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BACKGROUND: Atherosclerotic occlusive disease of the vertebral artery (VA) affects a significant proportion of patients with cerebrovascular disease and can cause significant morbidity and mortality despite maximal medical therapy. Careful selection of both symptomatic and asymptomatic patients for intervention based on neurological symptoms, as well as anatomical and hemodynamic considerations, is essential. METHODS: To achieve proper results with angioplasty and stenting, standard endovascular techniques are modified for the unique anatomical considerations of the VA. Several technical nuances are described here to aid in the endoluminal revascularization of the VA. RESULTS: Technical success (<50% residual diameter stenosis) rates ranging from 94 to 98% and low rates of periprocedural complications have been achieved with VA angioplasty and stenting in select series with angiographic follow-up. The long-term success in those series is limited by the high (10-43%) rate of recurrent stenosis. Proper placement of the stent can reduce the risk of periprocedural complications and restenosis. In-stent stenosis appears most commonly during the first 6-12 months after stent placement, but does not appear to correlate with return of neurological symptoms. We believe the high rate of recurrent stenosis makes follow-up angiography essential, especially in the first 12 months after the procedure. CONCLUSION: Endovascular VA angioplasty with stent placement provides an innovative approach to treat a difficult clinical entity. Evolving therapies, including drug-eluting stents or bioresorbable stents, may prove to provide better long-term results. [ABSTRACT FROM AUTHOR]