Stenting for Symptomatic Vertebral Artery Stenosis: The Vertebral Artery Ischaemia Stenting Trial - Journal of Vascular Surgery

Stenting in extracranial stenosis appears safe with low complication rates. This study provides class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting. Large phase 3 trials are required to determine whether stenting reduces stroke risk. The objective of this study is to compare the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis. The Vertebral Artery Ischaemia Stenting Trial (VIST) was a prospective, randomized, open-blinded end point clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis > 50% (confirmed on angiogram) were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial versus intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants but for adequate power was estimated to need 245 per group. Follow-up was a minimum of >1 year for each participant. Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1-4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; two strokes occurred during intracranial stenting. The primary end point of fatal or nonfatal stroke in any arterial territory occurred in five patients in the stent group versus 12 in the medical group (hazard ratio 0.40; 95% confidence interval 0.14-1.13; P = .08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The secondary end points were stroke and transient ischemic attack (TIA) during follow-up, posterior circulation stroke (including periprocedural) during follow-up, fatal/nonfatal stroke in any arterial territory within 90 days of randomization, and all cause death during follow-up. The hazard ratio for stroke or TIA was 0.50 (P = .05). The hazard ratio in patients with extracranial and intracranial vertebral artery stenosis was 0.37 (95% CI 0.10-1.36) and 0.47 (95% CI 0.08-2.60), respectively. Other secondary end points demonstrated no difference between groups. There was no difference between groups in terms of adverse events. Past studies treating patients