Arterial occlusions increase the risk of in-stent restenosis after vertebral artery ostium stenting

In-stent restenosis and stented-territory infarction after carotid and vertebrobasilar artery stenting

BACKGROUND

Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS.

METHODS

We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared.

RESULTS

Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS.

CONCLUSIONS

Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.

Using drug-coated balloons for symptomatic vertebral artery origin stenosis: A systematic review and meta-Analysis

BACKGROUND

Endovascular stenting has emerged as an effective treatment for patients with symptomatic vertebral artery origin stenosis (VAOS), but the incidence of severe restenosis is concerning. Angioplasty alone with a drug-coated balloon (DCB) is a potential treatment for VAOS. The purpose of this systematic review and meta-analysis was to assess the utility of DCB angioplasty for VAOS.

METHODS

A systematic search of the Medline (PubMed), Embase, CNKI, and Cochrane databases for studies on the treatment of VAOS by DCB angioplasty published in English and Chinese before June 15, 2022 was conducted. Data were extracted using standardized methods. The incidence rates of restenosis, technical success, and perioperative complication in the follow-up period were pooled using Freeman-Tukey double arcsine transformation with random or fixed-effect models. Tests for heterogeneity and publication bias were performed.

RESULTS

A total of seven studies containing 159 patients were included in this review and meta-analysis. The pre-treatment stenosis rate of the vertebral artery in the DCB group ranged from 70.0 % to 86.3 %, and the median follow-up time ranged from 6.0 to 14.1 months. The pooled restenosis incidence was 11.9 % (95 % CI: 3.4 %-23.4 %; I² = 59 %, p = 0.02) during the follow-up period. The pooled technical success rate was 96.6 % (95 % CI: 91.4 %-99.7 %; I² = 37 %, p = 0.14). The overall perioperative complication rate was 2.9 % (95 % CI: 0.3 %-6.9 %; I² = 0 %, p = 0.64). According to the funnel diagram and Egger's test, there was no evidence of publication bias.

CONCLUSION

It is suggested in this review and meta-analysis that angioplasty with DCB may be a potential treatment for VAOS. However, randomized studies including a large representative sample of VAOS patients are needed to validate our findings.

Risk factors for in-stent restenosis after vertebral artery stenting of V1 segment: A systematic review and meta-analysis

OBJECTIVE

In-stent restenosis (ISR) remains a challenge in the treatment of vertebral artery V1 segment stenosis. The aim of this meta-analysis is to identify the risk factors of ISR.

METHODS

Studies eligible for inclusion criteria were found in PubMed, Embase, and Cochrane Library databases. Data related to risk factors of ISR were extracted from the included studies, and pooled analysis was performed when data of the same factor were available in ≥2 studies. Dichotomous outcomes were analyzed with odds ratios (OR) and continuous outcomes were analyzed with a weighted mean difference (WMD). The Stata 14.0 program was used for the meta-analysis.

RESULTS

A total of 11 studies involving 1356 patients were included in our analysis. Pooled analyses showed that younger age (p = 0.01; WMD= -1.958; 95% confidence interval [CI], -3.453 to -0.463) and V1 tortuosity (p = 0.004; OR = 4.145; 95% CI, 1.56-11.012) significantly associated with higher risk of ISR in V1 segment stenting. While bare-metal stents, stent diameter and length, diabetes mellitus, coronary artery disease, and smoking were not found to increase ISR rates.

CONCLUSIONS

This meta-analysis showed that young age and V1 tortuosity increase the ISR rates after vertebral V1 segment stenting.

A Comparison of Different Endovascular Treatment for Vertebral Artery Origin Stenosis

OBJECTIVE

To compare the safety and efficacy of stenting with drug-eluting stent (DES), stenting with bare mental stent (BMS), and angioplasty alone with drug-coated balloon (DCB) in patients with symptomatic vertebral artery origin stenosis (VAOS) who did not respond to aggressive medical management.

METHODS

We performed a retrospective analysis of consecutive patients with symptomatic VAOS who underwent endovascular treatment between December 2018 and November 2021 at our institution. The main outcome compared were technical success, perioperative complications, residual stenosis, stroke recurrence, progression of residual stenosis, and restenosis.

RESULTS

A total of 46 patients were included: 29 were stented with DES, 12 were stented with BMS, and 5 received angioplasty alone with DCB. Technical success was achieved in 100%, 100%, and 60%, respectively (P = 0.008). Residual stenosis was 10.8%, 20.2%, and 51.2%, respectively (P < 0.001). Perioperative complications occurred only in 1 case in the DES group (P = 1.00). During a mean follow-up of 14.1 months, stroke recurrence rate was 6.9%, 16.7%, and 0% respectively (P = 0.73). Absolute progression of residual stenosis was 10.1%, 34.9%, and -8.0%, respectively (P < 0.001). Restenosis rate was 6.9%, 50.0%, and 20.0%, respectively (P = 0.007).

CONCLUSIONS

In patients with symptomatic VAOS who did not respond to aggressive medical management, stenting with DES shows superiority in the lowering the restenosis rate compared with stenting with BMS. Angioplasty alone with DCB is associated with the slowest progression of stenosis in spite of moderate residual stenosis.

A retrospective study of drug-coated balloon angioplasty for vertebral artery origin stenosis

PURPOSE

Angioplasty using drug-coated balloon (DCB) for treatment of symptomatic vertebral artery origin stenosis (VAOS) is promising, but of uncertain benefit. This study aimed to evaluate the feasibility, safety, and effectiveness of using DCB in the treatment of severe VAOS.

METHODS

This study included 20 patients with severe VAOS treated with DCB alone between April 2018 and December 2019. Vascular death, transient ischemic attack (TIA), and stroke related to the responsible artery within 30 days after procedure were recorded as primary endpoints. Restenosis, late TIA, and stroke related to VAOS and satisfied clinical outcome [modified Rankin Scale (mRS) ≤ 2] were documented at follow-up visit as secondary endpoints.

RESULTS

Of 20 patients, 16 were performed DCB dilation successfully, and 4 were excluded due to further bailout stenting. After the procedure, no adverse event occurred within 30 days. Ten of 16 patients achieved residual VAOS (rVAOS) < 50% (lower rVAOS group), and the remaining 6 patients achieved rVAOS ≥ 50% but < 70% (higher rVAOS group). During follow-up, vertebral artery origin restenosis was detected in 3 (18.8%) of 16 patients by ultrasound. Among the 3 patients with restenosis, 2 were belonged to the higher rVAOS group, which might indicate a tendency that the more severe the residual stenosis, the higher the restenosis rate. All patients had no complaint in the whole follow-up period (median, 7 months; InterQuartile Range, 1-18 months).

CONCLUSIONS

Angioplasty using DCB for VAOS may be feasible, safe, and effective. The degree of residual stenosis after using DCB alone may affect the restenosis rate.

Effects of the Vertebral Artery Ostium/Subclavian Artery Angle on In-Stent Restenosis after Vertebral Artery Ostium Stenting

Methods

Between January 2016 and October 2018, sixty-four consecutive patients who underwent a total of 66 stenting procedures were screened for symptomatic and asymptomatic atherosclerotic VAOS. Of these patients, 57 had complete follow-up data. The baseline patient demographics and morphological features of the VAO were recorded. Potential factors influencing ISR, including conventional cerebrovascular disease risk factors, were assessed, together with outcome events including recurrent transient ischemic attack (TIA), stroke, and vascular-related mortality.

Results

The average follow-up period was 13.2 ± 4.6 months. Technical success was achieved in all interventions. The degree of stenosis was reduced from 77.2 ± 6.1% to 13.7 ± 8.9% after the procedure. ISR was detected in eight treated vessels (14.0%) and occlusion in two (5.3%) arteries. Of the 57 patients, one had an ischemic stroke and 5 had TIAs. The angle of the VAO at the subclavian artery was associated with the risk of restenosis (preoperative, P = 0.04; postoperative, P = 0.02).

Conclusions

Stenting is a feasible and effective treatment for VAOS. The angle of the VAO at the subclavian artery may contribute to the development of ISR.

A novel angiographic classification for the endovascular recanalization of symptomatic nonacute extracranial vertebral artery occlusion

BACKGROUND

There remains major uncertainty regarding the optimal therapy for symptomatic nonacute extracranial vertebral artery occlusion (EVAO). Endovascular recanalization for EVAO is technically challenging, and limited data are available. This research aimed to report a multicenter clinical experience of endovascular recanalization for symptomatic nonacute EVAO and establish a novel angiographic classification.

METHODS

From June 2011 to December 2019, 50 symptomatic nonacute EVAO patients treated with endovascular recanalization in three regional referral stroke centers were retrospectively analyzed. All patients were categorized into four groups based on the angiographic classification. The rates of technical success, periprocedural complications, any stroke or death within 1 month, and follow-up data were assessed.

RESULTS

The rates of technical success, periprocedural complications, and any stroke or death within 1 month were 86.0% (43/50), 12.0% (6/50), and 4.0% (2/50), respectively. The recanalization rates gradually decreased from Type A to Type D (100%, 94.7%, 80%, and 63.6%, respectively; P=0.007). The EVAO patients in the Type A group with tapered stump and short-segment occlusions showed excellent recanalization effects, with 100% technical success rates and no complications. Conversely, the lowest recanalization rate of 63.6% (7/11) and the highest periprocedural complication rate of 27.3% (3/11) were observed for the Type D group.

CONCLUSIONS

Endovascular recanalization for symptomatic nonacute EVAO is technically feasible, especially Type A EVAO patients, which can provide an alternative treatment option for recurrent vertebrobasilar ischemia despite optimal medical therapy. The angiographic categorization established in this study is conducive to the selection of suitable patients prior to treatment decision.

Drug-coated balloon for vertebral artery origin stenosis: a pilot study

BACKGROUND

Drug-coated balloon (DCB) is a potential treatment for patients with low restenosis risk in vertebral artery origin stenosis (VAOS). However, the clinical data of long-term outcome are limited.

OBJECTIVE

To evaluate the safety and efficacy of a DCB in patients with severe VAOS.

METHODS

A prospective, non-randomized, single-center pilot study enrolled 30 patients with severe VAOS treated with DCB between 2017 and 2018. The first 20 patients were treated with a balloon-to-vessel ratio of predilation (pBVR)＜0.8 (small-size balloon predilation) and the following 10 patients were treated with a pBVR 0.8-1.0 (large-size balloon predilation). Primary safety endpoints included 30-day death, stroke, and transient ischemic attack (TIA). The main efficacy outcome was restenosis at 6 months, defined as a peak systolic velocity >140 cm/s measured by Doppler ultrasound. Long-term outcomes, including TIAs, stroke, death, and modified Rankin Scale score, were followed up to 2 years.

RESULTS

Technical success (<50% residual stenosis) was achieved in 26 patients (mean age 66.2±7.0; seven women). Four patients received bailout stenting and were excluded. Ultrasound confirmed restenosis at 6 months in 10 (38.5%) of 26, which was significantly less frequent in LSBP (LSBP vs SSBP=10% vs 56.3%, p<0.05). No adverse events occurred within 30 days of treatment. 19 patients were followed up for 2 years, with two deaths due to cancer.

CONCLUSION

This pilot study suggests that DCB is a safe approach for VAOS. The relatively low restenosis rate indicates the its potential long-term efficacy for VAOS. Future randomized controlled trials to confirm its efficacy are warranted.

Validation and comparison of drug eluting stent to bare metal stent for restenosis rates following vertebral artery ostium stenting: A single-center real-world study

BACKGROUND AND PURPOSE

While drug-eluting stents (DES) have been widely applicated in coronary stenosis, uncertainty persists concerning the relative performance and clinical benefit in patients undergoing vertebral artery stenting when compared with a bare metal stent (BMS). We sought to compare in-stent restenosis (ISR) rates of DES and BMS in the treatment of vertebral artery ostium (VAO) stenosis.

MATERIALS AND METHODS

This study analyzed a single-center prospective cohort. Over 1.5-year period (January 2014-June 2015), 137 consecutive patients underwent VAO stenting involving deployment of 76 DES and 74 BMS. Patient demographics, comorbidities, stenosis severity, stent diameters and lengths, periprocedural complications, imaging and duplex ultrasonography follow-up and recurrent symptoms were assessed.

RESULTS

Technical success was achieved in all patients. Mean VAO stenosis at presentation were 82.4 ± 7.2% in the DES group and 83.3 ± 7.5% in the BMS group and were reduced to 12.5 ± 4.5% and 11.3 ± 4.0%. Mean stent diameter was 3.53 ± 0.40 mm in DES and 5.05 ± 0.40 mm in BMS (p < 0.0001). Mean follow-up was 12.3 months for DES and 11.7 months for BMS. The use of DES was associated with significant lower ISR rates compared with BMS (18.4% vs. 31.1%; OR = 2.628, p = 0.021). Recurrent symptoms rates were similar in DES vs. BMS (2.6% vs 2.7%, p = 0.680). Stent type and stent diameter were independent risk factors for ISR (P = 0.026).

CONCLUSION

Our results suggest superior efficacy of deploying DES for the treatment of VAO stenosis with lower ISR rates as compared to BMS, but do not support significant differences in periprocedural risk and recurrent symptoms rate.