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Table of Contents
NEW TECHNOLOGY
Year : 2018  |  Volume : 1  |  Issue : 3  |  Page : 110-114

Severe vertebral artery stenosis treated by directional atherectomy


Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Date of Web Publication30-Apr-2019

Correspondence Address:
Yongquan Gu
Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing 100053
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_17_18

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  Abstract 

We report the outcomes of directional atherectomy using a distal protective device and drug-coated balloon angioplasty in four patients with severe atherosclerotic vertebral artery stenosis. All cases were clinically successful with complete resolution of the symptoms. Immediate and postoperative results showed a good technical success. These results suggest that vertebral artery stenosis treated with directional atherectomy is technically feasible and may be a safe and effective option when performed by experienced endovascular surgeons.

Keywords: Atherectomy, atherosclerosis, endovascular, outcomes, vertebral artery stenosis


How to cite this article:
Gu Y, Guo J, Guo L, Cui S, Aridi HD, Malas MB, Tong Z, Qi Y, Qi L. Severe vertebral artery stenosis treated by directional atherectomy. Vasc Invest Ther 2018;1:110-4

How to cite this URL:
Gu Y, Guo J, Guo L, Cui S, Aridi HD, Malas MB, Tong Z, Qi Y, Qi L. Severe vertebral artery stenosis treated by directional atherectomy. Vasc Invest Ther [serial online] 2018 [cited 2019 Aug 19];1:110-4. Available from: http://www.vitonline.org/text.asp?2018/1/3/110/257414


  Introduction Top


Around 20%–25% of ischemic strokes are located in the posterior circulation involving the vertebrobasilar system.[1] The risk of stroke secondary to symptomatic vertebral artery stenosis ranges between 30% and 35% at 5 years. Surgical bypass is rarely performed, due to high morbidity and mortality.[2] With the evolution of endovascular revascularization with primary stenting and its established safety and effectiveness, it has become the most common treatment method for severe vertebral artery stenosis.[3],[4] However, the rates of restenosis remain relatively high and often lead to recurrent severe ischemia. Directional atherectomy combined with drug-coated balloon angioplasty has achieved favorable outcomes in the treatment of atherosclerotic lower limb ischemia. In this report, we present the outcomes of this approach in four patients with cerebral ischemia secondary to severe vertebral artery stenosis.


  Case Reports Top


Case 1

A 67-year-old male patient with dizziness presented to our hospital. The patient had no history of prior cerebral infarction. Carotid ultrasound and computed tomography angiography (CTA) performed at another hospital suggested occlusion of the right vertebral artery, severe stenosis at the initial segment of left vertebral artery, and stenosis of the left subclavian artery. The left vertebral artery was treated with directional atherectomy combined with drug-coated balloon angioplasty, and a stent was implanted in the left subclavian artery. Initial intraoperative angiography confirmed severe stenosis at the initial segment of the left vertebral artery and proximal subclavian artery [Figure 1]a. The distal protective device (SpiderFX, ev3, Medtronic) was placed along a 0.014' guidewire and released fully at the distal end of the vertebral V1 segment. The directional atherectomy system (LS-M, Silverhawk, Medtronic) was inserted along the guidewire and resected the stenotic lesions at various angles from the proximal to the distal end of the vertebral artery [Figure 1]b. Postatherectomy angiography showed significant improvement in the morphology of the vertebral artery [Figure 1]c. Then, a 4.5 mm drug balloon (Orchid, Acotec) was applied at the vertebral artery lesions and inflated for 30 s [Figure 1]d. We withdrew the protective device where a small amount of patch tissue and plaque were retrieved [Figure 1]e. A 9–30 mm metal bare stent (Lifestent, Bard) was placed in the stenotic lesion of the left subclavian artery. The completion angiography showed complete resolution of the stenosis in the left subclavian artery and the left vertebral artery with no obvious arterial dissection around, or obstruction to blood flow at the distal vertebral artery [Figure 1]f. A large amount of visible intimal tissue was captured while cleaning the atherectomy device collecting groove [Figure 1]g. The patient had an uneventful recovery, and his dizziness disappeared completely after the operation.
Figure 1: Case 1. Left vertebral artery stenosis treated by directional atherectomy combined with drug-coated balloon angioplasty

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Case 2

A 70-year-old male patient was admitted for gait instability and disequilibrium. The patient has a history of cerebral infarction 6 years ago, manifested primarily as right limb weakness 3 years ago, and improved after conservative treatment. Ultrasound examination of the carotid artery showed right vertebral artery occlusion, left vertebral artery stenosis (V1 segment: 70%–99%), and right subclavian arterial stenosis (<50%). Intraoperative angiography confirmed severe stenosis at the initial segment of the left vertebral artery [Figure 2]a. We elected to perform left vertebral artery plaque atherectomy under local anesthesia combined with drug-coated balloon angioplasty and stent implantation. After the distal protective device (SpiderFX, ev3, Medtronic) was placed, the vertebral artery stenotic lesions were resected from proximal to distal at multiple angles with a directional atherectomy system (LS-M, Silverhawk, Medtronic) [Figure 2]b. Residual stenosis was still visible after resection [Figure 2]c; thus, a 5–40 mm drug-coating balloon (Orchid) angioplasty was performed for 30 s [Figure 2]d, and a 5–19 mm stent (ExpressSD, Boston Scientific) was implanted in the left vertebral artery. The protective umbrella was retrieved, and completion angiography showed satisfactory stent position, with no residual stenosis in the left vertebral artery [Figure 2]e. No neurological changes were detected. The patient had an uneventful hospital course with complete resolution of his symptoms.
Figure 2: Case 2. Left vertebral artery stenosis treated by directional atherectomy combined with drug-coated balloon angioplasty and stent implantation

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Case 3

A 61-year-old male patient, male, with a history of the bilateral carotid artery and left subclavian artery stenting 2 years ago, was admitted to our hospital with intermittent dizziness and tinnitus. The patient was shown to have bilateral vertebral artery stenosis (V1 segment: 70%–69% on the left side, <50% on the right side) on ultrasound intraoperative angiography confirmed severe stenosis at left vertebral artery V1 segment [Figure 3]a. A distal protective device (SpiderFX, ev3, Medtronic) was placed and fully released. The vertebral artery stenotic lesions were resected at multiple angles by the directional atherectomy system (LS-M, Silverhawk, Medtronic) [Figure 3]b. Subsequently, angioplasty with a 4–40 mm drug-coated balloon (Orchid) was performed in the vertebral artery lesions for 30 s [Figure 3]c. No residual stenosis or dissection was observed on completion angiography [Figure 3]d. The patient had a smooth recovery with the disappearance of his presenting symptoms.
Figure 3: Case 3. Left vertebral artery stenosis treated by directional atherectomy combined with drug-coated balloon angioplasty

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Case 4

A 55-year-old female patient was admitted to the hospital due to dizziness and left upper limb weakness. CTA demonstrated severe stenosis in the left subclavian artery and the left vertebral artery [Figure 4]a. Directional atherectomy combined with drug-coated balloon angioplasty was performed with bailout stent placement in the left vertebral artery. After placement of the distal protection device, the atherectomy device (LS-M, Silverhawk, Medtronic) was rotated to debulk the vertebral artery [Figure 4]b and subclavian artery lesions, followed by angioplasty with a 4.5–60 mm drug-coated balloon [Figure 4]c. A bailout 5–15 mm stent (ExpressSD, Boston Scientific) was placed in the left vertebral artery [Figure 4]d. In addition, a 6–40 mm drug-coated balloon was used to revascularize the left subclavian artery [Figure 4]e. Follow-up CTA at 30 days showed normal blood flow in the left subclavian artery and left vertebral artery blood flow without any residual stenosis [Figure 4]f and [Figure 4]g.
Figure 4: Case 4. Left vertebral artery stenosis treated by directional atherectomy combined with drug-coated balloon angioplasty and bail-out stent implantation

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  Discussion Top


Ischemic stroke is an important cause of disability and mortality worldwide. Over two million individuals suffer from new-onset strokes in China each year.[3] Vertebrobasilar insufficiency accounts for approximately 25% of ischemic strokes.[5] Ischemic stroke due to ischemia of the posterior circulation has a poor prognosis, with a survival rate of 72% at 2 years and 48% at 5 years.[6] Stent implantation is the most effective treatment for vertebrobasilar artery stenosis at present. However, in-stent restenosis remains an important problem to be solved. The rate of restenosis is 26% at 14 months,[7] with a 5-year survival rate of only 64%.[3]

The effectiveness and safety of directional atherectomy with drug-coated balloon angioplasty offers an attractive treatment option for patients with vertebral artery stenosis. This technique has been used in the field of lower extremity atherosclerotic occlusive disease treatment and showed satisfactory results.[8],[9],[10],[11] The directional system consists of a cutting catheter and drive unit. The tapered tip of the cutting catheter is followed by a retractable annular alloy blade and a gooseneck collecting groove. The diameter of the artery treated by directional atherectomy devices is between 1.5 and 7 mm. If the diameter of the target vessel is larger than 7 mm, the cutting blade and the artery lesion cannot fit tightly due to its structural limitation. Anatomical data show that the average vertebral artery diameter in Chinese patients ranges between 3 and 5 mm, making it suitable for the use of directional atherectomy devices in our patient population.

Moreover, drug-coated balloon angioplasty is an effective and safe technology for the treatment of atherosclerotic stenosis or occlusive disease. Numerous studies have demonstrated lower restenosis rates and improved patency with paclitaxel-coated balloons.[12],[13] Compared with drug-coated balloon angioplasty alone, the combination of debulking procedures and drug-coated balloon angioplasty has shown better patency rates.[14],[15] For this reason, we decided to perform atherectomy with drug-coated ballooning in these patients.

According to our own studies and experience, several principles should be considered. First, anticoagulation should be adequately used to prevent thrombosis. Low molecular weight heparin therapy and antiplatelet therapy (aspirin or clopidogrel) should be started immediately after the surgery and continued for 1 week, followed by dual antiplatelet therapy for 6 months, then using either aspirin or clopidogrel. Second, atherectomy should not be performed in lesions that are nearly occluded. Moreover, we do not recommend this technique if the guidewire cannot pass through the true lumen, due to the high risk of artery rupture. Third, the use of embolic protection devices before the atherectomy is integral to retain embolic material and avoid cerebral infarction. The SpiderFX embolic protection device has a soft texture and network structure made by titanium alloy and showed no vasospasm during any procedure. Some atheroma or debris can be detected sometimes in the harvest nest. Fourth, the lesion should be assessed preoperatively by computed tomography scan. For severely calcified lesions, the atherectomy should be done slowly, and the operator should avoid manipulating the same site repeatedly.


  Conclusion Top


The initial use of directional atherectomy with drug-coated balloon angioplasty to treat vertebral artery stenosis shows satisfactory technical and clinical success. Further studies with long-term follow-up are needed to confirm the safety and effectiveness of this new technology.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was supported by Beijing Hospital Administration Clinical Technology Innovation Project (Sail Project) XMLX201610; Beijing Hospital Administration “Dengfeng” Talent training Program DFL20150801; Capital Health Development and Research Special Project 2016-1-2012; National key R & D Project 2017YFC1104100; Beijing Health system High-level Health Technology Talent training Program 2014-3-059; Beijing excellent talents training Youth backbone individual Project 2016000020124G108; Xuanwu Hospital “Talent training Plan;” Beijing Municipal Administration of Hospital' Youth Programme. QML20180804.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352:2618-26.  Back to cited text no. 1
    
2.
Thevenet A, Ruotolo C. Surgical repair of vertebral artery stenoses. J Cardiovasc Surg (Torino) 1984;25:101-10.  Back to cited text no. 2
    
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Che WQ, Jiang XJ, Dong H, Peng M, Zou YB, Song L, et al. Effect of stenting for the proximal atherosclerotic extracranial vertebral artery stenosis. Zhonghua Xin Xue Guan Bing Za Zhi 2017;45:34-8.  Back to cited text no. 3
    
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Yong-Chang Z, Shi-Xin C, Ya-Min L, Qiang L, Baoshan L. Efficacy and safety of intravascular intervention in the treatment of carotid and vertebral artery stenosis. Prog Mod Biomed 2017;17:696-8, 708.  Back to cited text no. 4
    
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Marquardt L, Kuker W, Chandratheva A, Geraghty O, Rothwell PM. Incidence and prognosis of > or = 50% symptomatic vertebral or basilar artery stenosis: Prospective population-based study. Brain 2009;132:982-8.  Back to cited text no. 5
    
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Qureshi AI, Ziai WC, Yahia AM, Mohammad Y, Sen S, Agarwal P, et al. Stroke-free survival and its determinants in patients with symptomatic vertebrobasilar stenosis: A multicenter study. Neurosurgery 2003;52:1033-9.  Back to cited text no. 6
    
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Eberhardt O, Naegele T, Raygrotzki S, Weller M, Ernemann U. Stenting of vertebrobasilar arteries in symptomatic atherosclerotic disease and acute occlusion: Case series and review of the literature. J Vasc Surg 2006;43:1145-54.  Back to cited text no. 7
    
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Yongquan G, Lianrui G, Jianming G, Qi L, Tong Z, Cui S, et al. Endovascular treatment of lower limb chronic ischemia by silverhawk atherectomy combined with paclitaxel-eluting; Balloon. Chin J Minim Invasive Surg 2017;17:65-8.  Back to cited text no. 8
    
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Yongquan G, Lianrui G, Lixing Q, Li X, Cui S, Tong Z, et al. Plaque excision with silverhawk treating atherosclerotic lower extremity ischemia: Report of 14 cases. Chin J Minim Invasive Surg 2011;11:1022-4.  Back to cited text no. 9
    
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Jianming G, Yongquan G, Lianrui G, Tong Z, Gao X, Wu Y, et al. Turbohawk plaque resection system for lower extremity arteriosclerosis occlusive disease. Chin J Gen Surg 2015;6:915-6.  Back to cited text no. 10
    
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Jianming G, Yongquan G, Lianrui G, Tong Z, Wu X, Cui S, et al. Silverhawk atherectomy and adjunctive angioplasty for severe arterial atherosclerotic occlusive disease below the knee. Chin J Gen Surg 2014;23:732-6.  Back to cited text no. 11
    
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Rong L, Shixin MA, Gang Z, Jingyu H, Meng W, Zhigang L. Long-term lumen area enlarged in coronary in-stent restenosis after the treatment of paclitaxel drug-coated balloon dilatation. J Interv Radiol 2017;26:367-9.  Back to cited text no. 12
    
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Xupin X, Xin F, Changpin H, Yongchang L, Dong X, Jianyun L, et al. Drug-coated balloon with paclitaxel for in-stent restenosis of femoral popliteal artery: Initial experience in 18 patients. J Interv Radiol 2017;26:544-7.  Back to cited text no. 13
    
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Redfors B, Maehara A, Witzenbichler B, Weisz G, Stuckey TD, Henry TD, et al. Outcomes after successful percutaneous coronary intervention of calcified lesions using rotational atherectomy, cutting-balloon angioplasty, or balloon-only angioplasty before drug-eluting stent implantation. J Invasive Cardiol 2017;29:378-86.  Back to cited text no. 14
    
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Dessì K, Giovannacci L, van den Berg JC. Debulking plus drug-coated balloon combination as revascularization strategy for complex femoropopliteal lesions. J Cardiovasc Surg (Torino) 2018;59:70-8.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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