerotic vertebral artery disease is an underdiagnosed cause of posterior circulation ischemia. Revascularization should be considered in symptomatic patients in whom medical therapy has failed. Both surgical and endoluminal approaches to treating the vertebral artery should be considered. The choice between the two is often determined by the nature of the lesion requiring intervention as well as the particular anatomic location. Such consideration requires a complete understanding of vertebrobasilar anatomy and the use of appropriate preintervention imaging studies. Open techniques for revascularization of the vertebral artery have proven clinical durability and acceptable surgical morbidity in experienced hands. Endoluminal techniques, which have gained momentum over the past decade, have been shown to be clinically feasible but have yet to deliver on durability benchmarks set by open surgical revascularization. As such, vertebral artery stenting should be reserved to select centers with high volume experience that have established acceptable outcomes in both clinical success and safety. Patient evaluation, indications for intervention, technical aspects of both open and endovascular therapies and outcome data are discussed. For each individual patient who suffers from medically refractive vertebrobasilar ischemia, practitioners must carefully balance the risks of surgery versus the limitations of endoluminal intervention before recommending intervention. Appropriate intervention can significantly impact longevity and patient quality of life.