Solitaire Stent Permanent Implantation as an Effective Rescue Treatment for Emergency Large Artery Occlusion

Clinical outcomes of rescue stenting for failed endovascular thrombectomy: a multicenter prospective registry

BACKGROUND

Mechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome.

METHODS

A multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups.

RESULTS

A total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013).

CONCLUSIONS

In this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.

Efficacy of Solitaire AB stent-release angioplasty in acute middle cerebral artery atherosclerosis obliterative cerebral infarction

BACKGROUND

In both national and international studies, the safety and effectiveness of treatment with the Solitaire stent in patients with ischemic stroke caused by acute large vessel occlusion were good, and the disability rate was significantly reduced. However, there are currently only a few reports on the differences in endovascular treatment for different etiological classifications, especially in the anterior cranial circulation, aorta atherosclerotic stenosis, and acute thrombosis.

AIM

To investigate the efficacy of Solitaire AB stent-release angioplasty in patients with acute middle cerebral artery atherosclerosis obliterative cerebral infarction.

METHODS

Twenty-five patients with acute middle cerebral atherosclerosis obliterative cerebral infarction were retrospectively enrolled in this study from January 2017 to December 2019. The Solitaire AB stent was used to improve anterior blood flow to maintain modified cerebral infarction thrombolysis [modified thrombolysis in cerebral infarction (mTICI)] at the 2b/3 level or above, the stent was then unfolded and released.

RESULTS

All 25 patients underwent successful surgery, with an average recanalization time of 23 min. One patient died of cerebral hemorrhage and cerebral herniation after the operation. The National Institutes of Health Stroke Scale (NIHSS) scores immediately after surgery (7.5 ± 5.6), at 24 h (5.5 ± 5.6) and at 1 wk (3.6 ± 6.7) compared with the preoperative NIHSS score (15.9 ± 4.4), were significantly different (P < 0.01). One case of restenosis was observed 3 mo after surgery (the stenosis rate was 50% without clinical symptoms), the modified Rankin scale scores were 0 points in 14 cases (56%), 1 point in 4 cases (16%), 2 points in 2 cases (8%), 3 points in 3 cases (12%), 4 points in 1 case (4%), and 6 points in 1 case (4%).

CONCLUSION

In acute middle cerebral artery atherosclerosis obliterative cerebral infarction, when the Solitaire AB stent is unfolded and the forward blood flow is maintained at mTICI level 2b/3 or higher, stent release may be a safe and effective treatment method; however, long-term observation and a larger sample size are required to verify these findings.

Rescue permanent LVIS stenting with post-stenting angioplasty after failed mechanical thrombectomy for refractory internal carotid artery occlusion at the paraclinoid segment: two-case report

BACKGROUND

Previous studies indicated the effectiveness of permanent stenting when dealing with retriever-failed refractory large vascular occlusion (LVO). Variety types of stents were implanted permanently to achieve recanalization. Low-profile visualized intraluminal support (LVIS) is generally used as a supportive device for embolization of intracranial aneurysm. Its specific structural and functional characteristics contribute to its potential of treating LVO.

CASES PRESENTATION

A 51-year-old male was transferred to our stroke center because of conscious disturbance with the weakness of the left upper limb. The National Institute of Health Stroke Scale (NIHSS) was 24; the Glasgow Coma Scale (GCS) was 10. Digital subtraction angiography (DSA) showed that his paraclinoid segment of R-ICA was occluded due to hard clot embolization. Thrombectomy was performed 6 times, but the occlusion remained. Finally, LVIS was implanted permanently and post-dilation was performed, which successfully recanalized the artery (eTICI 2c). The post-operative NIHSS and GCS were 20 and 11, respectively, which were 10 and 14 when discharged. Another patient was a 71-year-old male who suffered weakness of left limbs. NIHSS was 15; GCS was 11. DSA confirmed that the paraclinoid segment of his R-ICA was occluded due to hard clot embolization. Totally 6 times of mechanical thrombectomy, angioplasty, and tirofiban infusion were performed, which failed to recanalize the artery. In the end, LVIS implantation with post-dilation was performed, and full recanalization was achieved (mTICI 3). The post-operative NIHSS and GCS were 9 and 15, respectively, which were 3 and 15 when discharged.

CONCLUSIONS

These 2 cases invited LVIS into the treatment of refractory occlusion due to hard clot embolization at the paraclinoid segment, and the outcomes were preferable because of the higher visibility, higher flexibility, and lower cell size of LVIS.

Solitaire AB stent-angioplasty for stenoses in perforator rich segments: A single-center experience

BACKGROUND

Vascular angioplasty and stenting of middle cerebral artery (MCA) and basilar artery (BA) stenoses are associated with poor clinical outcomes and high mortality rates thought to be related to the abundance of perforating arteries in those segments. This study explores the use of Solitaire AB as an off-label vascular stent to treat stenoses in the MCA and BA.

METHODS

Solitaire AB stents were placed during angioplasty and stenting of MCA and BA stenoses in patients at our department between January 2015 and May 2017 with 6-36 months follow-up. Operative results were assessed by follow-up angiography and transcranial doppler after the procedure. Neurologic status was evaluated before and after treatment according to the modified Ranking Scale (mRS).

RESULTS

A total of 32 patients were included in the study. Seventeen (53.12%) patients presented with MCA stenosis and 15 (46.87%) with BA stenosis. The 30-day rate of procedure-related complications was 3.1% (1/32). Post-stenting residual stenosis degrees ranged from 0% to 40% (mean 13.44% ± 10.66%). Mean degree of residual stenosis in 26 patients followed up by DSA was 8.64% ± 9.67%. The mRS 0-2 was achieved in all (100%) patients at 6-12 months post-procedure.

CONCLUSIONS

Our study indicates the off-label use of Solitaire AB for stenting is effective and safe for MCA and BA stenoses with high technical success and low complications. We recommend that lesion-specific therapy with an anatomically fitted stent design enables optimal treatment for intracranial stenosis.