Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery: A matched case-control study

BACKGROUND

Although radiotherapy is common for head/neck and chest cancers (HNCC), it can result in post-irradiation stenosis of the subclavian artery (PISSA). The efficacy of percutaneous transluminal angioplasty and stenting (PTAS) to treat severe PISSA is not well-clarified.

AIMS

To compare the technical safety and outcomes of PTAS between patients with severe PISSA (RT group) and radiation-naïve counterparts (non-RT group).

METHODS

During 2000 and 2021, we retrospectively enrolled patients with severe symptomatic stenosis (>60%) of the subclavian artery who underwent PTAS. The rate of new recent vertebrobasilar ischaemic lesions (NRVBIL), diagnosed on diffusion-weight imaging (DWI) within 24 h of postprocedural brain MRI; symptom relief; and long-term stent patency were compared between the two groups.

RESULTS

Technical success was achieved in all 61 patients in the two groups. Compared with the non-RT group (44 cases, 44 lesions), the RT group (17 cases, 18 lesions) had longer stenoses (22.1 vs 11.1 mm, P = 0.003), more ulcerative plaques (38.9% vs 9.1%, P = 0.010), and more medial- or distal-segment stenoses (44.4% vs 9.1%, P<0.001). The technical safety and outcome between the non-RT group and the RT group were NRVBIL on DWI of periprocedural brain MRI 30.0% vs 23.1%, P = 0.727; symptom recurrence rate (mean follow-up 67.1 ± 50.0 months) 2.3% vs 11.8%, P = 0.185; and significant in-stent restenosis rate (>50%) 2.3% vs 11.1%, P = 0.200.

CONCLUSION

The technical safety and outcome of PTAS for PISSA were not inferior to those of radiation-naïve counterparts. PTAS for PISSA is an effective treatment for medically refractory ischaemic symptoms of HNCC patients with PISSA.

Comparing the Impact of Stenting vs. Medical Therapy for Intracranial Arterial Stenosis : A Systematic Review and One-stage and Two-stage Meta-Analysis of Randomized Clinical Trials

PURPOSE

In the treatment of intracranial arterial stenosis (ICAS), controversies remain regarding the optimal treatment strategy. Our study aims to conduct an individual patient-level data meta-analysis of existing RCTs comparing PTAS versus best medical therapy and to identify differences in outcomes such as incidence of ischemic stroke or death.

METHODS

Randomised controlled trials comparing the outcomes of stenting versus best medical therapy for patients who had symptomatic ICAS of >50%. Excluded studies included case reports, case series, reviews, observational studies,  letters or studies evaluating isolated angioplasty techniques without stenting. Data was extracted in accordance with PRISMA guidelines.

RESULTS

7 studies involving 1425 participants were included. There was an increased risk in the incidence of stroke and death within the first 30 days post-procedure for patients treated with PTAS over best medical therapy (RR = 2.22 [1.28-3.86], I² = 0%). Patients who underwent stenting also had a significantly higher risk of intracranial haemorrhage (RR = 12.66 [2.41-66.45], I² = 0%) and death (RR = 5.41 [1.20-24.28], I² = 0%).Under the shared frailty model, stenting when compared to medical therapy has a HR of 1.81 (95% CI:1.25-2.6) of stroke or death across 1 year. Under the parametric Royston-Parmar model, stenting has a significant decrease in the RMST(-0.83 months; 95% CI: -1.30-0.37). Stenting continued to show worse outcomes up to the 3 year mark with a HR of 1.60 (95% CI: 1.11-2.32).

CONCLUSIONS AND RELEVANCE

There is an increased risk of peri- and post-procedural stroke and death over best medical therapy in patients with symptomatic ICAS who undergo PTAS. Further work is required to refine patient selection and mitigate peri-procedural risks.

Plaque features of the middle cerebral artery are associated with periprocedural complications of intracranial angioplasty and stenting

PURPOSE

The identification of plaque features in the middle cerebral artery (MCA) may help minimize periprocedural complications and select patients suitable for percutaneous transluminal angioplasty and stenting (PTAS). However, relevant research is lacking.

METHODS

We retrospectively included patients with symptomatic MCA stenosis who received PTAS. All patients underwent intracranial vessel wall MRI (VWMRI) before surgery. Periprocedural complications (PC) included ischemic and hemorrhagic stroke within 30 days. Stenosis location, MCA shape, plaque eccentricity and distribution, plaque thickness and length, and enhancement ratio were compared between patients with and without PC.

RESULTS

Sixty-six patients were included in the study, of which 12.1% (8/66) had PC. Of the eight patients with PC, seven (87.5%) had superior wall plaques. In the non-PC group (n = 58), nine (17%) patients had superior wall plaques. Compared with patients without PC, those with PC had more frequent superior wall plaques (17% vs 87.5%, p < 0.001) and s-shaped MCAs (19% vs 50%, p = 0.071), different stenosis locations (p = 0.012), thicker plaques (1.58 [1.35, 2.00] vs 1.98 [1.73, 2.43], p = 0.038), and less frequent inferior wall plaques (79.2% vs 12.5%, p < 0.001). Multivariate analysis showed that only the presence of superior wall plaques (OR = 41.54 [2.31, 747.54]) was independently associated with PC.

CONCLUSION

MCA plaque features were highly correlated with PC in patients with symptomatic MCA stenosis who underwent PTAS.

Intracranial Stenosis Treated with Stenting in Patients with Suspected Cerebral Vasculitis: Two Case Reports

Central nervous system vasculitis (CNSV) is an uncommon and poorly understood form of vasculitis. Early recognition is important because medical treatment might improve the outcome. However, randomized clinical trials on CNSV treatment do not exist. Endovascular treatment has been reported in few cases, but no data exist for intracranial stenting. We report 2 cases of patients with suspected CNSV and recurrent clinical episodes, treated with intracranial stenting. A 48-year-old man had relapsing episodes of right hemiparesis. Neuroradiological exams showed severe left carotid terminus stenosis. Despite immunosuppressive therapy, neuroradiological follow-up exams showed a worsening of the aforementioned stenosis with many transient episodes of weakness in the right limbs and aphasia. A 64-year-old woman had a sudden onset of dysarthria and transient aphasia. Neuroradiological exams showed a severe arterial stenosis involving the origin of left anterior cerebral artery and middle cerebral artery (MCA). Despite dual antiplatelet therapy, she presented an acute onset of severe aphasia, due to an occlusion of the left carotid terminus and proximal MCA. In both cases, endovascular procedure and intracranial stenting was performed, with marked improvement of cerebral blood flow. No more clinical episodes were reported. Intracranial stenting may be a valid therapeutic option in selected patients with CNSV and involvement of medium or large size vessels with clinical worsening despite best medical treatment.

Endovascular Therapy for Symptomatic Intracranial Artery Stenosis: a Systematic Review and Network Meta-analysis

Intracranial artery atherosclerotic stenosis (ICAS) is one of the most common causes of stroke. Endovascular therapy including balloon angioplasty alone (BA), balloon-mounted stent (BMS), or self-expanding stent (SES) was an important alternative to treat symptomatic ICAS refractory to medical treatment, while none of the three subtypes has been established to be the primary option. We conducted a systematic review and network meta-analysis to determine both the safety and efficacy and establish a hierarchy of different endovascular therapies on symptomatic ICAS. Major databases including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies comparing outcomes of three different endovascular approaches and other comparable non-endovascular therapies for symptomatic ICAS patients published from 1 January 2000 to 1 November 2021. Primary outcomes included short-term mortality or stroke rate (peri-procedural, or mean follow-up ≤ 3 months), and long-term mortality or stroke rate (mean follow-up ≥ 6 months). Pairwise and network meta-analyses based on the above systematic review were conducted. A total of 19 eligible studies involving 3386 patients treated with 4 different approaches (BA, SES, BMS, and medical treatment) were analyzed. For primary outcome, BA had the highest ranking (SUCRA value 78), followed by BMS (SUCRA value 21.5) and SES (SUCRA value 13.1). The short-term mortality or stroke rate was significantly lower in the BA group compared to SES (OR = 2.50; 95% CI 1.12 to 5.57; p = 0.026) or BMS (OR = 0.43; 95% CI 0.19 to 0.96; p = 0.038). Other primary and secondary outcomes were no different among all three types of endovascular therapy. Overall, the studies were of good methodological quality and the consistency was acceptable across all network meta-analyses. BA offers the highest level of safety outcomes in terms of short-term mortality or stroke in treating symptomatic patients with intracranial artery stenosis, compared to SES and BMS, which needs to be confirmed in future studies. Trial registration in PROSPERO database: CRD42018084055.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery

BACKGROUND/PURPOSE

The therapeutic efficacy of percutaneous transluminal angioplasty and stenting (PTAS) of post-irradiated stenosis of subclavian artery (PISSA) was not well clarified. This retrospective study was designed to evaluate the technical safety and outcome of the patients of severe symptomatic PISSA accepted PTAS.

METHODS

Between 2000 and 2019, 16 cases with 17 lesions of symptomatic and medically refractory PISSA accepted PTAS were included. We evaluated their technical success, peri-procedural complications and diffusion-weight imaging (DWI) of brain magnetic resonance imaging (MRI), results of symptom relief, and long-term stent patency.

RESULTS

The stenosis of the 17 stenotic lesions were 81.2 ± 11.1%. The most common symptom of the 16 patients was dizziness (14/16, 87.5%). All successfully accepted PTAS without neurological complication and had symptom relief after PTAS (17/17, 100%). Of the 12 patients accepted pre-procedural and early post-procedural MRI follow-up, 2 patients had an asymptomatic tiny acute embolic infarct in the territory of vertebrobasilar system. In a 51.9 ± 54.9 months follow-up, all patients had no severe restenosis and no recurrent vertebrobasilar ischemic symptoms.

CONCLUSION

For patients with PISSA and medically refractory ischemic symptoms, PTAS can be an effective alternative management.

Long-Term Evolutionary Change in the Lumen of Intracranial Atherosclerotic Stenosis Following Angioplasty and Stenting

BACKGROUND

Angioplasty and stenting is a recognized treatment option for patients with intracranial atherosclerosis.

OBJECTIVE

To evaluate the long-term evolutionary luminal changes of intracranial atherosclerosis after angioplasty and stenting.

METHODS

This was a retrospective study with patient consent. Eighty-two patients presenting with acute and minor cerebral ischemia due to stenosis ≥70%, who had received medical therapy with or without stenting (Wingspan), were invited. Luminal imaging was provided using 3-dimensional rotational angiography (3-DRA) at baseline and 12 mo, and cone-beam computed tomography angiography with intravenous contrast (CBCT) was provided at follow-up (median 82.4 mo [interquartile range 61.9-96.9 mo]).

RESULTS

Thirty-six patients in the stenting group and 26 patients in the medical group were recruited and completed the study. There was no statistically significant difference in demographics between the 2 patient groups. The luminal gain at 12 or 80 mo as compared to baseline in the stenting group was significantly greater than that in the medical group (12 mo: median gain 30% vs 7.2%, P < .001; 80 mo: median gain 42.9% vs 7.2%, P < .0001). Luminal loss or unchanged lumen was correlated with recurrent ischemic event. The differences in the stenosis degree assessment between CBCT and 3-DRA in the same 10 patients with or without stenting were 1.2 ± 0.6% or 0.2 ± 0.06%, respectively. There was a correlation between recurrent ischemic events and luminal loss.

CONCLUSION

Arterial lumen after angioplasty and stenting can probably be well maintained and delayed luminal gain does occur, long-term luminal loss is associated with recurrent ischemic events, CBCT might be useful as a less-invasive means for long-term assessment.

Endovascular and Open Surgery for Deep Vein Thrombosis

The surgical treatment of deep venous thrombosis (DVT) has significantly evolved and is focused on different strategies of early thrombus removal in the acute phase and deep venous recanalization or bypass in the chronic phase. Along with the use of anticoagulation agents, endovascular techniques based on catheter-directed thrombolysis and pharmacomechanical thrombectomy have been increasingly used in patients with acute extensive DVT. Patient selection is crucial to provide optimal outcomes and minimize complications.

Evaluation of a modified Cheatham-Platinum stent for the treatment of aortic coarctation by finite element modelling

Objectives

Stent implantation for the treatment of aortic coarctation has become a standard approach for the management of older children and adults. Criteria for optimal stent design and construction remain undefined. This study used computational modelling to compare the performance of two generations of the Cheatham-Platinum stent (NuMED, Hopkinton, NY, USA) deployed in aortic coarctation using finite element analysis.

Design

Three-dimensional models of both stents, reverse engineered from microCT scans, were implanted in the aortic model of one representative patient. They were virtually expanded in the vessel with a 16 mm balloon and a pressure of 2 atm.

Results

The conventional stent foreshortened to 96.5% of its initial length, whereas the new stent to 99.2% of its initial length. Diameters in 15 slices across the conventional stent were 11.6–15 mm (median 14.2 mm) and slightly higher across the new stent: 10.7–15.3 mm (median 14.5 mm) (p= 0.021). Apposition to the vessel wall was similar: conventional stent 31.1% and new stent 28.6% of total stent area.

Conclusions

The new design Cheatham-Platinum stent showed similar deployment results compared to the conventional design. The new stent design showed slightly higher expansion, using the same delivery balloon. Patient-specific computational models can be used for virtual implantation of new aortic stents and promise to inform subsequent in vivo trials.

Usefulness of Early Stenting for Symptomatic Extracranial Carotid Stenosis

BACKGROUND

While carotid angioplasty and stenting (CAS) have become an established procedure, outcomes of early CAS for symptomatic extracranial carotid stenosis (SECS) remain poorly understood. The present study aimed at determining the effectiveness of early CAS in SECS.

METHODS

Herein, 224 SECS patients underwent elective CAS between January 2008 and June 2015. The study population was stratified based on the time from symptom onset to the procedure (early CAS group: within 14 days; delayed CAS group: later than 14 days). Subgroup analysis (chi-square test, Mantel-Haenszel chi-square test, and analysis of covariance) evaluated the demographics, incidence of periprocedural thromboembolic complications, cerebral hyperperfusion syndrome (CHS), intracranial bleeding, and treatment outcomes on the modified Rankin Scale (mRS).

RESULTS

Symptomatic thromboembolic complications and CHS were noted in 2.68% and 0.89% of patients, respectively. The initial National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in patients who underwent early CAS than in those who underwent delayed CAS (2.50 ± 3.97 vs. 0.97 ± 2.08, P = 0.001). After adjusting for age, duration of preprocedural dual antiplatelet therapy, initial NIHSS score, and preprocedural NIHSS score, the groups did not differ significantly regarding the incidence of symptomatic thromboembolic complications (P = 0.195), incidence of CHS (P = 0.950), incidence of intracranial bleeding (P = 0.970), 30-day mRS score (P = 0.124), and mRS score at final follow-up (P = 0.132).

CONCLUSIONS

For SECS patients who cannot undergo early carotid endarterectomy, early CAS is effective and safe if selectively indicated considering disease severity. Early and delayed CAS provide comparable mRS scores, incidence of symptomatic thromboembolic complications, CHS, and intracranial bleeding.

Transplant renal artery stenosis: The impact of endovascular management and their outcomes

Introduction:

Transplant renal artery stenosis (TRAS) is a well-known vascular complication of renal transplantation. The aim of this analysis was to assess the short and midterm outcomes of endovascular therapy to salvage transplant kidney.

Methods:

We retrospectively analyzed our transplant database from 2000 to 2015. Percutaneous transluminal angioplasty/stenting was done in 24 patients (22 men and two women) with significant TRAS. The mean age was 59 ± 12 years. The parameters analyzed were: Technical success, pre- and post-treatment serum creatinine and number of antihypertensive drugs before and after treatment and vessel patency on Doppler ultrasonography at 3 and 6 months.

Results:

Overall incidence of TRAS in this study was 5.06%. Incidence of TRAS following live donor transplantation was 4.68% while that in deceased donors was 11.5%. Technical success was 100%. There were no periprocedural deaths. Renal function was improved from 2.32 ± 0.5 mg/dL to 1.72 ± 0.3 mg/dL (P < 0.001) and number of antihypertensive medications after the procedure was reduced from 2.9 ± 0.7 to 2 ± 0.6 (P < 0.001) at 6 months follow-up. One patient developed restenosis within 5 months (4.2%). Clinical success at 6 months follow-up was 79.2%.

Conclusions:

Endovascular treatment of TRAS has high technical success with minimal complications. It also provides satisfactory clinical success with improvement in overall transplant renal function and renovascular hypertension in early follow-up.

Intracranial atherosclerotic disease; current options for surgical or medical treatment

Recently, intracranial atherosclerosis has become a major cause of ischemic stroke, appearing more frequently in Koreans than Caucasians. Symptomatic or asymptomatic intracranial atherosclerosis is a disease that could recur readily even during the treatment with anti-platelet agents. When the symptoms develop, ischemic stroke can not be recovered readily. Therefore, aggressive treatments such as endovascular therapy and bypass surgery are required in addition to medical treatment for the intracranial artery stenosis. Recent intracranial stenting and drug eluting stenting have shown as very advanced effective therapeutic modalities. Nevertheless, until now, a randomized controlled study has not been conducted. Regarding bypass surgery, since the failed EC-IC bypass surgery study performed 20 years ago, extensive studies on its efficacy has not been conducted yet, and thus it has to be performed strictly only in hemodynamically compromised patients. Unless breakthrough drugs that suppress the progression of intracranial atherosclerosis and the formation of thrombi, and facilitate the regression of the arterial stenosis, the treatment concept of the recovery of the blood flow of stenotic arterial territory by mechanical recanalization or bypass surgery would be remained for the prevention as well as treatment of ischemic stroke caused by intracranial atherosclerosis.