Endovascular Strategies for In-Stent Restenosis Post Vertebral Artery Stenting

Introduction In‐stent restenosis (ISRS) is a major concern following vertebral artery (VA) ostial stenting, potentially leading to recurrent symptoms or ischemic strokes. Despite the growing use of endovascular treatment for VA ostial stenosis (VAOS), data on efficacy and safety of the endovascular re‐ treatment for ISRS is sparse. Aim of study To evaluate the incidence of ISRS after VA ostial stenting and assess the safety and effectiveness of endovascular re‐interventions. Methods This single‐center retrospective analysis included patients who underwent re‐treatment for ISRS >50% using either balloon angioplasty with a conventional or drug‐coated balloon (DCB), or re‐stenting with drug‐eluting balloon‐mounted stents (DES). The angiographic follow‐up was performed in all cases following re‐treatment. Periprocedural neurological events, need for re‐treatment, and follow‐up outcomes were systematically evaluated. Results Over a mean follow‐up period of 56 months (range: 9‐183 months) after 564 stenting procedures for VAOS in 525 patients, ISRS > 50% was observed in 89 stents (15.8%), with a mean time to diagnosis of 12.3 months (range: 1‐147 months) following the initial treatment. No recurrent strokes occurred after the initial stent angioplasty. One patient experienced a TIA, and six reported recurrent vertigos. Re‐treatment was performed in 88 cases, using DES in 43.2% and DCB in 56.8% of cases. No periprocedural strokes were observed. Recurrent ISRS was detected in 19 stents (21.6%) at a mean of 23.2 months (range: 4‐117 months) following re‐treatment. Tobacco use and dyslipidemia were significantly associated with the development of ISRS and its recurrence. Conclusion Re‐treatment with DES or DCB appears to be a safe and effective approach for managing high‐grade ISRS following VA ostial stenting. Addressing comorbidities and promoting lifestyle modifications may further reduce the risk of ISRS.