Optimization technique for stenting of ostial vertebral artery stenosis

  • Yu.V. Cherednychenko Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov https://orcid.org/0000-0002-2683-8608
  • A.Yu. Miroshnychenko Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov
  • M.O. Zorin Dnipropetrovsk Medical Academy
  • L.A. Dzyak Dnipropetrovsk Medical Academy
  • O.S. Tsurkalenko Dnipropetrovsk Medical Academy
Keywords: stenosis; vertebral artery; stenting; eluting stent; anchoring technique; Szabo technique; ischemic stroke.


Objective ‒ to develop a technique for endovascular treatment of symptomatic ostial stenosis of the vertebral arteries, which allows to minimize risks of delayed stent breakage and restenosis. 
Materials and methods. This is analysis of prospectively collected data from patients presenting from 2016 to 2019 in the endovascular center of the Dnepropetrovsk Regional Clinical Hospital named after I.I. Mechnikov. One hundred four stents were placed in 99 patients using the author’s complex method, which is based on our modification of Szabo technique. The principles of the method were developed based on a literature review and in vitro tests using 7 silicone models of the initial segments of the subclavian and vertebral arteries with different angles of divergence of the vertebral arteries (30, 45, 60, 90, 120, 135, 150°) and 9 balloon mounted drug-eluting stents with open-cell design Resolute (Medtronic).
Results. There were no cases of displacement of the stent proximally or distally during implantation. In all cases, stents were implanted in the affected segment exactly and did not prolapse more than 1 mm beyond the ostium of the vertebral artery into the subclavian artery. There were no «clinical» ischemic complications in the early postoperative period. In 5 cases, isolated subclinical ischemic lessions in the carotid circulation were revealed during one-session stenting of ostial stenosis of the vertebral arteries and carotid stenting. In the posterior circulation, ischemic lessions on MRI in the early postoperative period were not detected in any observations.
Conclusions. Developed complex stenting method based on our modification of Szabo technique allows us to achieve optimal long-term results of stenting of symptomatic ostial stenosis of the vertebral arteries.


Download data is not yet available.


Caplan L, Chung CS, Wityk R et al. New England medical center posterior circulation stroke registry: I. Methods, data base, distribution of brain lesions, stroke mechanisms, and outcomes. J Clin Neurol. 2005 Apr;1(1):14-30. PMCID: PMC2854928 PMID: 20396469 https://doi.org/10.3988/jcn.2005.1.1.14

Pirau L, Lui F. Vertebrobasilar insufficiency. [Updated 2020 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482259/

Amin-Hanjani S, Pandey DK, Rose-Finnell L et al. Effect of hemodynamics on stroke risk in symptomatic atherosclerotic vertebrobasilar occlusive disease. JAMA Neurol. 2016 Feb 1. 73 (2):178-85. PMID: 26720181 PMCID: PMC5274634 https://doi.org/10.1001/jamaneurol.2015.3772

Gulli G, Marquardt L, Rothwell P, Sci F, Markus H. Stroke risk after posterior circulation stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis. Stroke. 2013;44(3):598-604. https://doi.org/10.1161/STROKEAHA.112.669929.

Teraa M, Moll FL, van der Worp BH, Lo RT, de Borst GJ. Symptomatic vertebral artery stent fracture: a case report. J Vasc Interv Radiol. 2010 Nov;21(11):1751-4. PMID: 20884238 https://doi.org/10.1016/j.jvir.2010.07.007.

Dabus G, Gerstle RJ, Derdeyn CP, Cross DT 3rd, Moran CJ. Endovascular treatment of the vertebral artery origin in patients with symptoms of vertebrobasilar ischemia. Neuroradiology. 2006 Dec;48(12):917-23. PMID: 17086409. https://doi.org/10.1007/s00234-006-0151-7.

Gulli G, Khan S, Markus HS. Vertebrobasilar stenosis predicts high early recurrent stroke risk in posterior circulation stroke and TIA. Stroke. 2009; 40:2732-7. PMID: 19478210 https://doi.org/10.1161/STROKEAHA.109.553859

Kim YJ, Lee JH, Choi JW et al. Long-term outcome of vertebral artery origin stenosis in patients with acute ischemic stroke. BMC Neurol.2013;13:171. https://doi.org/10.1186/1471-2377-13-171

Wang Z, Lee AM, Bai HX, Tang H, Yang L. Stenting of symptomatic extracranial vertebral artery stenosis: Is further testing indica-ted? Int J Stroke. 2016 Feb;11(2):NP22-4. https://doi.org/10.1177/1747493015616640. PMID: 26783319.

Taylor RA, Siddiq F, Memon MZ et al. Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results. Neuroradiology. 2009 Aug;51(8):531-9. PMID: 19437002. https://doi.org/10.1007/s00234-009-0531-x.

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 Jun;43(6):1145-54. PMID: 16765230. https://doi.org/10.1016/j.jvs.2006.02.027.

Edgell RC, Yavagal DR, Drazin D, Olivera R, Boulos AS. Treatment of vertebral artery origin stenosis with anti-proliferative drug-eluting stents. J Neuroimaging. 2010 Apr;20(2):175-9. PMID: 19040627. https://doi.org/10.1111/j.1552-6569.2008.00330.x.

Stayman AN, Nogueira RG, Gupta R. A systematic review of stenting and angioplasty of symptomatic extracranial vertebral artery stenosis. Stroke. 2011 Aug;42(8):2212-6. PMID: 21700936. https://doi.org/10.1161/STROKEAHA.110.611459.

Albuquerque FC, Fiorella D, Han P, Spetzler RF, McDougall CG. A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis. Neurosurgery. 2003 Sep;53(3):607-14; discussion 614-6. PMID: 12943577. https://doi.org/10.1227/01.neu.0000079494.87390.28.

Tsutsumi M, Kazekawa K, Onizuka M et al. Stent fracture in revascularization for symptomatic ostial vertebral artery stenosis. Neuroradiology. 2007 Mar;49(3):253-7. PMID: 17151868. https://doi.org/10.1007/s00234-006-0185-x.

Baik MW, Yoo SH, Park IS, Kim SD, Kim MC. Stent fracture and restenosis after placement of a drug-eluting device in the vertebral artery origin and treatment with the stent-in-stent technique. Report of two cases. J Neurosurg. 2007 May;106(5):907-11. PMID: 17542539. https://doi.org/10.3171/jns.2007.106.5.907.

Tang X, Tang F, Hu C et al. Dynamic respiratory tortuosity of the vertebral artery ostium. J Endovasc Ther. 2017 Feb;24(1):124-9. PMID: 27831484. https://doi.org/10.1177/1526602816676254.

Lu J, Liu J, Wang D, Wang S. Stent fracture and occlusion after treatment of symptomatic vertebral artery ostium stenosis with a self-expanding device. A case report. Interv Neuroradiol. 2014 Dec;20(6):755-60. https://doi.org/10.15274/INR-2014-10068. Epub 2014 Dec 5. Erratum in: Interv Neuroradiol. 2015 Feb;21(1):137-8. PMID: 25496687; PMCID: PMC4295249.

Markus HS, Larsson SC, Kuker W, Schulz UG, Ford I, Rothwell PM, Clifton A; VIST Investigators. Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial. Neurology. 2017 Sep 19;89(12):1229-1236. PMID: 28835400; PMCID: PMC5606920. https://doi.org/10.1212/WNL.0000000000004385.

Markus H, Harshfield E, Compter A et al. Stenting for symptomatic vertebral artery stenosis: a preplanned pooled individual patient data analysis. The Lancet. Neurology. 2019;18(7):666-73. https://doi.org/10.1016/s1474-4422(19)30149-8

Sun X, Ma N, Wang B et al. The long term results of vertebral artery ostium stenting in a single center. J Neurointerv Surg. 2015 Dec;7(12):888-91. PMID: 25332411. https://doi.org/10.1136/neurintsurg-2014-011356.

Li MKA, Tsang AC, Tsang FC, et al. Long-term risk of in-stent restenosis and stent fracture for extracranial vertebral artery stenting. Clin Neuroradiol. 2019;29:701-6. https://doi.org/10.1007/s00062-018-0708-y

Taylor RA, Siddiq F, Suri MF et al. Risk factors for in-stent restenosis after vertebral ostium stenting. J Endovasc Ther. 2008 Apr;15(2):203-12. PMID: 18426264. https://doi.org/10.1583/07-2175.1.

Song L, Li J, Gu Y et al. Drug-eluting vs. bare metal stents for symptomatic vertebral artery stenosis. J Endovasc Ther. 2012 Apr;19(2):231-8. PMID: 22545889. https://doi.org/10.1583/11-3718.1.

Tank VH, Ghosh R, Gupta V et al. Drug eluting stents versus bare metal stents for the treatment of extracranial vertebral artery disease: a meta-analysis. J Neurointerv Surg. 2016 Aug;8(8):770-4. PMID: 26180094. https://doi.org/10.1136/neurintsurg-2015-011697.

Langwieser N, Buyer D, Schuster T et al. Bare metal vs. drug-eluting stents for extracranial vertebral artery disease: a meta-analysis of nonrandomized comparative studies. J Endovasc Ther. 2014 Oct;21(5):683-92. PMID: 25290797. https://doi.org/10.1583/14-4713MR.1.

Jiang Y, Xu X, Wen Z et al. In-stent restenosis after vertebral artery stenting. Int J Cardiol. 2015;187:430-3. PMID: 25841142. https://doi.org/10.1016/j.ijcard.2015.03.377.

Hatano T, Tsukahara T, Miyakoshi A et al. Stent placement for atherosclerotic stenosis of the vertebral artery ostium: angiographic and clinical outcomes in 117 consecutive patients. Neurosurgery. 2011 Jan;68(1):108-16; discussion 116. PMID: 21099720. https://doi.org/10.1227/NEU.0b013e3181fc62aa.

Weber W, Mayer TE, Henkes H et al. Efficacy of stent angioplasty for symptomatic stenoses of the proximal vertebral artery. Eur J Radiol. 2005 Nov;56(2):240-7. PMID: 15961267. https://doi.org/10.1016/j.ejrad.2005.05.009.

Ogilvy CS, Yang X, Natarajan SK et al. Restenosis rates following vertebral artery origin stenting: does stent type make a difference? J Invasive Cardiol. 2010 Mar;22(3):119-24. PMID: 20197579.

Tang F, Wang Q, Hu C, Li P, Li L. Use of the Szabo technique to guide accurate stent placement at the vertebral artery ostium. J Endovasc Ther. 2013 Aug;20(4):554-60. PMID: 23914867. https://doi.org/10.1583/13-4298.1.

Jokhi P, Curzen N. Percutaneous coronary intervention of ostial lesions. EuroIntervention. 2009 Sep;5(4):511-4. PMID: 19755342. https://doi.org/10.4244/eijv5i4a81.

Sakurai R, Ako J, Morino Y, Sonoda S, Kaneda H, Terashima M, Hassan AH, Leon MB, Moses JW, Popma JJ, Bonneau HN, Yock PG, Fitzgerald PJ, Honda Y; SIRIUS Trial Investigators. Predictors of edge stenosis following sirolimus-eluting stent deployment (a quantitative intravascular ultrasound analysis from the SIRIUS trial). Am J Cardiol. 2005 Nov 1;96(9):1251-3. PMID: 16253592. https://doi.org/10.1016/j.amjcard.2005.06.066.

Szabo S, Abramowitz B, Vaitkus PT. New technique for aorto-ostial stent placement. Am J Cardiol. 2005;96:212H. https://doi.org/10.1016/j.amjcard.2005.09.057

Kern MJ, Ouellette D, Frianeza T. A new technique to anchor stents for exact placement in ostial stenoses: the stent tail wire or Szabo technique. Catheter Cardiovasc Interv. 2006 Dec;68(6):901-6. PMID: 17086534. https://doi.org/10.1002/ccd.20613.

Applegate RJ, Davis JM, Leonard JC. Treatment of ostial lesions using the Szabo technique: a case series. Catheter Cardiovasc Interv. 2008 Nov 15;72(6):823-8. PMID: 18798240. https://doi.org/10.1002/ccd.21723.

Salazar M, Kern MJ, Patel PM. Exact deployment of stents in ostial renal artery stenosis using the stent tail wire or Szabo technique. Catheter Cardiovasc Interv. 2009 Nov 15;74(6):946-50. PMID: 19496146. https://doi.org/10.1002/ccd.22116.

Jain RK, Padmanabhan TN, Chitnis N. Causes of failure with Szabo technique – an analysis of nine cases. Indian Heart J. 2013 May-Jun;65(3):264-8. PMID: 23809379; PMCID: PMC3861314. https://doi.org/10.1016/j.ihj.2013.04.023.

Ferrer-Gracia MC, Sánchez-Rubio J, Calvo-Cebollero I. Stent dislodgement during Szabo technique. Int J Cardiol. 2011 Feb 17;147(1):e8-9. PMID: 19203809. https://doi.org/10.1016/j.ijcard.2008.12.215.

Cherednichenko YuV. Opyt primeneniya modificirovannoj ankernoj tehniki stentirovaniya ustevyh porazhenij arterij golovy i shei. Endovaskulyarnaya nejroradiologiya. 2017;2:30-40. https://doi.org/10.1583/13-4298.1. (in Russian)

Sakaguchi M, Kitagawa K, Hougaku H et al. Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology. 2003 Sep 23;61(6):845-7. PMID: 14504337. https://doi.org/10.1212/01.wnl.0000078081.12097.ae.

Vajda Z, Miloslavski E, Güthe T et al. Treatment of stenoses of vertebral artery origin using short drug-eluting coronary stents: improved follow-up results. AJNR Am J Neuroradiol. 2009 Oct;30(9):1653-6. PMID: 19729536. PMCID: PMC7051514. https://doi.org/10.3174/ajnr.A1715.

Lin YH, Liu YC, Tseng WY et al. The impact of lesion length on angiographic restenosis after vertebral artery origin stenting. Eur J Vasc Endovasc Surg. 2006 Oct;32(4):379-85. PMID: 16682238. https://doi.org/10.1016/j.ejvs.2006.02.016.

Chakravarty T, White AJ, Buch M et al. Meta-analysis of incidence, clinical characteristics and implications of stent fracture. Am J Cardiol. 2010 Oct 15;106(8):1075-80. https://doi.org/10.1016/j.amjcard.2010.06.010.

How to Cite
Cherednychenko, Y., Miroshnychenko, A., Zorin, M., Dzyak, L., & Tsurkalenko, O. (2020). Optimization technique for stenting of ostial vertebral artery stenosis. Ukrainian Interventional Neuroradiology and Surgery, 34(4), 34-44. https://doi.org/10.26683/2304-9359-2020-4(34)-34-44