Vertebral Artery Stenting
th
VIST meeting 12 October
Dr Andrew Clifton
Atkinson Morley Wing
St George’s Hospital
Technical Aspects
 Patients should be pre-medicated with antiplatelet agents
– Recommended with aspirin 75mg a day for at least 7 days prior to
the procedure, or a 600mg loading dose the day before the
procedure and 75mg on the day,
– plus clopidogrel 75mg a day for at least 7 days before the
procedure, or a 600mg loading the dose the day before the
procedure and 75mg on the day of the procedure.
 75mg of both agents continued for 6 weeks and one agent,
usually aspirin, 75mg a day for life.
 If a platelet functional analyser such as VerifyNow is
available antiplatelet function should be tested prior to the
procedure and dosages adjusted accordingly.
Extracranial Stenting
 Most stenoses at origin. Stenting within the foramina is not generally
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recommended as neck movement can cause stent fracture and
occlusion.
Stenting at the origin can be performed under local anaesthesia +/(plus or minus) sedation. 5 or 6 French groin puncture depending on
the size of the guiding sheath needed.
Full angiography to both subclavian arteries to look at both vertebral
origins and collateral flow and views of intracranial circulation.
5000 units of heparin given intravenously before insertion of the
guiding catheter.
Appropriate ACT levels obtained prior to inserting the guiding
catheter.
Extracranial Stenting
 Usual practice is for balloon mounted stents under road mapping, the
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lesion is crossed with an 014 or 018 wire, depending on the stent used,
and a balloon mounted stent deployed across the stenosis leaving a few
millimetres of stent in the subclavian artery.
Post dilatation a check angiogram is performed and if satisfactory
appearances the delivery system is removed.
Rarely the lesion needs to be pre-dilated.
Technical tip: access to the right vertebral can often be difficult and
sometimes using a 7 French sheath with a wire into the subclavian
stabilises the system to gain access.
Brachial artery puncture using a 5 French sheath is sometimes
necessary for access.
Stent types: Monorail preferred, various stent types are available
including cardiac, renal, and specific intracranial stents such as the
Pharos.
Intracranial Stenting
 Premedication as above. Heparinisation as above.
 Procedure is ideally preformed under general
anaesthesia.
 Both balloon mounted Pharos and self expanding
stents are used. Self expanding stents usually
require pre-dilatation of the lesion using a gateway
balloon to approximately 75% of the diameter of
the normal vessel before deployment of the stent.
Intracranial Stenting
 Post procedure care: Extracranial can be managed in a high dependency unit
over night. Heparinisation is not necessary for
extracranial stents.
 Intracranial stenting:- essential the patient has access to an
HDU or even an ITU bed overnight for close monitoring of
blood pressure and other neurological parameters.
Heparinisation is usually continued for 24 hours after the
procedure.
 It goes without saying that all these patients have
atheromatous disease and will be managed by a
Neurologist or Stroke Physician with control of risk factors
such as hypertension, glucose, cholesterol etc.
Imaging Follow Up
 Unless follow up is prescribed as part of a
trial non-invasive imaging such as
ultrasound, particularly to look at flow
through an origin stenosis, or CTA or MRA
would be indicated. Angiography we
reserve for those who become symptomatic
or as follow up as part of a trial.