What is the role of endovascular procedures in the treatment of vertebral artery dissection (VAD)?

Updated: Feb 21, 2019
  • Author: Eddy S Lang, MDCM, CCFP(EM), CSPQ; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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Answer

New technological advancements in endovascular procedures indicate the growing popularity of endovascular recanalization of dissections. These procedures are viable, effective, and tolerable treatment alternatives with impressive radiographic results. [43] However, endovascular treatments are controversial, as most of the related mortality and morbidity is secondary to emboli formation in the vessel, which is amenable to antiplatelet or anticoagulation therapy. Furthermore, most dissections heal spontaneously. Surgical or endovascular repair of dissections is best reserved for patients who experience recurrent ischemic episodes despite antithrombotic therapy. It may also have a role for patients with intracranial dissections who present with subarachnoid hemorrhage. [44]

A 2014 meta-analysis of vertebral artery dissections (VADs) treated endovascularly found that 86.3% of procedures were associated with good or excellent outcomes. [45] Postoperative complications occurred in 10.5% (complications included vasospasm, postoperative rebleeding, and ischemia) with an overall mortality of 8.7%. The authors suggested that reduced operating time, minimal invasiveness, and comparative safety make endovascular procedures suitable options for intervention-amenable dissections. [45]

Surgical treatment is reserved for those patients in whom symptoms are persistent and refractory to maximal medical therapy and who are not candidates for endovascular procedures. Surgical options for vertebral artery dissections include in situ interposition grafting or extracranial-intracranial bypasses. [46]


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