A case of intimal hyperplasia induced by stenting for vertebral artery origin stenosis: assessed on intravascular ultrasound

Intravascular ultrasound guided vertebral artery stenting after basilar artery thrombectomy for acute brain stem stroke

A 64-year-old lady presented as right vertebral artery occlusion and brain stem stroke (Figure 1A). Emergent thrombectomy opened the artery, but it re-occluded 10 minutes later (Figure 1B,C). Intravascular ultrasound showed heavy plaque burden and guided a balloon-expandable stenting successfully (Figure 1D-F).

A Case of Internal Carotid Artery Restenosis Due to Neointimal Hyperplasia Following Balloon Angioplasty

Objective

The causes of restenosis following balloon angioplasty are reported to be vasospasm, thrombosis, and recurrence of atherosclerosis. We report a case of internal carotid artery (ICA) occlusion treated by emergency endovascular renacalization and carotid endarterectomy (CEA) for the restenosis, which revealed that the cause of restenosis was neointimal hyperplasia.

Case Presentation

A 70-year-old man was brought to our hospital because of sudden onset left hemiparesis. His National Institute of Health Stroke Scale (NIHSS) score was 13. Magnetic resonance imaging diffusion weighted imaging (MRI DWI) demonstrated hyper-intensity in the right basal ganglia, indicating acute ischemia. Neither the right ICA nor the MCA was visualized on MR angiography. Following intravenous tPA therapy, endovascular treatment was employed. First, the right ICA occlusion was treated by balloon angioplasty and the right M1 occlusion was recanalized by the stent-type thrombus retriever. Complete recanalization was achieved and the patient fully recovered. However, restenosis of the right ICA developed 5 months later and CEA was performed. The postoperative course was uneventful. Based on the pathological examination, the cause of restenosis was migration and proliferation of dedifferentiated smooth muscle (SM) cells, that is, neointimal hyperplasia.

Conclusion

Neointimal hyperplasia can be a cause of restenosis following balloon angioplasty.

Endovascular treatment of vertebral artery-origin and innominate/subclavian disease: indications and technique

Approximately 20% to 40% of patients who have cerebral vascular disease have a vertebral artery-origin stenosis. Atherosclerotic lesions of vertebral arety origin are a potential cause of posterior circulation ischemia, which can be disabling or deadly. Endovascular treatment of vertebral artery-origin and innominate/subclavian artery stenosis has changed in the last 15 years. Surgery usually is successful technically; however, it is also associated with high rates of procedural and periprocedural complications. New techniques and technologies that can be used in the treatment of such lesions are being developed. In this article, the authors discuss the indications, technical aspects, and long-term results of angioplasty and stenting of these vessels.

Successful percutaneous transluminal angioplasty and stenting for symptomatic intracranial vertebral artery stenosis using intravascular ultrasound virtual histology

This is the first report of percutaneous transluminal angioplasty (PTA) of an intracranial artery applying intravascular ultrasound virtual histology (IVUS-VH), which has been recently developed for tissue characterization of coronary artery plaque. We report a case of successful PTA and stenting for symptomatic intracranial vertebral artery stenosis using IVUS-VH.

Endovascular treatment of the vertebral artery origin in patients with symptoms of vertebrobasilar ischemia

INTRODUCTION

We report our experience with the endovascular treatment of the vertebral artery origin in patients presenting with symptomatic vertebrobasilar ischemia and compare our results with those reported in the literature.

METHODS

In 25 patients, 28 procedures were performed. Patients presented with posterior circulation ischemic symptoms despite optimal medical therapy with antiplatelet drugs and had a digital subtraction angiogram demonstrating stenosis of the origin of the vertebral artery greater than 50%. Retrospective review of the medical records, clinical notes and radiologic-procedural reports was performed.

RESULTS

Of the 25 patients, 18 were male and 7 female. Their ages ranged from 50 to 84 years. In 23 of the 25 patients the contralateral vertebral artery was occluded, hypoplastic, absent, or had greater than 50% stenosis. In 13 of the 25 patients angiographic evidence of significant anterior circulation disease was demonstrated. In 18 of the 25 patients the left vertebral artery was affected. The mean stenosis was 82.6%. Follow-up records were available in 19 patients. The mean follow-up was 24 months. Five of the 19 patients had recurrent symptoms of vertebrobasilar ischemia and three patients were retreated. Of the 28 procedures performed, 23 were angioplasty/stenting and 5 were angioplasties alone. Overall technical success was achieved in 26 of the 28 procedures (92.8%). No procedure-related transient ischemic attack, stroke or death was noted.

CONCLUSION

Endovascular treatment of the vertebral artery origin in this patient population is feasible, safe, and effective. There are some questions regarding the long-term follow-up and rate of restenosis and clinical recurrences that are yet to be answered.