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Table of Contents
COMMENTARY
Year : 2018  |  Volume : 1  |  Issue : 3  |  Page : 115

Commentary on paper “Severe vertebral artery stenosis treated by directional atherectomy” by Yongquan Gu, et al. Vasc Invest Ther 2018;1:110-4


Department of Surgery, Imperial College London, London, UK; Department of Surgery, University of Nicosia Medical School, Egkomi, Cyprus

Date of Web Publication30-Apr-2019

Correspondence Address:
Andrew Nicolaides
Imperial College London, London; University of Nicosia Medical School, Egkomi

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_4_19

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How to cite this article:
Nicolaides A. Commentary on paper “Severe vertebral artery stenosis treated by directional atherectomy” by Yongquan Gu, et al. Vasc Invest Ther 2018;1:110-4. Vasc Invest Ther 2018;1:115

How to cite this URL:
Nicolaides A. Commentary on paper “Severe vertebral artery stenosis treated by directional atherectomy” by Yongquan Gu, et al. Vasc Invest Ther 2018;1:110-4. Vasc Invest Ther [serial online] 2018 [cited 2019 May 19];1:115. Available from: http://www.vitonline.org/text.asp?2018/1/3/115/257418

Two randomized controlled trials, the vertebral artery ischemia stenting trial (VIST), and vertebral artery stenting trial revealed that stenting of extracranial vertebral artery stenosis can be performed with a low-operative stroke risk (0%–2%, respectively).[1],[2] In VIST, the hazard ratio for stroke during follow-up was 0.34 (95% confidence interval 0.12–0.98; P = 0.046) after adjusting for days from last symptoms.[2] Despite the relief of symptoms following extracranial vertebral artery stenting, there was a high rate of restenosis (15% and 22%, respectively).

Following percutaneous balloon angioplasty (PTA), early restenosis is caused by arterial wall recoil in cases with bulky fibrotic or calcified atherosclerotic plaques. Later restenosis is caused by intimal hyperplasia. The first cause can be avoided by atherectomy, and the second by the use of drug-coated balloons (DCB).

In patients with lower limb arterial disease, directional atherectomy using the Silverhawk atherectomy device (LS-M, Silverhawk, Medronic) which reduces plaque volume has been successful in improving claudication distance and increasing limb salvage by 83% at 3 years.[3] In the absence of stenting, a 12-month patency rate of 77% has been reported.[4] Although Silverhawk atherectomy in the lower limb provided good early results, intimal hyperplasia with a peak growth at 5–6 months remained a problem and hence that the results were not better than PTA alone.[5]

Subsequently, several studies indicated that in patients with complex lesions in the lower limb arteries, the combination of atherectomy with PTA using a DCB yielded better outcomes.[6],[7]

The application of directional atherectomy combined with DCB angioplasty for symptomatic severe vertebral artery lesions is a novel approach, and the authors[8] should be congratulated. Although the feasibility and efficacy in relieving symptoms have been demonstrated, the long-term studies are needed to confirm these early results and determine the criteria for selection of patients.

 
  References Top

1.
Markus HS, Larsson SC, Kuker W, Schulz UG, Ford I, Rothwell PM, et al. Stenting for symptomatic vertebral artery stenosis: The vertebral artery ischaemia stenting trial. Neurology 2017;89:1229-36.  Back to cited text no. 1
    
2.
Drazyk AM, Markus HS. Recent advances in the management of symptomatic vertebral artery stenosis. Curr Opin Neurol 2018;31:1-7.  Back to cited text no. 2
    
3.
Minko P, Buecker A, Jaeger S, Katoh M. Three-year results after directional atherectomy of calcified stenotic lesions of the superficial femoral artery. Cardiovasc Intervent Radiol 2014;37:1165-70.  Back to cited text no. 3
    
4.
Garcia LA, Jaff MR, Rocha-Singh KJ, Zeller T, Bosarge C, Kamat S, et al. Acomparison of clinical outcomes for diabetic and nondiabetic patients following directional atherectomy in the DEFINITIVE LE claudicant cohort. J Endovasc Ther 2015;22:701-11.  Back to cited text no. 4
    
5.
Brodmann M, Rief P, Froehlich H, Dorr A, Gary T, Eller P, et al. Neointimal hyperplasia after silverhawk atherectomy versus percutaneous transluminal angioplasty (PTA) in femoropopliteal stent reobstructions: A controlled, randomized pilot trial. Cardiovasc Intervent Radiol 2013;36:69-74.  Back to cited text no. 5
    
6.
Bague N, Nasr B, Chaillou P, Costargent A, Gouailler-Vulcain F, Goueffic Y, et al. The role for DCBs in the treatment of ISR. J Cardiovasc Surg (Torino) 2016;57:578-85.  Back to cited text no. 6
    
7.
Werner M. Angioplasty with drug coated balloons for the treatment of infrainguinal peripheral artery disease. Vasa 2016;45:365-72.  Back to cited text no. 7
    
8.
Gu Y, Guo J, Guo L, Aridi SC, Malas MB, Tong Z, et al. Severe vertebral artery stenosis treated by directional atherectomy. Vasc Invest Ther 2018;1:110-4.  Back to cited text no. 8
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