Comparison of Drug-Coated Balloons to Bare Metal Stents in the Treatment of Symptomatic Vertebral Artery-Origin Stenosis: A Prospective Randomized Trial

Percutaneous transluminal angioplasty for vertebral artery origin stenosis under the flow-reversal protection using Mo.MA™ Ultra: A technical case report

Background

Vertebral artery origin stenosis (VAOS) is a major cause of ischemic stroke of the posterior circulation. Aggressive medical treatment using dual antiplatelet therapy is the most common treatment approach to symptomatic VAOS; however, the effectiveness of endovascular treatment (EVT) for VAOS has recently been reported. Here, we report a case of VAOS treated with percutaneous transluminal angioplasty (PTA) under flow reversal protection using Mo.MA™ Ultra.

Case Description

The patient was a 78-year-old man. He underwent mechanical thrombectomy for acute right posterior cerebral artery occlusion, and recanalization was achieved. Subsequently, artery-to-artery (A-to-A) embolism caused by the right VAOS was revealed as the etiology. PTA under the flow-reversal protection using Mo.MA™ Ultra was performed electively, and the VAOS and antegrade flow of the right vertebral artery (VA) improved.

Conclusion

In EVT for symptomatic VAOS, lesion cross for distal protection device placement is considered to create a high risk of distal embolism due to the anatomic and clinicopathological characteristics of VAOS lesions, especially in A-to-A embolism cases. The flow-reversal protection using Mo.MA™ Ultra can be performed with EVT to prevent distal embolism with lesion cross by retrograde flow of the VA. This method is feasible, especially for cases in which antegrade flow to the basilar artery through the developed contralateral VA is anticipated during the Mo.MA™ Ultra protection.

Microsurgical revascularization of a symptomatic proximal vertebral artery: pilot experiences from a single center

Background

Vertebral artery stenosis and occlusion (VASO) is a high-risk factor for posterior circulation stroke. Post-stent restenosis and drug tolerance have facilitated the exploration of microsurgical vascular reconstruction. This study aims to evaluate the safety and efficacy of microsurgical reconstruction of the proximal VA.

Methods

Twenty-nine patients (25 men, aged 63.2 years) who had symptoms of posterior circulation ischemia underwent microsurgical revascularization for proximal VASO were retrospectively included in this study. Procedural complications and clinical and angiographic outcomes were reviewed.

Results

Twelve, three, and five patients underwent VA endarterectomy, artery transposition, or both, respectively; seven patients underwent vertebral endarterectomy plus stent implantation; and two patients failed surgery because of the difficult exposure of the VA and the occurrence of vascular dissection. The perioperative period-related complications included seven cases of Horner's syndrome, five cases of hoarseness, and one case of chylothorax. No cases of perioperative stroke or death were reported. The mean follow-up period was 28.4 (8-62 months). Most patients improved clinically; however, the vertebrobasilar ischemia symptoms did not decrease significantly in two patients during the follow-up. Moreover, follow-up imaging was performed in all the patients, and no signs of anastomotic stenosis were reported.

Conclusion

Microsurgical reconstruction is an alternative option that can effectively treat refractory proximal VASO disease and in-stent stenosis, with a high rate of postoperative vascular recirculation. Prospective cohort studies with larger sample sizes must be conducted to validate the above conclusions.

Evaluation of coronary stents: A review of types, materials, processing techniques, design, and problems

In the world, one of the leading causes of death is coronary artery disease (CAD). There are several ways to treat this disease, and stenting is currently the most appropriate way in many cases. Nowadays, the use of stents has rapidly increased, and they have been introduced in various models, with different geometries and materials. To select the most appropriate stent required, it is necessary to have an analysis of the mechanical behavior of various types of stents. The purpose of this article is to provide a complete overview of advanced research in the field of stents and to discuss and conclude important studies on different topics in the field of stents. In this review, we introduce the types of coronary stents, materials, stent processing technique, stent design, classification of stents based on the mechanism of expansion, and problems and complications of stents. In this article, by reviewing the biomechanical studies conducted in this field and collecting and classifying their results, a useful set of information has been presented to continue research in the direction of designing and manufacturing more efficient stents, although the clinical-engineering field still needs to continue research to optimize the design and construction. The optimum design of stents in the future is possible by simulation and using numerical methods and adequate knowledge of stent and artery biomechanics.

Using drug-coated balloons for symptomatic vertebral artery origin stenosis: A systematic review and meta-Analysis

BACKGROUND

Endovascular stenting has emerged as an effective treatment for patients with symptomatic vertebral artery origin stenosis (VAOS), but the incidence of severe restenosis is concerning. Angioplasty alone with a drug-coated balloon (DCB) is a potential treatment for VAOS. The purpose of this systematic review and meta-analysis was to assess the utility of DCB angioplasty for VAOS.

METHODS

A systematic search of the Medline (PubMed), Embase, CNKI, and Cochrane databases for studies on the treatment of VAOS by DCB angioplasty published in English and Chinese before June 15, 2022 was conducted. Data were extracted using standardized methods. The incidence rates of restenosis, technical success, and perioperative complication in the follow-up period were pooled using Freeman-Tukey double arcsine transformation with random or fixed-effect models. Tests for heterogeneity and publication bias were performed.

RESULTS

A total of seven studies containing 159 patients were included in this review and meta-analysis. The pre-treatment stenosis rate of the vertebral artery in the DCB group ranged from 70.0 % to 86.3 %, and the median follow-up time ranged from 6.0 to 14.1 months. The pooled restenosis incidence was 11.9 % (95 % CI: 3.4 %-23.4 %; I² = 59 %, p = 0.02) during the follow-up period. The pooled technical success rate was 96.6 % (95 % CI: 91.4 %-99.7 %; I² = 37 %, p = 0.14). The overall perioperative complication rate was 2.9 % (95 % CI: 0.3 %-6.9 %; I² = 0 %, p = 0.64). According to the funnel diagram and Egger's test, there was no evidence of publication bias.

CONCLUSION

It is suggested in this review and meta-analysis that angioplasty with DCB may be a potential treatment for VAOS. However, randomized studies including a large representative sample of VAOS patients are needed to validate our findings.

Risk factors for in-stent restenosis after vertebral artery stenting of V1 segment: A systematic review and meta-analysis

OBJECTIVE

In-stent restenosis (ISR) remains a challenge in the treatment of vertebral artery V1 segment stenosis. The aim of this meta-analysis is to identify the risk factors of ISR.

METHODS

Studies eligible for inclusion criteria were found in PubMed, Embase, and Cochrane Library databases. Data related to risk factors of ISR were extracted from the included studies, and pooled analysis was performed when data of the same factor were available in ≥2 studies. Dichotomous outcomes were analyzed with odds ratios (OR) and continuous outcomes were analyzed with a weighted mean difference (WMD). The Stata 14.0 program was used for the meta-analysis.

RESULTS

A total of 11 studies involving 1356 patients were included in our analysis. Pooled analyses showed that younger age (p = 0.01; WMD= -1.958; 95% confidence interval [CI], -3.453 to -0.463) and V1 tortuosity (p = 0.004; OR = 4.145; 95% CI, 1.56-11.012) significantly associated with higher risk of ISR in V1 segment stenting. While bare-metal stents, stent diameter and length, diabetes mellitus, coronary artery disease, and smoking were not found to increase ISR rates.

CONCLUSIONS

This meta-analysis showed that young age and V1 tortuosity increase the ISR rates after vertebral V1 segment stenting.

A Comparison of Different Endovascular Treatment for Vertebral Artery Origin Stenosis

OBJECTIVE

To compare the safety and efficacy of stenting with drug-eluting stent (DES), stenting with bare mental stent (BMS), and angioplasty alone with drug-coated balloon (DCB) in patients with symptomatic vertebral artery origin stenosis (VAOS) who did not respond to aggressive medical management.

METHODS

We performed a retrospective analysis of consecutive patients with symptomatic VAOS who underwent endovascular treatment between December 2018 and November 2021 at our institution. The main outcome compared were technical success, perioperative complications, residual stenosis, stroke recurrence, progression of residual stenosis, and restenosis.

RESULTS

A total of 46 patients were included: 29 were stented with DES, 12 were stented with BMS, and 5 received angioplasty alone with DCB. Technical success was achieved in 100%, 100%, and 60%, respectively (P = 0.008). Residual stenosis was 10.8%, 20.2%, and 51.2%, respectively (P < 0.001). Perioperative complications occurred only in 1 case in the DES group (P = 1.00). During a mean follow-up of 14.1 months, stroke recurrence rate was 6.9%, 16.7%, and 0% respectively (P = 0.73). Absolute progression of residual stenosis was 10.1%, 34.9%, and -8.0%, respectively (P < 0.001). Restenosis rate was 6.9%, 50.0%, and 20.0%, respectively (P = 0.007).

CONCLUSIONS

In patients with symptomatic VAOS who did not respond to aggressive medical management, stenting with DES shows superiority in the lowering the restenosis rate compared with stenting with BMS. Angioplasty alone with DCB is associated with the slowest progression of stenosis in spite of moderate residual stenosis.

A retrospective study of drug-coated balloon angioplasty for vertebral artery origin stenosis

PURPOSE

Angioplasty using drug-coated balloon (DCB) for treatment of symptomatic vertebral artery origin stenosis (VAOS) is promising, but of uncertain benefit. This study aimed to evaluate the feasibility, safety, and effectiveness of using DCB in the treatment of severe VAOS.

METHODS

This study included 20 patients with severe VAOS treated with DCB alone between April 2018 and December 2019. Vascular death, transient ischemic attack (TIA), and stroke related to the responsible artery within 30 days after procedure were recorded as primary endpoints. Restenosis, late TIA, and stroke related to VAOS and satisfied clinical outcome [modified Rankin Scale (mRS) ≤ 2] were documented at follow-up visit as secondary endpoints.

RESULTS

Of 20 patients, 16 were performed DCB dilation successfully, and 4 were excluded due to further bailout stenting. After the procedure, no adverse event occurred within 30 days. Ten of 16 patients achieved residual VAOS (rVAOS) < 50% (lower rVAOS group), and the remaining 6 patients achieved rVAOS ≥ 50% but < 70% (higher rVAOS group). During follow-up, vertebral artery origin restenosis was detected in 3 (18.8%) of 16 patients by ultrasound. Among the 3 patients with restenosis, 2 were belonged to the higher rVAOS group, which might indicate a tendency that the more severe the residual stenosis, the higher the restenosis rate. All patients had no complaint in the whole follow-up period (median, 7 months; InterQuartile Range, 1-18 months).

CONCLUSIONS

Angioplasty using DCB for VAOS may be feasible, safe, and effective. The degree of residual stenosis after using DCB alone may affect the restenosis rate.