Are people who have had either a stroke or ministroke less likely to have another if, in addition to lifestyle changes and medication, a balloon and stent are used to widen the blood vessels in the neck?

Key messages

• Adding a balloon or stent procedure (endovascular angioplasty to widen blood vessels in the neck) to standard treatment may make little to no difference to the chance of another stroke or mini-stroke (transient ischaemic attack (TIA)) compared with standard treatment alone.

• Our confidence in these findings is limited because the studies were small, three ended early, and participants and doctors knew which treatment was given, so the true effects may be better or worse than the results suggest.

• We need more, larger, and better-conducted studies to investigate this question. Future studies should focus on where and how serious the blood vessel narrowing is, what methods are used to address it, and follow people for longer.

What is vertebral artery stenosis?

The vertebral arteries are blood vessels that run from the collar bone alongside the spine in the neck to supply the back of the brain with blood. Over time, fatty deposits can build up on the walls of the blood vessels, making them narrow and restricting blood flow. This is called stenosis. In the studies in this review, some people had narrowing in the part of the vertebral artery outside the skull and others in the part inside the skull. This narrowing increases the risk of stroke or mini-stroke (transient ischaemic attack (TIA)). People have no symptoms, and the narrowing is only seen when scans are done. People who have had a stroke or mini-stroke because of narrowing in the blood vessels in the neck have 'symptomatic vertebral artery stenosis (VAS).'

How is symptomatic vertebral artery stenosis (VAS) treated?

Symptomatic VAS is treated by managing risk factors, for example, by quitting smoking, exercising, and losing weight. Medications that reduce blood clotting, control blood pressure and cholesterol, and manage diabetes are also used.

In some people, doctors insert a small tube (catheter) through an artery in the groin or wrist and guide it to the narrowed vertebral artery. A balloon is inflated to widen the narrowing, and sometimes a stent (tiny tube) is left in place to keep the artery open. This procedure is called 'endovascular angioplasty.'

Other operations, which are not the focus of this review (such as open surgical reconstruction, bypass surgery, and endarterectomy), have been used, but they are more invasive and may have different risks and recovery times.

What did we want to find out?

We wanted to find out whether adding endovascular angioplasty to standard treatment (lifestyle changes and medication) makes it less likely that people with symptomatic VAS will have another stroke or mini-stroke compared to those receiving standard care alone. We also wanted to know if it reduces the risk of death or serious complications (such as restenosis) and increases participants' everyday function.

What did we do?

We searched for randomised controlled studies that investigated endovascular angioplasty plus standard treatment compared with standard treatment alone in people with symptomatic VAS.

We compared and combined the results. We rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 429 people with symptomatic VAS (mostly male) and an average age of 63 years. Of these, 231 participants received endovascular angioplasty plus standard treatment, and 198 people received standard treatment alone. Some had narrowing inside the skull and others outside it.

Three trials ended early, and it was not possible to keep people and doctors unaware of which treatment was given. Overall, adding the procedure to medical treatment may make little or no difference to death or stroke within 30 days, or to stroke, TIA, or death during follow-up. A few people had serious complications from the procedure. No studies reported results for restenosis (narrowing of the vessel again) or good functional outcomes. Follow-up was short-term (within 30 days of treatment) or longer-term (from 30 days, ranging from 32 to 42 months after treatment).

Main results

For people with symptomatic VAS, adding endovascular angioplasty to standard treatment may make little or no difference to:

• short-term (30-day) death or stroke (4 studies; 429 participants);

• longer-term stroke () from the treated vertebral artery (4 studies; 429 participants);

• any stroke, death, or mini-stroke during the entire follow-up period (4 studies; 429 participants). A few people had serious complications from the procedure. No studies reported results for restenosis or good functional outcome.

What are the limitations of the evidence?

Our confidence in the evidence is low for several reasons:

• Studies were small, and few people who took part had had a stroke or mini-stroke.

• Three studies finished early, so they did not report all the data we wanted.

• People in the studies knew which treatment they were getting, which may influence the results.

• Three studies were completed between 2014 and 2017, so they did not use the most up-to-date techniques, stents, and treatments.

How up-to-date is this evidence?

This evidence is current to 9 December 2025.