Comparison Between Medical Therapy And Endovascular Treatment Of The Extracranial Atherosclerotic Vertebral Artery Disease: A Systematic Review

Objective: To assess the potential benefit of endovascular treatment compared to medical treatment in patients with symptomatic extracranial vertebral artery (ECVA) atherosclerotic disease in terms of clinical outcomes through a systematic literature review of published reports. Methods: We identified ECVA studies published between January 1966 and December 2017 using a search on PubMed and Cochrane libraries supplemented by review of bibliographies of selected publications based on pre-specified criteria. The rates of stroke and stroke and/or death were estimated for best medical treatment and endovascular treatment, at 1 month and at last follow-up. A random effects model was used to calculate pooled proportions (PP) across all studies and 95% confidence intervals. Results: Of a total of 57 reports reviewed, 8 studies reported outcomes in patients receiving medical treatment only (362 patients) and 49 studies reported upon patients treated with endovascular approach (2142 patients). The mean age of patients in the medical group was 65.6 years (range 61.3 - 69.0 years) and 64.1 years (range 53.5 - 72 years ) in the endovascular group. The 30 day incidence of stroke was 26 (7.2%) in the medical treatment group compared to 18 (0.84%) in the endovascular group, resulting in a higher risk for patients in the best medical treatment when compared to endovascular treatment [PP 0.0559 vs. 0.0025; p-value = 0.0001)]. Similarly at follow-up, 33 (12.3 %) stroke were observed in the medical group compared to 51(2.4 %) in the endovascular group [PP 0.1027 vs. 0.0109 ; p-value = 0.0001)].There was also statistically difference in stroke related death in the medical group vs endovascular group 12 (4.5 % ) vs 1 (0.04% ) [PP 0.03309 vs. 0.0000 ;p-value =0.001] . There was no statistically significant difference in the rates of recurrent TIA or death to other causes between the two groups. Conclusion: Our analysis demonstrated that endovascular treatment significantly reduced the risk of stroke and death when compared to best medical treatment alone at 30 days and at follow-up. Randomized clinical trial is warranted for further understanding of the safety and efficacy of the endovascular treatment