Clinical Scorecard: Endovascular Recanalization with Distal Protection for Symptomatic Chronic Occlusions of the Vertebrobasilar Artery

At a Glance

Key Highlights

• Non-acute occlusion defined as symptomatic complete occlusion >48 hours after last seen well, presumed atherosclerotic
• Endovascular recanalization with distal protection stent retriever technique aims to reduce ischemic and hemorrhagic complications
• Successful recanalization assessed by mTICI ≥ 2b; restenosis defined as ≥ 50% stenosis or ≥ 20% luminal loss at 6-month follow-up

Guideline-Based Recommendations

Diagnosis

• Confirm symptomatic intracranial VBA occlusion by angiography
• Exclude non-atherosclerotic causes such as vasculitis, dissection, or embolism
• Assess hemodynamic failure clinically and with imaging

Management

• Initiate dual antiplatelet therapy (aspirin 100 mg and clopidogrel 75 mg) at least 3 days before procedure
• Perform endovascular recanalization under general anesthesia using distal protection with stent retriever
• Use balloon angioplasty sequentially from distal to proximal segments after thrombus removal
• Withdraw stent after confirming absence of thrombus and stable antegrade flow

Monitoring & Follow-up

• Assess antegrade blood flow post-procedure using mTICI grading
• Perform digital subtraction angiography at 6 months to evaluate for restenosis
• Monitor for periprocedural complications including perforator stroke, vascular dissection, acute thrombosis, distal embolism, and hemorrhage

Risks

• Periprocedural ischemic complications such as perforator stroke and distal embolism
• Vascular dissection and acute thrombosis
• Hemorrhagic complications related to intervention

Patient & Prescribing Data

Eight patients (87.5% male, mean age 56) with symptomatic chronic intracranial VBA occlusion refractory to medical therapy

Distal protection with stent retriever during endovascular recanalization may decrease procedure-related complications and procedural time

Clinical Best Practices

• Careful patient selection excluding non-atherosclerotic occlusions and contraindications to antiplatelet therapy
• Pre-procedural dual antiplatelet therapy to reduce thrombotic risk
• Use of distal protection device (Syphonet stent) to capture thrombus and prevent distal embolization
• Sequential balloon angioplasty from distal to proximal to restore vessel patency
• Close angiographic monitoring during procedure to guide intervention and confirm recanalization

References

• Study on endovascular recanalization for intracranial VBA occlusion
• Modified thrombolysis in cerebral infarction (mTICI) grading