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Xue H, Xi J, Wu XF, Feng S, Wang J, Chen L. Evaluation of paclitaxel-coated balloon angioplasty for the treatment of symptomatic intracranial in-stent restenosis. Front Neurol 2024; 15:1360609. [PMID: 38841701 PMCID: PMC11150793 DOI: 10.3389/fneur.2024.1360609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024] Open
Abstract
Background Symptomatic intracranial in-stent restenosis (sISR) poses a major challenge in the management of cerebrovascular diseases, often requiring effective and safe treatment options. Objectives This study aims to evaluate the efficacy and safety of paclitaxel-coated balloon (PCB) angioplasty for treating sISR. Methods We conducted a retrospective analysis of five patients aged 49-74 years, who were treated with PCB angioplasty between January 2017 and June 2022. Treatment procedures included pre-operative digital subtraction angiography, antiplatelet therapy, and the use of the SeQuent Please balloon. Patients received aspirin and clopidogrel prior to and after the procedure. Results The procedure achieved a 100% success rate. The degree of ISR was significantly reduced from an average pre-operative rate of 72±18.9% to a post-operative rate of 34±8.22%. Long-term follow-up showed that the majority of patients did not experience restenosis, confirming the long-term effectiveness of the treatment. Conclusions PCB angioplasty demonstrates significant potential as an effective and safe treatment option for patients with sISR, especially those considered to be at high risk. This study supports further investigation into PCB angioplasty as a standard treatment for sISR.
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Affiliation(s)
| | | | | | | | | | - Liwei Chen
- Department of Neurology, Sanmenxia Hospital of the Yellow River, Sanmenxia, China
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2
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Gimžauskaitė A, Inčiūra D, Diringytė G, Lukoševičius S, Kaupas R, Pranculis A, Mačiulaitytė A, Basevičius A, Kuprytė M, Stankevičius E, Plisienė J. Assessment of Plaque Characteristics by Contrast-Enhanced Ultrasound and Stent Restenosis following Carotid Artery Stenting: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:836. [PMID: 38793019 PMCID: PMC11123181 DOI: 10.3390/medicina60050836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024]
Abstract
Background and objective: carotid artery stenosis contributes significantly to ischemic strokes, with management options including carotid endarterectomy (CEA) and carotid artery stenting (CAS) ischemic stroke risk can be reduced. Controversies persist regarding their efficacy and factors influencing complications, and understanding the relationship between atherosclerotic plaque characteristics and stent restenosis after CAS is crucial. Methods: we conducted a retrospective study involving 221 patients who underwent CAS for symptomatic or asymptomatic carotid artery stenosis. Comprehensive assessments of plaque morphology were performed using contrast-enhanced ultrasound (CEUS) before CAS. Patient demographics, including smoking status and diabetes, were also recorded. Stent restenosis was diagnosed using various imaging modalities, including ultrasound, angiography, and digital subtraction angiography (DSA). Results: plaque analysis using CEUS revealed a significant association between plaque grade and restenosis incidence (p < 0.001), particularly with grade 0 (11.1%) and grade 2 plaques (66.7%). Smoking was notably associated with plaque vascularization and restenosis (p < 0.001), while diabetes did not significantly impact plaque characteristics or restenosis risk (p > 0.05). The mean duration of restenosis was 17.67 months. Stenting was the most frequent treatment modality for restenosis (70.6%). However, no significant relationship was found between restenosis type and plaque morphology (p = 0.268). Furthermore, while no clear relationship was observed between plaque morphology and the type of restenosis, our findings underscored the importance of plaque characterization in predicting post-CAS outcomes. Conclusions: this study highlights the utility of CEUS in predicting stent restenosis following CAS. There was a significant association between stent restenosis within 12-24 months after the carotid stenting procedure and an elevated grade of plaque vascularization. Moreover, one of the main factors possibly determining the grade of plaque vascularization was smoking. Further research is warranted to elucidate the underlying mechanisms and refine risk stratification in this patient population.
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Affiliation(s)
- Agnė Gimžauskaitė
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Donatas Inčiūra
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Gintautė Diringytė
- Faculty of Medicine, Medical Academy, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania;
| | - Saulius Lukoševičius
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Rytis Kaupas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Andrius Pranculis
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Aistė Mačiulaitytė
- Department of Cardiac, Thoracic and Vascular Surgery, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (D.I.); (A.M.)
| | - Algidas Basevičius
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania; (S.L.); (R.K.); (A.P.); (A.B.)
| | - Milda Kuprytė
- Department of Pathological Anatomy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
| | - Edgaras Stankevičius
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
| | - Jurgita Plisienė
- Department of Cardiology Medical Academy, Lithuanian University of Health Sciences, LT-50161 Kaunas, Lithuania;
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Yang B, Kang K, Gao F, Mo D, Tong X, Song L, Sun X, Liu L, Huo X, Miao Z, Ma N. Association of occlusion time with successful endovascular recanalization in patients with symptomatic chronic intracranial total occlusion. J Neurosurg 2022; 137:1095-1104. [PMID: 35120327 DOI: 10.3171/2021.12.jns212337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endovascular treatment is one of the choices for symptomatic chronic intracranial total occlusion (CITO); however, its safety and efficacy remain unclear. The present study was performed to evaluate the safety and long-term outcome of endovascular treatment for CITO at a high-volume stroke center. METHODS Data about patients with symptomatic CITO who received endovascular treatment were retrospectively collected. Technique success was regarded as ≤ 30% residual stenosis. Periprocedural complications within 30 days were used to evaluate safety. Baseline characteristics and lesion features were compared between patients with successful recanalization and those with recanalization failure. Stroke recurrence and in-stent restenosis (ISR) of the culprit arteries during follow-up were used to evaluate long-term efficacy. RESULTS From June 2012 to September 2019, 117 patients (mean ± SD age 55.8 ± 9.6 years) were included. The successful recanalization rate was 82.9% (97/117 patients). The combined rate of periprocedural stroke, myocardial infarction, and death was 8.5% (10/117). Compared with patients with successful recanalization, patients with recanalization failure had longer occlusion time and longer lesion length (27.0 mm vs 15.4 mm, p = 0.001). In the median 23.0-month clinical follow-up period, recurrent stroke occurred in 12.6% (11/87) of patients with successful recanalization. In the median 5-month imaging follow-up period, ISR was detected in 26.6% (21/79) of patients. CONCLUSIONS Endovascular treatment was relatively safe for patients with symptomatic CITO. Shorter occlusion time and shorter lesion length may be associated with higher recanalization rate. The rates of stroke recurrence and symptomatic ISR were acceptable but need to be confirmed in future studies.
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Affiliation(s)
- Bo Yang
- 1Department of Neurology, Beijing Jiangong Hospital, Beijing, China
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Kaijiang Kang
- 2Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Feng Gao
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Dapeng Mo
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xu Tong
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Ligang Song
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xuan Sun
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Lian Liu
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xiaochuan Huo
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhongrong Miao
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Ning Ma
- 3Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- 4China National Clinical Research Center for Neurological Diseases, Beijing, China; and
- 5Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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4
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Cheng X, Dong Z, Liu J, Li H, Zhou C, Zhang F, Wang C, Zhang Z, Lu G. Prediction of Carotid In-Stent Restenosis by Computed Tomography Angiography Carotid Plaque-Based Radiomics. J Clin Med 2022; 11:jcm11113234. [PMID: 35683623 PMCID: PMC9180993 DOI: 10.3390/jcm11113234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/12/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
In-stent restenosis (ISR) after carotid artery stenting (CAS) critically influences long-term CAS benefits and safety. The study was aimed at screening preoperative ISR-predictive features and developing predictive models. Thus, we retrospectively analyzed clinical and imaging data of 221 patients who underwent pre-CAS carotid computed tomography angiography (CTA) and whose digital subtraction angiography data for verifying ISR presence were available. Carotid plaque characteristics determined using CTA were used to build a traditional model. Backward elimination (likelihood ratio) was used for the radiomics model. Furthermore, a combined model was built using the traditional and radiomics features. Five-fold cross-validation was used to evaluate the accuracy of the trained classifier and stability of the selected features. Follow-up angiography showed ISR in 30 patients. Carotid plaque length and thickness were independently associated with ISR (multivariate analysis); regarding the conventional model, the area under the curve (AUC) was 0.84 and 0.82 in the training and validation cohorts, respectively. The corresponding AUC values for the radiomics-based model were 0.87 and 0.82, and those for the optimal combined model were 0.88 and 0.83. Plaque length and thickness could independently predict post-CAS ISR, and the combination of radiomics and plaque features afforded the best predictive performance.
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Affiliation(s)
- Xiaoqing Cheng
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210029, China; (X.C.); (J.L.); (C.Z.)
| | - Zheng Dong
- Department of Diagnostic Radiology, Xuzhou Medical University, Xuzhou 221004, China;
| | - Jia Liu
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210029, China; (X.C.); (J.L.); (C.Z.)
| | - Hongxia Li
- Department of Diagnostic Radiology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing 210000, China;
| | - Changsheng Zhou
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210029, China; (X.C.); (J.L.); (C.Z.)
| | - Fandong Zhang
- DeepWise AI Lab, Beijing 100080, China; (F.Z.); (C.W.)
| | - Churan Wang
- DeepWise AI Lab, Beijing 100080, China; (F.Z.); (C.W.)
| | - Zhiqiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210029, China; (X.C.); (J.L.); (C.Z.)
- Correspondence: (Z.Z.); (G.L.); Tel.: +86-139-1388-5490 (Z.Z.); +86-136-7514-5822 (G.L.)
| | - Guangming Lu
- Department of Diagnostic Radiology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210029, China; (X.C.); (J.L.); (C.Z.)
- Correspondence: (Z.Z.); (G.L.); Tel.: +86-139-1388-5490 (Z.Z.); +86-136-7514-5822 (G.L.)
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Yu Y, Yan L, Lou Y, Cui R, Kang K, Jiang L, Mo D, Gao F, Wang Y, Lou X, Miao Z, Ma N. Multiple predictors of in-stent restenosis after stent implantation in symptomatic intracranial atherosclerotic stenosis. J Neurosurg 2021:1-10. [PMID: 34715652 DOI: 10.3171/2021.6.jns211201] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to identify predictors of intracranial in-stent restenosis (ISR) after stent placement in symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS The authors retrospectively collected data from consecutive patients who suffered from symptomatic ICAS and underwent successful stent placement in Beijing Tiantan hospital. Eligible patients were classified into "ISR," "indeterminate ISR," or "no-ISR" groups by follow-up digital subtraction angiography or CT angiography. A multivariate logistic regression model was used to explore the predictors of intracranial ISR after adjustments for age and sex. In addition, ISR and no-ISR patients were divided into two groups based on the strongest predictor, and the incidence of ISR, recurrent stroke, and symptomatic ISR was compared between the two groups. RESULTS A total of 511 eligible patients were included in the study: 80 ISR, 232 indeterminate ISR, and 199 no-ISR patients. Elevated high-sensitivity C-reactive protein (hs-CRP; odds ratio [OR] 4.747, 95% confidence interval [CI] 2.253-10.01, p < 0.001), Mori type B and C (Mori type B vs Mori type A, OR 3.119, 95% CI 1.093-8.896, p = 0.033; Mori type C vs Mori type A, OR 4.780, 95% CI 1.244-18.37, p = 0.023), coronary artery disease (CAD; OR 2.721, 95% CI 1.192-6.212, p = 0.017), neutrophil/lymphocyte ratio (NLR; OR 1.474 95% CI 1.064-2.042, p = 0.020), residual stenosis (OR 1.050, 95% CI 1.022-1.080, p = 0.001) and concurrent intracranial tandem stenosis (OR 2.276, 95% CI 1.039-4.986, p = 0.040) synergistically contributed to the occurrence of intracranial ISR. Elevated hs-CRP (hs-CRP ≥ 3 mg/L) was the strongest predictor for ISR, and the incidence of ISR in the elevated hs-CRP group and normal hs-CRP group (hs-CRP < 3 mg/L) was 57.14% versus 21.52%, respectively, with recurrent stroke 44.64% versus 16.59%, and symptomatic ISR 41.07% versus 8.52%. CONCLUSIONS Elevated hs-CRP level, NLR, residual stenosis, Mori type B and C, CAD, and concurrent intracranial tandem stenosis are the main predictors of intracranial ISR, and elevated hs-CRP is crucially associated with recurrent stroke in patients with symptomatic ICAS after intracranial stent implantation.
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Affiliation(s)
- Ying Yu
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases.,3Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Long Yan
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases
| | - Yake Lou
- 4Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases; and
| | - Rongrong Cui
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases.,3Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Kaijiang Kang
- 2China National Clinical Research Center for Neurological Diseases.,3Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Lingxian Jiang
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases.,3Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Dapeng Mo
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases
| | - Feng Gao
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases
| | - Yongjun Wang
- 2China National Clinical Research Center for Neurological Diseases.,3Neurology, Beijing Tiantan Hospital, Capital Medical University
| | - Xin Lou
- 5Department of Radiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhongrong Miao
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases
| | - Ning Ma
- 1Departments of Interventional Neuroradiology and.,2China National Clinical Research Center for Neurological Diseases
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Intracranial Angioplasty with Enterprise Stent for Intracranial Atherosclerotic Stenosis: A Single-Center Experience and a Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6645500. [PMID: 33959660 PMCID: PMC8075681 DOI: 10.1155/2021/6645500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/16/2021] [Accepted: 03/26/2021] [Indexed: 01/11/2023]
Abstract
Background The high rate of periprocedural complications for the endovascular stent procedure in the Stenting Versus Aggressive Medical Management Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial resulted in it being less recommended than medical therapy to treat intracranial atherosclerotic stenosis (ICAS). Because Enterprise stent use might reduce the incidence of complications in ICAS treatment compared to other frequently used stents, this paper evaluated the safety and effectiveness of the Enterprise stent for the treatment of ICAS. Methods We performed a comprehensive literature search for reports on intracranial angioplasty using the Enterprise stent for ICAS treatment from the earliest date available from each database to May 2020 for PubMed, EMBASE, Web of Science, Cochrane, and Clinical Trials databases. We also reviewed the single-center experience of the First Affiliated Hospital of Harbin Medical University. We extracted information regarding periprocedural complications, procedure-related morbidity, mortality, immediate angiographic outcome, and long-term clinical and angiographic outcomes, among others. Event rates were pooled across studies using random-effects or fixed-effects models depending on the heterogeneity. Results Five hundred fifty-seven patients with 588 lesions from seven studies, including the institutional series, were included in the analysis. The incidence of stroke or death within 30 days was 7.4% (95% confidence interval (CI), 5.5%-10.1%). The incidence of ischemic stroke or TIA in the territory of the qualifying artery beyond 30 days and during follow-up was 3.2% (95% CI, 1.1%-9.5%). The incidence of in-stent restenosis was 10.1% (95% CI, 4.6%-22.2%), and the incidence of symptomatic restenosis was 4.1% (95% CI, 1.7%-9.9%). Conclusions Intracranial angioplasty utilizing the Enterprise stent for ICAS treatment was relatively safe and effective but required further verification using additional sources for evidence.
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Current Advances in Endovascular Treatment of Intracranial Atherosclerotic Disease and Future Prospective. J Stroke Cerebrovasc Dis 2020; 30:105556. [PMID: 33360252 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105556] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/12/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES/BACKGROUND Medical therapy is the first line of treatment for intracranial atherosclerotic disease (ICAD). Percutaneous transluminal angioplasty and stenting (PTAS) are mainly considered for those patients with severe stenosis and recurrent events despite aggressive medical therapy. In this review, we discuss the application of PTAS as a treatment option for ICAD and its future prospect. MATERIALS AND METHODS We did the literature review of the key articles and guidelines to elaborate on the role of PTAS in the management of ICAD based on the current data and expert opinion. We searched PubMed, Google Scholar, and Scopus up to August 2020, and included articles published only in the English language. RESULTS Since the publication of the results from SAMMPRIS and VISSIT trials, stenting is no longer recommended for secondary stroke prevention in patients with symptomatic ICAD. However, recent clinical studies on intracranial stenting for a subgroup of ICAD patients have shown promising results, likely due to better patient selection and continued advancement of endovascular techniques. CONCLUSION There exists a lack of consensus regarding the best endovascular treatment approach (e.g., angioplasty alone or balloon mounted stent vs. self-expanding stent with or without prior angioplasty) or management of in-stent restenosis. Another area of clinical controversy relates to the ideal use and duration of antiplatelet therapy.
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