Symptomatic intracranial vertebral artery atherosclerotic stenosis (≥70%) with concurrent contralateral vertebral atherosclerotic diseases in 88 patients treated with the intracranial stenting

Percutaneous transluminal angioplasty and stenting (PTAS) in patients with symptomatic intracranial vertebrobasilar artery stenosis (IVBS)

BACKGROUND

Approximately 20% of all transient ischaemic attacks (TIAs) and ischaemic strokes occur within the posterior circulation, with vertebrobasilar stenosis identified as the cause in roughly 25% of the cases. Studies have shown that about a quarter of these patients have atherosclerotic stenosis of at least 50% of the vertebrobasilar artery. Stenosis has been shown to be associated with an increased risk of 90-day recurrent vertebrobasilar stroke, particularly in the first few weeks, which is significantly higher when compared with patients with stenosis of the anterior circulation. Therefore, aggressive treatment is important for the patient's prognosis. Stenting is emerging as a promising therapeutic strategy for persistent ischaemia events that do not respond to the best medical treatment, but it is not without complications. We systematically reviewed the literature on percutaneous transluminal angioplasty and stenting (PTAS) for intracranial vertebrobasilar artery stenosis (IVBS).

METHODS

PubMed, Web-of-Science and Scopus were searched upon the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to include prospective/retrospective cohort, randomised/non-randomised clinical trials and case series studies describing PTAS for IVBS. Pooled rates of intervention-related complications and outcomes were analysed with random-effect model meta-analysis using StataMP V.18.0 software.

RESULTS

31 studies were found eligible which included 1928 cases. 1103 basilar artery stenosis cases were reported in 27 studies 0.65 (95% CI 0.53, 0.76), I2: 99.72%. 648 vertebral cases were reported in 18 studies 0.60 (95% CI 0.49, 0.70), I2: 97.49%. In four studies, the rate of vertebrobasilar stenosis cases calculated as a proportion of the total sample size was 0.10 (95% CI 0.05, 0. 15). Mean stenosis in 21 included studies was found to be 0.83 (95% CI 0.79, 0.88), I2: 0.00%, which shows variation of baseline stenosis between studies was minimal. 51 deaths were recorded in 24 studies. Meta-analysis of mortality showed the overall rate of mortality was 0.03 (95% CI 0.02, 0.05), I2: 44.90%. In 14 studies, symptomatic intracranial haemorrhage events were recorded at an overall rate of 0.01 (95% CI 0.00, 0.02), I2: 0.00%. Generally, a follow-up period of at least 3 months was reported in the included studies. Furthermore, procedural stroke/TIA was evaluated in seven studies, four of which reported no events (0.03 (95% CI 0.00, 0.08), I2: 20.38%). Mean time from initial symptoms to recanalisation was 23.98 (95% CI 18.56, 29.40), I2=98.8%, p=0.00 days.

CONCLUSION

In certain individuals with medically unresolved, severe, symptomatic and non-acute IVBS, elective vertebrobasilar PTAS appears to be both safe and effective. Various stent designs and angioplasty-assisted techniques should be taken into consideration based on the specific clinical and radiological traits of the lesions. Future randomised controlled trials are required to verify these results.

Safety and efficacy of the Low-Profile Visualized Intraluminal Support stent in treating intracranial atherosclerotic stenosis

PURPOSE

The performance of the Low-Profile Visualized Intraluminal Support (LVIS) stent deployed following balloon angioplasty is unknown in treating intracranial atherosclerotic stenosis, and this study was to investigate the safety and efficacy of the LVIS stent in treating intracranial atherosclerotic stenosis in the middle cerebral artery M1 segment.

METHODS

Thirty-five patients were enrolled with 35 atherosclerotic stenoses at the M1 segment. The stenosis was about 75% in 16 patients, 80% in 15, and 90% in the rest four. The LVIS stent was used to treat these patients.

RESULTS

The success rate of stenting was 97.1%. The stenting procedure was failed in one patient because of intraprocedural dissection of the stenotic (75%) segment, resulting in a 30-day periprocedural complication rate of 2.9% (1/35). Before stenting, the stenosis rate ranged 75%-90% (mean 78.9%±4.7%), and after stenting, the diameter of the stented segment was significantly (P<0.0001) increased to 1.5-3.4mm (mean 2.1±0.32mm) ranging 68.2%-100% (mean 94.0%±5.8%) of the normal arterial diameter, with the residual stenosis ranging 0-31.8% (median 4.8%, IQR 2.4%-7.3%). Follow-up was performed at 6-20 months (mean 8.5) after stenting. One patient (2.9%) had occlusion of the stented M1 segment with no symptoms, and two patients (5.7%) had slight asymptomatic instent stenosis (40%) at the M1 segment, with the instent restenosis and occlusion rate of 8.6% (3/35).

CONCLUSION

The braided LVIS stent can be safely applied for treatment of intracranial atherosclerotic stenosis in the middle cerebral artery with good safety and efficacy immediately after stenting and at follow-up.

A non-linear relationship between lesion length and risk of recurrent cerebral ischemia after stenting for symptomatic intracranial stenosis with hemodynamic impairment

Background

Stent placement can be an effective treatment for patients with symptomatic intracranial stenosis (sICAS) and hemodynamic impairment (HI). However, the association between lesion length and the risk of recurrent cerebral ischemia (RCI) after stenting remains controversial. Exploring this association can help predict patients at higher risk for RCI and develop individualized follow-up schedules.

Method

In this study, we provided a post-hoc analysis of a prospective, multicenter registry study on stenting for sICAS with HI in China. Demographics, vascular risk factors, clinical variables, lesions, and procedure-specific variables were recorded. RCI includes ischemic stroke and transient ischemic attack (TIA), from month 1 after stenting to the end of the follow-up period. Smoothing curve fitting and segmented Cox regression analysis were used to analyze the threshold effect between lesion length and RCI in the overall group and subgroups of the stent type.

Results

The non-linear relationship between lesion length and RCI was observed in the overall population and subgroups; however, the non-linear relationship differed by subgroup of stent type. In the balloon-expandable stent (BES) subgroup, the risk of RCI increased 2.17-fold and 3.17-fold for each 1-mm increase in the lesion length when the lesion length was <7.70 mm and >9.00 mm, respectively. In the self-expanding stent (SES) subgroup, the risk of RCI increased 1.83-fold for each 1-mm increase in the lesion length when the length was <9.00 mm. Nevertheless, the risk of RCI did not increase with the length when the lesion length was >9.00mm.

Conclusion

A non-linear relationship exists between lesion length and RCI after stenting for sICAS with HI. The lesion length increases the overall risk of RCI for BES and for SES when the length was <9.00 mm, while no significant relationship was found when the length was >9.00 mm for SES.

Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints

Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone.

Safety and efficacy of the Low-Profile Visualized Intraluminal Support stent in treating intracranial atherosclerotic stenosis

PURPOSE

The performance of the Low-Profile Visualized Intraluminal Support (LVIS) stent deployed following balloon angioplasty is unknown in treating intracranial atherosclerotic stenosis, and this study was to investigate the safety and efficacy of the LVIS stent in treating intracranial atherosclerotic stenosis in the middle cerebral artery M1 segment.

METHODS

Thirty-five patients were enrolled with 35 atherosclerotic stenoses at the M1 segment. The stenosis was about 75% in 16 patients, 80% in 15, and 90% in the rest four. The LVIS stent was used to treat these patients.

RESULTS

The success rate of stenting was 97.1%. The stenting procedure was failed in one patient because of intraprocedural dissection of the stenotic (75%) segment, resulting in a 30-day periprocedural complication rate of 2.9% (1/35). Before stenting, the stenosis rate ranged 75%-90% (mean 78.9%±4.7%), and after stenting, the diameter of the stented segment was significantly (P<0.0001) increased to 1.5-3.4mm (mean 2.1±0.32mm) ranging 68.2%-100% (mean 94.0%±5.8%) of the normal arterial diameter, with the residual stenosis ranging 0-31.8% (median 4.8%, IQR 2.4%-7.3%). Follow-up was performed at 6-20 months (mean 8.5) after stenting. One patient (2.9%) had occlusion of the stented M1 segment with no symptoms, and two patients (5.7%) had slight asymptomatic instent stenosis (40%) at the M1 segment, with the instent restenosis and occlusion rate of 8.6% (3/35).

CONCLUSION

The braided LVIS stent can be safely applied for treatment of intracranial atherosclerotic stenosis in the middle cerebral artery with good safety and efficacy immediately after stenting and at follow-up.

Incidence and Risk Factors of In-Stent Restenosis for Symptomatic Intracranial Atherosclerotic Stenosis: A Systematic Review and Meta-Analysis

BACKGROUND

In-stent restenosis affects long-term outcome in patients with intracranial atherosclerotic stenosis.

PURPOSE

The aim of this meta-analysis was to evaluate the incidence and risk factors of in-stent restenosis.

DATA SOURCES

All literature that reported in-stent restenosis was searched on PubMed, Ovid EMBASE and Ovid MEDLINE data bases.

STUDY SELECTION

Original articles about stents for symptomatic intracranial atherosclerotic stenosis were selected.

DATA ANALYSIS

Meta-analysis was conducted to derive the pooled in-stent restenosis using a random-effects model. Meta-regression was performed to explore the risk factors predisposing to in-stent restenosis.

DATA SYNTHESIS

In total, 51 studies with 5043 patients were included. The pooled incidence rate of in-stent restenosis was 14.8% (95% CI, 11.9%-17.9%). Among the lesions with in-stent restenosis, 28.8% of them led to (95% CI, 22.0%-36.0%) related neurologic symptoms. The series in the United States had a higher in-stent restenosis rate (27.0%; 95% CI, 20.6%-33.9%) compared with those from Asia (13.6%; 95% CI, 10.3%-17.2%) and other regions as a whole (7.6%; 95% CI, 1.1%-18.1%) (P < .01). Multiregression analysis revealed that younger patient age was related to high in-stent restenosis rates (P = .019), and vertebrobasilar junction location (P = .010) and low residual stenosis (P = .018) were 2 independent risk factors for symptomatic in-stent restenosis rate.

LIMITATIONS

The heterogeneity of most outcomes was high.

CONCLUSIONS

Our study showed promising results of in-stent restenosis for symptomatic atherosclerotic stenosis. Studies are needed to further expatiate on the mechanisms by which younger patient age, vertebrobasilar junction location, and low residual stenosis could increase in-stent restenosis and symptomatic in-stent restenosis, respectively.

Leave Nothing Behind: Treatment of Intracranial Atherosclerotic Disease with Drug-Coated Balloon Angioplasty

PURPOSE

Intracranial atherosclerosis disease (ICAD) is an essential cause of stroke. The characteristics of effective treatment include low periprocedural risk and a sustained treatment effect. Angioplasty with a conventional balloon for ICAD is safe but has a dauntingly high restenosis rate. Drug-coated balloon (DCB) angioplasty might reduce the risk of restenosis while maintaining the overall safety of the procedure.

METHODS

This study included symptomatic ICAD patients with more than 70% stenosis. Intermediate catheters were placed distally, and the lesions were predilated with a conventional balloon, followed by a DCB (SeQuent Please, B Braun, Melsungen, Germany). The primary endpoint was any stroke or death within 30 days or ipsilateral ischemic stroke thereafter. The secondary endpoint was arterial restenosis of more than 50% during follow-up.

RESULTS

A total of 39 sessions of DCB angioplasty were performed for 39 lesions in 35 patients between October 2015 and April 2018 in a single center. All of the DCBs could be navigated to the lesions. Major periprocedural complications were noted in two patients (5.7%, 2/35), and minor periprocedural complications were also noted in two patients (5.7%, 2/35). The average percentages of stenosis of the lesions were 76.6% ± 7% before treatment, 32.4% ± 11.2% after DCB angioplasty, and 25% ± 16% at follow-up. Stenosis over 50% was present in 3 lesions during the follow-up period (8.3%, 3/36).

CONCLUSION

In this study, the application of DCBs to treat ICAD patients was feasible and safe. A larger scale clinical trial is warranted to further evaluate the safety and efficacy of this treatment.

Correlation Studies and Literature Review of Medullary Artery Occlusion After Intracranial Vertebral Artery Stenting

BACKGROUND

Stenosis of the target intracranial vertebral artery is one of the major causes of posterior circulation ischemic stroke. The objective of this paper is to explore methods for reducing the occurrence of medullary artery occlusion after intracranial vertebral artery stenting.

CASE DESCRIPTION

The current research presents a retrospective analysis of 48 patients who received Gateway-Wingspan stent angioplasty to treat severe stenosis of the intracranial vertebral artery, evaluates the results of stenosis remission and perfusion improvement after stent angioplasty, and explores the causes of postoperative medullary artery occlusion. A total of 49 Wingspan stents were implanted in the 48 patients, with a surgical success rate of 100%. After stent implantation, the patients' rates of intracranial vertebral artery stenosis dropped from 75.9% ± 6.3% to 28.4% ± 5.1%. Transcranial Doppler or cranial computed tomography angiography 3 months after surgery showed that none of the patients suffered from in-stent restenosis. Within 24 hours after surgery, medullary perforating artery occlusion occurred in 2 patients, probably because atherosclerotic plaque in the stenotic area became less stable and displaced under the mechanical action of postoperative saccule and stent. As a result, the medullary artery was blocked. After drug and rehabilitation therapies, the patients' symptoms were alleviated.

CONCLUSIONS

Perforating artery occlusion after intracranial vertebral artery stenting can be prevented by strict assessment and preparation before surgery, correct choices of saccule and stent during operation, and other measures. However, large sample data are needed for verification.

Incidence and Predictors of the In-stent Restenosis after Vertebral Artery Ostium Stenting

BACKGROUND

The incidence and predictors for in-stent restenosis (ISR) was not fully explored. We aim to investigate the incidence and predictors of ISR after stenting at the origin of vertebral artery.

MATERIALS AND METHODS

Two hundred and six patients with 229 stents implantation between July 1, 2005 and July 31, 2015 were included in the study. All patients underwent conventional clinical and angiographic (digital subtraction angiography) follow-up at around 6 months post procedure. ISR was defined as greater than 50% stenosis within or immediately (within 5 mm) adjacent to the stent. Multivariate Cox regression analyses were utilized to investigate the predictors for ISR.

RESULTS

The ISR was found in 30 patients (30/206, 14.6%) with 31 lesions (31/229, 13.5%) with the mean follow-up duration of 11.1-month (range: 3 - 92 months). Stent diameter (hazard ratio 0.504, 95% confidence interval 0.294 - 0.864) was an independent predictor for ISR.

CONCLUSION

ISR rate after Vertebral artery ostium stent placement is acceptable, which was conversely associated with the stent diameter.

Center volume and the outcomes of percutaneous transluminal angioplasty and stenting in patients with symptomatic intracranial vertebrobasilar stenoses: A meta-analysis

Background

Evidence for the preventative effects of percutaneous transluminal angioplasty and stenting (PTAS) on the recurrence of stroke in patients with severe intracranial vertebrobasilar stenoses (IVBS) varies, and the influence of study characteristics on the study outcomes have not been determined.

Methods

A study level based meta-analysis was performed to investigate the influence of baseline characteristics on the 30-day and follow-up stroke recurrence or death in symptomatic IVBS patients receiving PTAS. Relevant single center studies were retrieved by searching PubMed and Embase. A random effect model was applied to synthesize the outcomes. Meta-regression and subgroup analyses were performed to evaluate the potential influence of study characteristics on outcomes.

Results

Fifteen cohort studies comprising 554 symptomatic IVBS patients were included. PTAS was associated with an 8% incidence of stroke recurrence or death (95% CI: 5% to 12%) in IVBS patients within 30 days, and 8 per 100 person-years (95% CI: 5 to 11 per 100 person-years) of cumulative stroke recurrence or death during follow-up. Meta-regression indicated that the center volume, as defined by the numbers of cases per year, was negatively correlated with 30-day (regression coefficient = -0.09, p = 0.02) and follow-up (regression coefficient = -0.60, p = 0.01) stroke recurrence or death. Age, gender, or comorbidities have no significant effect on the outcomes.

Conclusions

Centers of higher procedural volume may be associated with better clinical outcomes for symptomatic IVBS patients receiving PTAS.

The Incidence and Risk Factors of In-Stent Restenosis for Vertebrobasilar Artery Stenting

BACKGROUND AND OBJECTIVES

In-stent restenosis (ISR) remains a challenge for vertebrobasilar artery stenting (VBAS). We aimed to investigate the incidence and risk factors of ISR.

METHODS

This was a retrospective study. From July 28, 2005, to July 30, 2015, patients who received VBAS with an angiographic follow-up time of 6 to 12 months after surgery were enrolled. The clinical and angiographic issues were recorded and analyzed.

RESULTS

In total, 283 patients with 335 stents were incorporated into the study. Vertebral ostial lesions accounted for 73.4% (246/335) of the lesions. During the follow-up period, 58 patients with 60 stents experienced ISR (>50%). Stepwise logistic regression analysis showed that the degree of residual stenosis, stent diameter, and alcohol consumption were independent predictors of ISR.

CONCLUSIONS

Our study demonstrated the incidence and risk factors of ISR after VBAS. This retrospective study with the largest cohort to date provided insight into the occurrence of ISR after VBAS.

Delayed Endovascular Stenting for Severe Vertebral Artery Stenosis with Precarious Thrombosis

A significant but less recognized cause of ischemic stroke and transient ischemic attack (TIA) is atherosclerosis of the vertebrobasilar system, which accounts for 20% of ischemic strokes. Pathology of the vertebrobasilar system can present significant challenges in determining the course of treatment. Due to the complexity of the vertebrobasilar system, there is slight disagreement about how to approach patients with atherosclerotic pathology of the posterior circulation. Two such approaches are either stenting of the vertebral or basilar artery or aggressive medical management. Here, we present the case of a 63-year-old male who presented with lightheadedness, diaphoresis, two episodes of loss of consciousness, and the abrupt onset of unilateral right-sided paresis. A computed tomography angiogram (CTA) of the head and neck demonstrated complex posterior circulation vertebrobasilar vascular stenosis and occlusions. There was an unstable clot located at the junction of the vertebral and basilar arteries requiring a carefully nuanced approach. The patient was started on dual antiplatelet therapy and heparin in an effort to resolve the clot. Repeat CTA after five days revealed resolution of the unstable clot; however, the distal intradural right vertebral artery remained occluded and the left vertebral artery remained stenosed. The patient was then treated with a balloon-mounted coronary stent to eliminate the stenosis, which ultimately restored normal posterior fossa flow dynamics. This case serves as a testament to the variability and complexity of vertebrobasilar arteriopathies as well as the benefit of experienced neurointerventionalists in the successful management of these cases.