Percutaneous transluminal angioplasty of intracranial artery stenosis: clinical results in 24 patients

Clinical and angiographic outcomes of wingspan stent placement for treatment of symptomatic intracranial stenosis: single center experience with 19 cases

Objective

The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent.

Methods

We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011.

Results

Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9-19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging.

Conclusion

Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.

Treatment of intracranial atherosclerotic disease with a balloon-expandable paclitaxel eluting stent: procedural safety, efficacy and mid-term patency

Purpose

Procedural safety and high rates of in-stent recurrent stenotic lesions (ISR) remain a concern in the endovascular treatment of intracranial atherosclerotic disease (ICAD). In the present study technical feasibility, safety and efficacy of the paclitaxel eluting balloon-expandable coronary stent Coroflex^® Please was assessed in the treatment of ICAD.

Methods

A total of 95 patients (79 male; median age 68 years) with 106 intracranial atherosclerotic stenotic lesions underwent endovascular treatment using Coroflex^® Please stents (B. Braun, Melsungen, Germany). Location and degree of target stenoses before and after treatment and at follow-up and adverse clinical sequelae of treatment were registered. Post-procedural medication included 100 mg acetylsalicylic acid (ASA) and 75 mg clopidogrel for 1 year. Angiographic follow-up was scheduled for 6, 12, 26 and 52 weeks after the treatment.

Results

The lesion locations were as follows: internal carotid artery (ICA) petrous (n = 44, 42%), ICA cavernous (n = 43, 41%), ICA paraclinoid (n = 4, 4%), intradural vertebral artery (VA; n = 11, 10%) and basilar artery (BA; n = 4, 4%). Of the lesions seven could not be treated due to difficult anatomy and stent stiffness (7% technical failure rate). The combined post-interventional neurological morbidity and mortality rate, including stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and carotid cavernous fistula (CCF) was n = 4 (3.7%) within and n = 1 (0.9%) at and beyond 30 days, respectively. Angiographic and clinical follow-up examinations were carried out for 78 (78%) of the lesions (mean 16.1 months, maximum 48 months). Asymptomatic recurrent stenosis was seen in 3 out of 78 (3.8%) lesions and there was 1 case of late stent thrombosis (0.9%).

Conclusions

Treatment of ICAD using drug-eluting coronary stents is safe and effective but technical failure due to stent stiffness remains a problem. Application of the more flexible, newest generation thin-strut stents, however, shows promising results.

Stent angioplasty of intracranial stenosis: single center experience of 54 cases

PURPOSE

The aim of the study was to retrospectively evaluate the safety and efficacy of stent angioplasty of symptomatic intracranial stenosis in a single center experience.

MATERIALS AND METHODS

Between November 2006 and September 2009 a total of 54 stent angioplasties were performed in 49 patients and of these 46 were done for symptomatic intracranial high-grade (>70%) stenoses and 8 for complete vessel occlusions in acute stroke. All elective treatments were carried out with patients under antithrombotic/anticoagulant medication. Self-expandable stents were used in 42 cases and balloon-expandable stents in 12 cases.

RESULTS

Stent angioplasty was successful in 53 out of 54 cases (98%). Periprocedural complications occurred in 6 patients, including 2 dissections, 1 contrast-mediated toxic reaction and 1 thromboembolic event with transient neurological deficits but did not cause permanent neurological deficits, in any of the cases. Adverse events within 30 days after intervention occurred in 11 of the 49 patients (20.4%) of which 4 were scheduled patients (8.3%) and 7 were treated for acute stroke with complete vessel occlusions (87.5%). Overall there were 9 cases of restenosis (7 out of 9>90% stenoses and 2 complete vessel occlusions), 5 out of 9 were asymptomatic, 4 out of 9 had a transient ischemic attack and 1 developed a major stroke. Two complete in-stent thromboses were seen in acute stroke patients with initial complete occlusion within 24 h after recanalization. One restenosis and one complete occlusion occurred under double antiplatelet medication, 4 out of 9 restenoses occurred under aspisol medication and 3 out of 9 after antiplatelet medication was discontinued. In 2 out of 9 restenoses, balloon-expandable stents had been used, the remaining 7 had been treated with self-expanding stents, 5 out of 9 restenoses were treated by balloon-angioplasty alone, in 3 out of 9 an additional stent had to be placed and 1 asymptomatic occlusion was left untreated.

CONCLUSIONS

The results demonstrate the technical feasibility and satisfactory success rates of stent angioplasty in intracranial atherosclerotic stenoses. The procedural success rate was 98% and the overall rate of adverse events was 20.4%. The rate of adverse events was high in unstable patients (87.5%) treated without antiplatelet premedication, especially in the setting of an acute stroke. In stable patients the rate of adverse events was much lower (8.3%). Future development of dedicated stents and a better understanding of factors that predispose to restenosis may help to further decrease the rate of periprocedural and postprocedural adverse events thus helping to improve both short-term and long-term outcome after intracranial stent angioplasty.

Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons

BACKGROUND AND PURPOSE

ISRs remain a major issue in the endovascular management of ICAD, requiring retreatment by reangioplasty. The aim of the present study was to evaluate the technical feasibility, safety, and efficiency of the novel DEBs for neurovascular ISRs.

MATERIALS AND METHODS

Fifty-one patients (median age, 67 years; age range, 34-82 years; male/female ratio, 37:14) underwent 63 balloon dilation procedures for ISRs in intracranial stented arterial segments between November 2007 and August 2010 in a single center. Of the 63 procedures, 20 (32%) were performed by using a conventional balloon and 43 (68%), by using a paclitaxel-eluting balloon (SeQuent Please). Angiographic and clinical follow-up was performed at 6 and 12 weeks, 6 and 12 months, and yearly thereafter. Technical success rate, periprocedural complications, occurrence of recurrent ischemic symptoms, and the development of a recurrent ISR after reangioplasty were analyzed.

RESULTS

Technical success, defined as <50% residual stenosis was achieved in all cases (100%), with failure of the DEB treatment in 6% of the attempts; those lesions were finally successfully treated with a conventional balloon. The combined permanent neurologic morbidity and mortality rate (stroke, ICH, and SAH) at 30 days was 1.6%. Substantial difference was found in the rate of recurrent stenosis when comparing conventional balloons and DEBs, with recurrent stenosis rates of 50% and 9%, respectively.

CONCLUSIONS

The initial results of reangioplasty of intracranial ISRs with DEBs are encouraging; further technical developments are, nevertheless, mandatory.

Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (WingSpan)

The endovascular treatment of atherosclerotic intracranial arterial stenoses has previously been based on balloon dilatation or the deployment of a balloon expandable stent. Both methods have advantages (balloon: flexibility; balloon expandable stent: high radial force) and drawbacks (balloon: risk of elastic recoil and dissection; balloon expandable stent: limited flexibility, risk of injury to the vessel due to excessive straightening, overexpansion at ends of stent). A new combination of balloon dilatation, followed by the deployment of a self-expanding microstent has been applied in 15 patients with atherosclerotic arterial stenoses, symptomatic despite medical treatment. An anatomically and clinically adequate result was achieved in all patients. The initial degree of stenosis was 72% (mean). Balloon dilatation resulted in an average residual stenosis of 54% (mean), reduced further to a mean of 38% after stent deployment. Arterial dissection, occlusion of the target artery or symptomatic distal emboli was not encountered. In one patient, a side branch occlusion occurred after dilatation of a M1 stenosis, with complete neurological recovery. All patients were either stable or improved 4 weeks after the treatment. Recurrent TIA did not occur in any patient. Balloon dilatation and subsequent deployment of a self-expandable stent for the treatment of symptomatic intracranial arterial stenoses combines the advantages of both techniques and allows a rapid, clinically effective and technically safe treatment of these frequently challenging lesions.