Guideline sources The following summarized guidelines for the evaluation and management of vertebral artery stenosis (VAS) 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 2 3 Guidelines 1. Screening and diagnosis Indications for screening: obtain full vascular assessment in all patients being candidates for heart transplantation or cardiac assist device implantation. B 2. Diagnostic investigations Vertebral arter imaging: https://web.pathway.md/diseases/recDZ4lmEcHOQ3kH8 1/5 6/29/23, 3:42 AM Vertebral artery stenosis Pathway Vertebral artery imaging: As per ESVS 2023 guidelines: Obtain computed tomographic angiography or contrast-enhanced MRA as first-line vascular imaging in patients with suspected vertebrobasilar ischemia. B 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. D As per AHA 2011 guidelines: Obtain CT angiography or MRA for detection of vertebral artery disease as part of the initial evaluation of patients with neurological symptoms referable to the posterior circulation, and in patients with subclavian steal syndrome. B Obtain CT angiography or MRA rather than ultrasound for evaluation of the vertebral arteries in patients with symptoms of posterior cerebral or cerebellar ischemia. B 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. C 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. A Show 4 more Management of hypertension: As per ESC 2018 guidelines: Target controlling BP at < 140/90 mmHg in patients with PAD and hypertension. A Consider offering ACEIs or ARBs as first-line therapy in patients with PAD and hypertension. C As per AHA 2011 guidelines: Initiate antihypertensive therapy in patients with hypertension and asymptomatic extracranial vertebral artery atherosclerosis to maintain BP < 140/90 mmHg. A Consider initiating antihypertensive therapy in patients with hypertension (except during the hyperacute period) and symptomatic extracranial vertebral artery atherosclerosis. Insufficient evidence to recommend a specific target BP (such as < 140/90 mmHg). C Management of dyslipidemia: As per ESC 2018 guidelines: Offer statins in all patients with PADs. A https://web.pathway.md/diseases/recDZ4lmEcHOQ3kH8 2/5 6/29/23, 3:42 AM Vertebral artery stenosis Pathway Target reducing LDL cholesterol to < 1.8 mmol/L (< 70 mg/dL) or decreasing it by 50% if baseline values are 1.8-3.5 mmol/L (70-135 mg/dL). B As per AHA 2011 guidelines, initiate statin therapy in all patients with extracranial vertebral artery atherosclerosis to reduce LDL cholesterol to < 100 mg/dL. B Show 4 more Management of diabetes mellitus: As per ESC 2018 guidelines, obtain strict glycemic control in patients with diabetes mellitus and PAD. B As per AHA 2011 guidelines, consider offering dietary modifications, exercise and glucose- lowering therapy in patients with diabetes mellitus and extracranial carotid artery atherosclerosis. Insufficient evidence to support the use of intensive glucose-lowering therapy to a HbA1c level < 7.0%. B 5. Nonpharmacologic interventions Lifestyle modifications: As per ESC 2018 guidelines, advise smoking cessation B , healthy diet and physical activity in all patients with PADs. B As per AHA 2011 guidelines, advise patients with extracranial vertebral artery atherosclerosis to quit smoking, if applicable, and offer smoking cessation interventions to reduce the risks of atherosclerosis progression and stroke. B 6. Therapeutic procedures Revascularization: As per ESVS 2023 guidelines, do not perform open or endovascular interventions in patients with asymptomatic vertebral artery atherosclerotic lesions. D Show 3 more As per ESC 2018 guidelines: Consider performing revascularization in patients with symptomatic extracranial VAS ( 50%) with recurrent ischemic events despite optimal medical management. C Do not perform revascularization in patients with asymptomatic VAS, irrespective of the degree of severity. D 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. D 8. Follow-up and surveillance Serial imaging surveillance: https://web.pathway.md/diseases/recDZ4lmEcHOQ3kH8 3/5 6/29/23, 3:42 AM Vertebral artery stenosis Pathway As per ESVS 2023 guidelines: Do not obtain serial surveillance with catheter angiography in patients undergoing vertebral artery interventions. D Consider obtaining serial noninvasive imaging surveillance in patients undergone an open or endovascular vertebral artery intervention. C As per AHA 2011 guidelines: Consider obtaining serial noninvasive imaging of the extracranial vertebral arteries to assess the progression of atherosclerotic disease and exclude the development of new lesions in patients with symptoms of posterior cerebral or cerebellar ischemia. C Consider obtaining serial noninvasive imaging of the extracranial vertebral arteries at intervals similar to those for carotid revascularization (1 month, 6 months, and annually after revascularization) in patients undergone vertebral artery revascularization. C 9. Quality improvement Hospital requirements: healthcare centers should set up a multidisciplinary vascular team to make decisions for the management of patients with PADs. B Public health measures: implement and support initiatives to improve medical and public awareness of PADs, especially cerebrovascular and lower extremity artery diseases. B Clinical findings Patient demographics Symptoms Age > 50 Blurry vision Confusion Past medical history Difficulty speaking Dizziness Coronary artery disease Double vision Diabetes mellitus Dysarthria Dyslipidemia Dysphagia FMD Facial numbness Hypertension Headache Obesity Hearing loss Stroke Hiccups TIA Loss of balance Social history Loss of consciousness Nausea Cigarette smoking Neck pain Physical inactivity Syncope Tinnitus Vertigo Visual hallucinations Vomiting https://web.pathway.md/diseases/recDZ4lmEcHOQ3kH8 4/5 6/29/23, 3:42 AM Vertebral artery stenosis Pathway Family history Vertebral artery stenosis Neurological exam Ataxia Hemiparesis Lethargy Nystagmus Visual field defect References 1. Brott TG, Halperin JL, Abbara S et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011 Jul 26;124 4 489 532. Open 2. Ross Naylor, Barbara Rantner, Stefano Ancetti et al. Editor's Choice European Society for Vascular Surgery ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65 1 7 111. Open 3. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E L Bartelink et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery ESVS Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization ESO The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology ESC and of the European Society for Vascular Surgery ESVS . Eur Heart J. 2018 Mar 1;39 9 763 816. Open 4. Naylor AR, Ricco JB, de Borst GJ et al. Editor's Choice Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery ESVS . Eur J Vasc Endovasc Surg. 2018 Jan;55 1 3 81. Open https://web.pathway.md/diseases/recDZ4lmEcHOQ3kH8 5/5