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Vertebral artery stenosis

Key sources
The following summarized guidelines for the evaluation and management of vertebral artery stenosis are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2023), the European Society of Cardiology (ESC/ESVS 2018), and the Society for Cardiovascular Angiography and Interventions (SCAI/SNIS/SVM/AANS/ASNR/CNS/AANN/SVS/AHA/ACR/SAIP/ACC/ASA/SIR 2011).


1.Screening and diagnosis

Indications for screening: obtain full vascular assessment in all patients being candidates for heart transplantation or cardiac assist device implantation.
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2.Diagnostic investigations

Vertebral artery imaging
As per ESVS 2023 guidelines:
Obtain CTA or contrast-enhanced MRA as first-line vascular imaging in patients with suspected vertebrobasilar ischemia.
Do not establish a diagnosis of vertebrobasilar ischemia (attributed to nipping of the vertebral arteries on head movement) in patients with vertigo or dizziness on head turning, unless corroborated by vascular imaging showing clear disruption of blood flow during head turning.

3.Diagnostic procedures

Catheter-based contrast angiography: consider obtaining catheter-based contrast angiography to define vertebral artery anatomy in patients with symptoms of posterior cerebral or cerebellar ischemia possibly being candidates for revascularization, when noninvasive imaging fails to define the location or severity of stenosis.

4.Medical management

Antiplatelet therapy: initiate antiplatelet therapy with aspirin 75-325 mg daily in patients with obstructive or nonobstructive atherosclerosis involving the extracranial vertebral arteries for the prevention of myocardial infarction and other ischemic cardiovascular events, but not for the prevention of stroke in asymptomatic patients.
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5.Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2018 guidelines, advise smoking cessation
, healthy diet and physical activity in all patients with PADs.

6.Therapeutic procedures

Revascularization: as per ESVS 2023 guidelines, do not perform open or endovascular interventions in patients with asymptomatic vertebral artery atherosclerotic lesions.
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7.Specific circumstances

Patients with carotid artery stenosis: do not perform synchronous carotid and vertebral artery revascularizations in patients with combined carotid and vertebral artery disease.

8.Follow-up and surveillance

Serial imaging surveillance
As per ESVS 2023 guidelines:
Do not obtain serial surveillance with catheter angiography in patients undergoing vertebral artery interventions.
Consider obtaining serial noninvasive imaging surveillance in patients undergone an open or endovascular vertebral artery intervention.

9.Quality improvement

Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs.

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