Angioplasty, stenting, or both - rescue maneuvers and reperfusion after endovascular therapy for intracranial atherosclerosis-related occlusion

Drug-eluting stent versus bare metal stent for symptomatic intracranial stenosis: a comparative systematic review and meta-analysis study

BACKGROUND

Intracranial atherosclerotic artery stenosis (ICAS) is a major cause of ischemic stroke globally and is associated with poor recanalization rates, high recurrence, and adverse functional outcomes. The use of stents has been explored as a treatment option to improve outcomes, despite concerns over procedure-related complications and in-stent restenosis (ISR). This study aimed to compare the efficacy and safety of drug-eluting stents (DES) versus bare metal stents (BMS) in treating patients with symptomatic ICAS (sICAS).

METHOD

A systematic review and meta-analysis were conducted according to PRISMA guidelines, with a comprehensive search of PubMed, Embase, and Web of Science up to March 1, 2024. Studies that reported outcomes such as technical and clinical success rates, periprocedural complications, ISR, and stroke rates were included. Statistical analysis was performed using Stata v.17.

RESULTS

A total of 44 studies involving 13,658 patients were included. DES demonstrated lower pooled rates of major stroke (3% [95% CI 2-4%]) and ISR (8% [95% CI 3-12%]) compared to BMS (5% [95% CI 3-6%] for major stroke and 19% [95% CI 14-24%] for ISR), though the difference in major stroke rate was not statistically significant. The clinical success rate was similar between DES (89% [95% CI 78-99%]) and BMS (86% [95% CI 76-97%]). Technical success rates were high and comparable for both stent types. Subgroup analyses and meta-regression identified significant factors influencing heterogeneity, including stent or wire length and diameter.

CONCLUSION

DES showed a significant advantage over BMS in reducing ISR and major stroke rates while maintaining comparable safety and technical success. These findings support the preferential use of DES in clinical practice for managing sICAS, emphasizing their role in enhancing patient outcomes through reduced restenosis and recurrent ischemic events.

Comparing the effectiveness and safety of rescue balloon angioplasty versus stenting in acute large vessel occlusion after thrombectomy

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is a leading cause of failed mechanical thrombectomy (MT). To achieve successful recanalisation, rescue strategies such as balloon angioplasty and stenting are frequently employed. In this study, we aimed to investigate the comparative efficacy and safety of these strategies.

METHODS

We retrospectively analysed the data of 321 patients with ICAS-related large vessel occlusion (LVO) treated with rescue balloon angioplasty (n=212) or stenting (n=109) after MT. The primary outcome was favourable outcomes (modified Rankin Scale score of 0-2) at 3 months. Multivariate logistic regression identified predictors of outcomes, including subgroup analyses for anterior and posterior circulation.

RESULTS

Overall, data of 321 patients (median age, 60 (IQR, 53-67) years; 80.4% male) were analysed from an initial cohort of 1601 patients. At 3 months, the balloon group demonstrated a trend towards a higher rate of favourable outcomes (34.9% vs 45.8%; OR 0.62, 95% CI 0.36 to 1.09, p=0.098). The stent group showed a trend towards a higher incidence of symptomatic intracranial haemorrhage (11.0% vs 4.2%; OR 2.22, 95% CI 0.80 to 6.14, p=0.124). In the posterior circulation subgroup, favourable outcomes were significantly lower in the stent group (20.5% vs 41.5%; OR 0.32, 95% CI 0.10 to 0.98, p=0.047).

CONCLUSION

Balloon angioplasty after MT may improve clinical outcomes to some extent in ICAS-related LVO with a lower incidence of intracranial haemorrhage compared with stenting, while stenting is an effective measure to prevent long-term restenosis.

Comparison of rescue intracranial stenting versus best medical treatment alone in acute refractory large vessel occlusion: study protocol for the PISTAR multicenter randomized trial

BACKGROUND

Mechanical thrombectomy (MT) has become a standard treatment for acute ischemic strokes (AIS). However, MT failure occurs in approximately 10-30% of cases, leading to severe repercussions (with mortality rates up to 40% according to observational data). Among the available rescue techniques, rescue intracranial stenting (RIS) appears as a promising option.

OBJECTIVE

This trial is poised to demonstrate the superiority of RIS in addition to the best medical treatment (BMT) in comparison with BMT alone, in improving the functional outcomes at 3 months for patients experiencing an AIS due to a large vessel occlusion refractory to MT (rLVO).

METHODS

Permanent Intracranial STenting for Acute Refractory large vessel occlusions (PISTAR) is a multicenter prospective randomized open, blinded endpoint trial conducted across 11 French University hospitals. Adult patients (≥18 years) with an acute intracranial occlusion refractory to standard MT techniques will be randomized 1:1 during the procedure to receive either RIS+BMT (intervention arm) or BMT alone (control arm).

RESULTS

The primary outcome is the rate of good clinical outcome at 3 months defined as a modified Rankin Scale score ≤2 and evaluated by an independent assessor blinded to the randomization arm. Secondary outcomes include hemorrhagic complications, all adverse events, and death. The number of patients to be included is 346. Two interim analyses are planned with predefined stopping rules.

CONCLUSION

The PISTAR trial is the first randomized controlled trial focusing on the benefit of RIS in rLVOs. If positive, this study will open new insights into the management of AIS.

TRIAL REGISTRATION NUMBER

NCT06071091.

Rescue Therapy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: A Pooled Analysis of the Society of Vascular and Interventional Neurology Registry

OBJECTIVE

We aimed to evaluate the association between rescue therapy (RT) and functional outcomes compared to medical management (MM) in patients presenting after failed mechanical thrombectomy (MT).

METHODS

This cross-sectional study utilized prospectively collected and maintained data from the Society of Vascular and Interventional Neurology Registry, spanning from 2011 to 2021. The cohort comprised patients with large vessel occlusions (LVOs) with failed MT. The primary outcome was the shift in the degree of disability, as gauged by the modified Rankin Scale (mRS) at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), symptomatic intracranial hemorrhage (sICH), and 90-day mortality.

RESULTS

Of a total of 7,018 patients, 958 presented failed MT and were included in the analysis. The RT group comprised 407 (42.4%) patients, and the MM group consisted of 551 (57.5%) patients. After adjusting for confounders, the RT group showed a favorable shift in the overall 90-day mRS distribution (adjusted common odds ratio = 1.79, 95% confidence interval [CI] = 1.32-2.45, p < 0.001) and higher rates of functional independence (RT: 28.8% vs MM: 15.7%, adjusted odds ratio [aOR] = 1.93, 95% CI = 1.21-3.07, p = 0.005) compared to the MM group. RT also showed lower rates of sICH (RT: 3.8% vs MM: 9.1%, aOR = 0.52, 95% CI = 0.28-0.97, p = 0.039) and 90-day mortality (RT: 33.4% vs MM: 45.5%, aOR = 0.61, 95% CI = 0.42-0.89, p = 0.009).

INTERPRETATION

Our findings advocate for the utilization of RT as a potential treatment strategy for cases of LVO resistant to first-line MT techniques. Prospective studies are warranted to validate these observations and optimize the endovascular approach for failed MT patients. ANN NEUROL 2024;96:343-355.

Risk prediction of CISS classification in endovascular treatment of basilar artery stenosis

Objective

To investigate the incidence of ischemic stroke complications after endovascular treatment for basilar artery stenosis used preoperative high-resolution magnetic resonance vascular wall imaging (HRMR/VWI) and diffusion-weighted imaging (DWI).

Methods

The clinical data of 47 patients with severe symptomatic basilar artery stenosis (stenosis rate ≥70 %) treated with endovascular therapy at the Neuro-interventional Center from December 2017 to December 2021 were retrospectively analyzed. High-resolution magnetic resonance angiography (HRMR VWI) and DWI were used to evaluate the location of atherosclerotic plaque at basilar artery stenosis and the distribution of cerebral infarction lesions in all patients before surgery.According to the CISS classification system for ischemic stroke, patients were divided into a perforation group and a hypoperfusion group, and the general situation, plaque distribution, and incidence of ischemic stroke complications 7 days after endovascular treatment in the two groups were analyzed.

Results

There was no significant difference in baseline data between the two groups. After 7 days of intravascular treatment, the incidence of ischemic stroke was higher in the perforation group (20.0 %) than in the hypoperfusion group (0.0 %), and the difference was statistically significant (P = 0.027). A significant association was found between the perforation group and the hypoperfusion group for the incidence of ischemic stroke at 7 days (P = 0.003, OR = 2.347; 95 % CI = 2.056-4.268). There were a higher proportion of ventral plaques (74.1 %) and a lower proportion of dorsal plaques (33.3 %) in the hypoperfusion group, which were 15.0 % and 90.0 % in the perforation group, respectively (χ2 = 16.045, P < 0.001; χ2 = 15.092, P < 0.001). There was no significant difference in the proportion of left and right plaques between the two groups.

Conclusions

The risk of ischemic stroke is greater in patients with perforator artery obstruction undergoing endovascular therapy, and lower in patients with hypoperfusion/embolus removal.