Percutaneous intervention for posterior fossa ischemia. A single center experience and review of the literature.

Objective: The purpose of our study was to evaluate the results of endovascular treatment of symptomatic vertebro-basilar insufficiency (VBI) unresponsive to medical therapy.

Methods: Cardiac patients regularly followed in our cardiology clinic with symptoms suggestive of posterior fossa ischemia diagnosed by the attending cardiologist, had diagnostic or suspicious findings of vertebral artery stenosis on ultrasound evaluation, with reversed vertebral flow on Doppler examination. These patients were referred for selective vertebral and subclavian artery angiography. All patients (17 men, 11 women; mean age of 64 years, range 54-87) had critical lesions (> 70% stenosis) in the vertebral or pre-vertebral subclavian arteries or both. After confirmation of the severity of the lesions and feasibility for revascularization, all these patients underwent percutaneous intervention and stent placement. All patients were followed-up through clinic visits for a mean of 14.2 months, (range 3.5-24.3).

Results: In our 28 patients that were treated, 25 vertebral and 10 subclavian stents were placed. Success (< 20% residual diameter stenosis, without stroke or death) was achieved in 27 patients (96%). One patient undergoing intervention for an ostial subtotal occlusion of the left subclavian artery, developed a minor posterior fossa transient ischemic attack. At follow-up, 25 patients (89%) were alive and 22 (88%) of those had no further neurologic complaints. Three (11%) patients that had vertebral artery stents, died during follow-up from cardiac complications, unrelated to the neurovascular intervention. One patient (3.5%) had recurrent symptoms with in-stent restenosis at 6 months with successful balloon angioplasty and resolution of symptoms. The two other patients with persistent symptoms (only dizziness) had no evidence of restenosis and underwent further work-up that has not clarified the etiology.

Conclusions: Posterior fossa ischemia is an under-diagnosed condition that occurs with relative frequency in cardiac patients. Awareness of this condition and adequate non-invasive testing permits identification of these patients. Endovascular treatment using coronary wires and stents including drug eluting stents, seems to be the treatment of choice for vertebral artery revascularization due to the high technical success rate, low complication rate, and long-term durability.