Factors affecting in-stent restenosis after angioplasty with the Enterprise stent for intracranial atherosclerotic diseases

Comparison of the safety and efficacy of Neuroform Atlas stent deployed via Gateway balloon catheter and microcatheter for the treatment of intracranial stenosis

OBJECTIVE

This study aimed to compare the safety and efficacy of the Atlas stent released by the Gateway catheter and microcatheter in the treatment of intracranial stenosis (IS).

METHODS

The primary efficacy and safety outcomes were the in-stent restenosis (ISR) rate and post-procedural stroke or death within one month.

RESULTS

Atlas stents were deployed using the Gateway catheter and microcatheter in 19 (57.6 %) and 14 (42.4 %) procedures, respectively. Follow-up imaging data were available for 26 patients; the incidence of ISR was 15.4 %, and the ISR rate was higher, though not significantly, in the microcatheter group than in the Gateway group (30.0% vs. 6.25 %, P = .39). Clinical follow-up data were available for 30 patients; the post-procedural stroke rate was 3.3 % within one month and 13.3 % from one month to one year. The post-procedural stroke rate within one month was higher, though not significantly, in the microcatheter group than in the Gateway group (7.7% vs. 0 %, P = .43). The Gateway group had a significantly lower rate of post-procedural stroke in the same territory than that of the microcatheter group (0% vs. 30.8 %, P = .026). A higher incidence of residual stenosis <30 % was found in the non-ISR group than in the ISR group (72.2% vs. 0 %, P = .014).

CONCLUSIONS

This study provides preliminary evidence that the Atlas stent is safe and effective for IS treatment. The use of the Gateway catheter to deliver the Atlas stent appears to be safer than using microcatheter. The incidence of ISR may be related to the degree of the residual stenosis.

Enterprise stents for the treatment of symptomatic non-acute intracranial artery stenosis disease: safety and efficiency evaluation

BACKGROUND

Enterprise stent was approved for the treatment of wide-necked intracranial aneurysms. However, it has been widely used in the endovascular treatment of intracranial artery stenosis, which is still controversial. The purpose of this study was to evaluate the safety and efficiency of the Enterprise stent in the endovascular treatment of intracranial artery stenosis disease.

METHODS

We conducted a retrospective case series of 107 patients with intracranial artery stenosis who received Enterprise stent implantation at Nanjing Drum Tower Hospital from January 2020 to December 2022. The rates of recanalization, perioperative complications, in-stent restenosis at 3-12 months and stroke recurrence were assessed for endovascular treatment.

RESULTS

A total of 107 individuals were included in this study, 88 were followed up, and 19 (17.8%) patients were lost to follow-up. The operation success rate was 100%, During the procedure,4（3.7%）patients had vasospasm, and 2(1.9%) patients showed symptomatic bleeding. The overall perioperative complication rate was 5.6%, including 2.8% distal artery embolism, 0.9% in-stent thrombosis, and 1.9% symptomatic bleeding. 88 (82.2%) patients were followed up from 3 to 12 months, of whom 12 (13.6%) had in-stent restenosis, 4 (4.7%) recurrent strokes and 2 died of pulmonary infection caused by COVID-19. Patients were divided into 3 groups according to the cerebral artery, including the middle cerebral artery group, internal carotid artery group, and vertebrobasilar artery group.

CONCLUSIONS

In this study, the placement of the Enterprise stent in patients with symptomatic non-acute intracranial stenosis was successful. However, the occurrence of periprocedural and long-term complications after stenting remains of high concern.

Safety and Efficacy of LVIS Jr Stent-assisted Coiling of Intracranial Aneurysms in Small-diameter Parent Arteries : A Single-center Experience

OBJECTIVE

To investigate the safety and efficacy of LVIS Jr stent-assisted coiling (SAC) of intracranial aneurysms (IAs) in small-diameter parent arteries and determine the factors influencing incomplete aneurysm occlusion.

MATERIAL AND METHODS

Clinical and imaging data of 130 patients with IAs in small-diameter parent arteries that were treated with LVIS Jr SAC were retrospectively analyzed. Stent apposition was evaluated by high-resolution flat detector CT, and aneurysm embolization density was evaluated using 2D-DSA. Perioperative complications were recorded. Multivariate logistic regression analyses were performed to determine possible factors for incomplete aneurysm occlusion.

RESULTS

In this study, 130 patients (60 and 70 patients with ruptured and unruptured aneurysms, respectively) were successfully treated with LVIS Jr SAC. Immediate digital subtraction angiography (DSA) showed that the aneurysm occlusion was Raymond-Roy class I, II, IIIa, and IIIb in 93 (71.5%), 24 (18.5%), 8 (6.2%), and 5 (3.8%) cases, respectively. There were three cases of acute in-stent thrombosis and two cases of severe vasospasm observed during the perioperative period. The 6‑month follow-up angiograms indicated that complete aneurysm occlusion in 122 patients was 79.5% (97/122). Multivariate logistic regression analyses showed that an aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck were possible risk factors for incomplete aneurysm occlusion.

CONCLUSION

The LVIS Jr SAC is effective for managing IAs in small-diameter parent arteries. An aneurysm size > 10.0 mm, parent artery mean diameter < 2.0 mm, and incomplete stent apposition at the aneurysm neck are possible risk factors for incomplete aneurysm occlusion.

The Enterprise stent…still useful after all these years

BACKGROUND

The Enterprise stent (Codman Neuro, Massachusetts, USA) received Food and Drug Administration (FDA) approval in 2007 for stent-assisted coiling (SAC). Since its introduction, newer stents and devices for aneurysm treatment have been developed resulting in a shift in the utilization of this stent from SAC to other off-label indications.

OBJECTIVE

To describe our experience with the Enterprise stent being used for SAC and other off-label indications.

METHODS

This is a multi-center retrospective review of the use of the Enterprise stent between 2018 and 2023. All patients in which the Enterprise stent was successfully deployed were included in the study.

RESULTS

Our study cohort comprised of 194 patients, mostly females (n = 112, 57.7%), with a mean age of 63.2 years ± 14.3. The Enterprise stent was used for SAC in only 24 (12.4%) patients and was used for rescue stenting in stroke in 101 patients (52.1%), treatment of intracranial stenosis in 53 patients (27.3%), treatment of in-stent stenosis in 1 patient (0.5%), and for treatment of dissections in 15 patients (7.7%). From 2018 to 2023, the use of Enterprise stents for SAC significantly decreased (p < 0.0001) while the use of Enterprise stents for non-SAC purposes was insignificantly variable (p = 0.05).

CONCLUSION

Our study shows that the Enterprise stent remains a reliable tool in neuroendovascular procedures, even if its original intended use has been supplanted by other devices.

Short-term outcome of stenting with Enterprise stents for symptomatic intracranial atherosclerotic disease at a single center

OBJECTIVE

To evaluate the safety and efficacy of stenting for symptomatic intracranial atherosclerotic severe stenosis or occlusion with Enterprise stents.

METHODS

Fifty-three consecutive patients with symptomatic intracranial atherosclerotic severe (70%-99%) stenosis or occlusion who underwent endovascular treatment with Enterprise stents between September 2019 and March 2022 were retrospectively analyzed. Primary outcomes included technical stenting success rates, the incidence of complications within 30 days of the procedure, and the in-stent restenosis rates during the follow-up period. These outcomes were further categorized based on lesion location and operation time.

RESULTS

Fifty-seven lesions in 53 patients aged 61.0 ± 10.0 years were treated with Enterprise stents with a technical success rate of 100%. Seven patients (12.3%) had severe complications within 30 days of the procedure: five had a symptomatic ischemic stroke, one had a symptomatic intracerebral hemorrhage, and one had a subarachnoid hemorrhage related to the procedure. No deaths were observed. The rate of in-stent restenosis was 18.2%, with a mean vascular imaging follow-up period of 6.7 months. The 30-day complication and in-stent restenosis rates did not differ significantly between patients with different lesion locations and operation times (P > 0.05).

CONCLUSION

This retrospective study suggests that percutaneous transluminal angioplasty and stenting with Enterprise stents is an effective treatment for symptomatic intracranial arterial stenosis or occlusion with a high technical success rate. It also indicates that stenting during the early nonacute stage after stroke may not increase the incidence of perioperative complications for symptomatic intracranial atherosclerotic stenosis when following strict inclusion criteria.

Novel technique of stent placement via gateway balloon in intracranial atherosclerosis-associated large vessel occlusion

BACKGROUND AND PURPOSE

Neuroform Atlas stent can be deployed directly via gateway balloon for angioplasty and stent placement without the need for exchange maneuver required for Wingspan stent use. We present our initial experience of this strategy in intracranial atherosclerosis-associated large vessel occlusions.

METHODS

Patients were identified through mechanical thrombectomy (MT) database from January 2020 to June 2022 at our institutions. Due to reocclusion or impending occlusion, rescue angioplasty with stent placement was performed after initial standard MT. Primary outcomes were good angiographic recanalization with modified thrombolysis in cerebral infarction (mTICI) score of 2b-3, rate of intracranial hemorrhage (ICH), and favorable functional outcome at 3 months, that is, modified Rankin Scale (mRS) score of 0-3.

RESULTS

We identified 22 patients treated using this technique. Among those, 11 were females with their average age at 66 years (range: 52-85). Initial median National Institute of Health Stroke Scale score was 11 (range: 5-30) and all patients received loading doses of aspirin and P2Y₁₂ inhibitor. After performing submaximal angioplasty and Neuroform Atlas stent deployment through the gateway balloon, we achieved final mTICI of 2b-3 in 20 (90%) patients. One patient had ICH post-op that was asymptomatic. Eight (36%) patients had mRS of 0-3 at 90 days.

CONCLUSION

Our preliminary experience suggests possible safety and feasibility of deploying Neuroform Atlas stent through a compatible Gateway balloon microcatheter without the need for ICH-associated microcatheter exchange. Further studies with long-term clinical and angiographic follow-up are warranted to corroborate our initial findings.

Identifying risk factors for in-stent restenosis in symptomatic intracranial atherosclerotic stenosis: a systematic review and meta-analysis

Background

In-stent restenosis (ISR) is an adverse and notable event in the treatment of intracranial atherosclerotic stenosis (ICAS) with percutaneous transluminal angioplasty and stenting (PTAS). The incidence and contributing factors have not been fully defined. This study was performed to evaluate factors associated with ISR after PTAS.

Data source

We identified studies on ISR after PTAS from an electronic search of articles in PubMed, Ovid MEDLINE, and the Cochrane Central Database (dated up to July 2022).

Results

A total of 19 studies, including 452 cases of ISR after 2,047 PTAS, were included in the meta-analysis. The pooled incidence rate of in-stent restenosis was 22.08%. ISR was more likely to occur in patients with coronary artery disease (OR = 1.686; 95% CI: 1.242-2.288; p = 0.0008), dissection (OR = 6.293; 95% CI: 3.883-10.197; p < 0.0001), and higher residual stenosis (WMD = 3.227; 95% CI: 0.142-6.311; p = 0.0404). Patients treated with Wingspan stents had a significantly higher ISR rate than those treated with Enterprise stents (29.78% vs. 14.83%; p < 0.0001).

Conclusions

The present study provides the current estimates of the robust effects of some risk factors for in-stent restenosis in intracranial atherosclerotic stenosis. The Enterprise stent had advantages compared with the Wingspan stent for ISR. The significant risk factors for ISR were coronary artery disease, dissection, and high residual stenosis. Local anesthesia was a suspected factor associated with ISR.

Optional or optimal? off-label stenting for intracranial atherosclerotic stenosis: A scoping review

BACKGROUND

Intracranial atherosclerotic stenosis is a major cause of ischemic stroke. In addition to the Wingspan stent system, several self-expanding stents have been used off-label to treat intracranial atherosclerotic stenosis lesions. The purpose of this review is to assess the existing data on the off-label use of self-expanding stents in intracranial atherosclerotic stenosis, to highlight methodological limitations in current study designs, and thus providing strategies and precautions for clinical practice.

METHODS

The PubMed, EMBASE, and the Cochrane Library databases were systematically searched for relevant articles published up to April 2022. In addition to the meta analysis of Enterprise, Neuroform EZ and closed cell stent respectively, we used a narrative synthesis to summarize and discuss the appropriate strategies and precautions for the use of each stent.

RESULTS

We identified 17 studies (1091 patients with 1124 lesions) reporting 6 types of off-label self-expanding stents. The most common endpoints reported were incidence of short-term complications (range: 0-15.8%, median: 3.8%), long-term complications (range: 0-12.0%, median: 0%). Potential risks include infeasibility of stenting hard lesions or tortuous vessels, stent migration, and in-stent thrombosis. Less is known about the conditions that are appropriate for an optimal stent (e.g., open-cell, close-cell, hybrid cell). There was considerable heterogeneity across studies with regards to study populations and study designs.

CONCLUSIONS

The potential risks and benefits should be carefully considered when using off-label stents for intracranial atherosclerotic stenosis, particularly given the current evidence power. As a potential option for the Wingspan stent, based on device's approval only, a tailored approach with lesion-specific devices could be beneficial in certain patients.

Effects of endovascular recanalization on symptomatic non-acute occlusion of intracranial arteries

To investigate the effect and safety of recanalization surgery for non-acute occlusion of large intracranial arteries and factors affecting clincial outcomes. Patients with non-acute occlusion of internal carotid artery (ICA), middle cerebral artery (MCA), and vertebrobasilar artery (VBA) treated with recanalization were retrospectively enrolled. The clinical and angiographic data were analyzed. 177 patients were enrolled, including 67 patients with intracranial ICA occlusion, 52 with MCA occlusion, and 58 with VBA occlusion. Successful recanalization was achieved in 152 (85.9%) patients. Complications occurred in 15 patients (8.5%). Followed up for 3-7 months, the 90 day mRS was significantly improved compared with that before the procedure. Among 152 patients with successful recanalization, eight patients experienced reocclusion (5.3%), and 11 patients experienced restenosis (7.2%). Successful recanalization was significantly (P < 0.05) associated with occlusion duration, calcification or angulation of the occluded segment. Complications were significantly (P < 0.05) associated with location of occlusion, hyperlipidemia, and patients' height. Restentosis or reocclusion at follow-up was significantly (P < 0.05) associated with complications and mRS at 90 days. The significant (P < 0.05) independent risk factors were angulation and calcification for successful recanalization, hyperlipidemia for complications, and mRS at 90 days for restenosis or reocclusion at follow-up. Recanalization surgery may be a safe and effective approach for patients with non-acute symptomatic occlusion of large intracranial arteries, and factors significantly independently associated with successful recanalization, periprocedural complications and restenosis or reocclusion after surgery have been identified for future reference to improve clinical outcomes.

Anterior cerebral artery dissection for a patient with ipsilateral aplastic or twig-like middle cerebral artery: An illustrative case report

Background

An aplastic or twig-like middle cerebral artery (Ap/T-MCA) is a rare anomaly, which sometimes causes ischemic infarction. Collateral flow from the ipsilateral anterior cerebral artery (ACA) is important for patients with Ap/T-MCA. If ipsilateral ACA stenosis or occlusion occurs, a large infarction with a wider field than the ACA territory could happen. First, mechanical thrombectomy was performed for the right ACA near occlusion caused by arterial dissection with ipsilateral Ap/T-MCA in this case. Second, Wingspan stenting was performed for the right ACA restenosis.

Case Description

A 77-year-old female presented to the hospital with the left hemiparesis. We diagnosed a right ACA infarction caused by right ACA occlusion. Digital subtraction angiography showed right Ap/T-MCA and ipsilateral ACA near occlusion. Thrombectomy was performed, and recanalization was achieved with mild ACA stenosis. The lesion was the dissection due to angiographical finding. Two months after treatment, transient left hemiparesis occurred and right ACA stenosis progressed. Computed tomography perfusion showed hypoperfusion of the right hemisphere. Wingspan stenting was performed from the left internal carotid artery through the anterior communicating artery with an intermediate catheter. The patient was discharged without any neurological deficit.

Conclusion

We reported the first case of a patient who underwent Wingspan stenting for the right ACA dissection with Ap/T-MCA. Short-term follow-up and aggressive intervention should be considered for collateral pathway dissection with Ap/T-MCA because the symptoms can become serious. The patients with Ap/T-MCA should be cautious about the collateral pathway arterial changes in particular ipsilateral ACA due to the increasing hemodynamic stress.

Efficacy and Prediction Model Construction of Drug-Coated Balloon Combined with Cutting Balloon Angioplasty in the Treatment of Drug-Eluting Stent In-Stent Restenosis

Objective

To investigate the efficacy of drug-coated balloon (DCB) combined with cutting balloon angioplasty (CBA) in the treatment of drug-eluting stent in-stent restenosis (DES-ISR) and to construct a predictive model for the occurrence of DES-ISR.

Methods

According to the criteria of diagnosis, inclusion, and exclusion, DES-ISR patients who were treated in the outpatient and inpatient departments of cardiovascular medicine of Second People's Hospital of Guangdong Province from July 2021 to December 2021 were included. A total of 72 cases were planned to be enrolled, including 36 cases in the control group and 36 cases in the experimental group. The control group was treated with DCB, and the experimental group was combined with CBA. The treatment success rate, coronary angiography results before and after surgery, and the incidence of major adverse cardiovascular events during the follow-up period were compared between the two groups. Seventy-two DES-ISR patients were divided into ISR group and 59 non-ISR patients were divided into non-ISR group. The clinical data of the two groups were compared to analyze the risk factors affecting the occurrence of DES-ISR, and the prediction model was established.

Results

The surgical success rate of the experimental group was 94.44% (34/36), which was higher than the 77.78% (28/36) of the control group (P < 0.05). The minimum lumen diameter (MLD) of the experimental group 6 months after operation was greater than that of the control group, the late lumen loss (LL) and lumen stenosis rate were higher than those in the control group, and the incidence of major adverse cardiovascular events was lower than that in the control group (P < 0.05). In the ISR group, the proportion of patients with abnormal BMI, smoking, hypertension, diabetes, and family history of coronary heart disease and multivessel coronary artery disease was higher than that in the non-ISR group, the degree of stenosis target lesion was higher than that in the non-ISR group, the diameter of target lesion and stent diameter were smaller than those in the non-ISR group, and the length of target lesion and stent length were longer than those in the non-ISR group; the number of stents was more than that in the non-ISR group (P < 0.05). Combined hypertension, multiple coronary artery lesions, stenosis target lesion degree ≥85.05%, and target lesion length ≥36.88 mm were risk factors for DES-ISR, and target lesion diameter ≥3.15 mm and stent diameter ≥3.15 mm were protective factors (P < 0.05). The prediction model of DES-ISR was obtained by multiple logistic regression analysis, P = 1[1 + e (2.281 + 3.321Xhypertension + 3.427Xumber of arterial lesions + 3.359Xstenosis target lesion degree - 3.143Xtarget lesion diameter + 0.650Xtarget lesion length - 10.159Xstent diameter)]. The Hosmer-Lemeshow test showed that Hosmer-Lemeshow χ 2 = 0.925, P =0.413; the ROC curve analysis showed that the AUC of the prediction model for the occurrence of DES-ISR was 0.924, the SE value was 0.022, and the 95% CI was 0.880-0.967.

Conclusion

DCB combined with CBA has good clinical efficacy in the treatment of DES-ISR, which can reduce the rate of lumen stenosis and the incidence of adverse cardiovascular events. The prediction model established according to risk factors has high predictive value for the occurrence of DES-ISR.

Hemodynamic and Geometric Risk Factors for In-Stent Restenosis in Patients with Intracranial Atherosclerotic Stenosis

Methods

Severe ICAS patients managed with percutaneous transluminal angioplasty and stenting (PTAS) were included in the retrospective cohort study and were divided into two groups according to whether ISR occurred at follow-up (ISR group and no-ISR group). Computational fluid dynamics models were built based on digital subtraction angiography before and after PTAS to simulate blood flow and quantify hemodynamic parameters. The associations between vessel geometry, hemodynamics, and ISR in ICAS patients were investigated.

Results

Among 39 patients, ISR occurred in seven patients (17.95%) after a mean follow-up period of 6.69 ± 3.24 months. Stenting decreased vessel angulation (51.11° [40.07°-67.27°] vs. 15.97° [0.00°-36.16°], P = 0.000) and vessel tortuosity (0.09 [0.06-0.13] vs. 0.01 [0.00-0.03], P = 0.000). Meanwhile, the translational pressure ratio (PR) dramatically increased (0.07 [0.00-0.31] vs. 0.62 [0.41-0.82], P = 0.000) with the wall shear stress ratio decreased (13.93 [8.37-40.30] vs. 2.90 [1.69-4.48], P = 0.000). In the multivariate analysis, smaller Δ tortuosity (P = 0.038) was independently associated with the occurrence of ISR, and smaller post-PTAS translesional PR was also a predictive factor of marginal significance (P = 0.059).

Conclusion

PTAS decreased vessel angulation, vessel tortuosity, and translesional wall shear stress ratio while it increased translesional pressure ratio (PR) dramatically in ICAS patients. Smaller Δ tortuosity was found to be a risk factor for ISR, and smaller post-PTAS translesional PR was also a predictive factor of marginal significance, indicating that both geometric and hemodynamic parameters played important roles in the occurrence of ISR after PTAS.