The resolute Onyx drug eluting stent for neurointervention: A technical series

Management of a Twisted Flow Diverting Stent With a Balloon Mounted Cardiac Stent in a Pediatric Aneurysm: A Technical Report

BACKGROUND AND IMPORTANCE

Giant aneurysms can present technical challenges during treatment with flow diversion including inability to access the aneurysm outflow directly. Encircling the aneurysm with a microwire/microcatheter has been well described; however, it can result in a twisted stent because of catheter twisting during the reduction maneuver, which, in turn, could lead to thromboembolic complications.

CASE PRESENTATION

Here, we describe a novel technique to manage the twist of the flow diverter in a giant internal carotid artery aneurysm using a combination of angioplasty and off-label placement of a balloon-mounted cardiac stent within the flow diverter.

CONCLUSION

At 1 year, the aneurysm is completely occluded on digital subtraction angiography and MRI, and the patient is neurologically intact.

Onyx frontier DES in the setting of intracranial atherosclerotic disease: multicenter retrospective insights from early clinical experience

BACKGROUND

Intracranial atherosclerotic disease (ICAD) is a leading cause of stroke, often refractory to aggressive medical therapy. Recent advancements in drug-eluting stents (DES) show promise for improved efficacy in intracranial applications relative to traditional ICAD treatments.

METHODS

We retrospectively collected all consecutive deployments of the Onyx Frontier [Medtronic, Santa Rosa, CA] stent in the setting of ICAD between August 2022 and August 2024 at six high-volume neuro-interventional centers across the US. Patients were included if their indication for stenting (eg, acute/recurrent stroke) was secondary to ICAD. Primary outcome was periprocedural stroke (<72 hours) and secondary outcomes included degree of pre- and post-stent vessel stenosis and National Institutes of Health Stroke Scale (NIHSS) scores at most recent follow-up. Secondary outcomes were assessed via paired t-tests.

RESULTS

Among 55 patients that met our inclusion criteria, the mean age was 62, mean presentation NIHSS was 10, and 40% were female. A total of 62 devices were used. Most common occlusion locations included the middle cerebral and internal carotid arteries. The periprocedural stroke rate was 10.9%, with a mortality rate of 1.8%. Mean vessel stenosis significantly decreased from 84.90% pre-stent to 2.00% post-stent (P<0.05). Mean NIHSS score improved from 10.37 preoperatively to 3.23 at follow-up (p<0.05). Procedural failure did not occur, however complications occurred in 16.4% of cases.

CONCLUSION

Our findings suggest that stenting in this setting results in a lower periprocedural stroke rate than appreciated in historical trials such as SAMMPRIS and VISSIT. However, recent CASSISS and BASIS trials demonstrate far reduced periprocedural stroke rates in the context of submaximal angioplasty for ICAD. This, in conjunction with complication rate, suggest that the Onyx Frontier, while promising, may not offer a definitive solution to ICAD.

Use of Onyx Frontier™ for intracranial stenting in stroke patients: A multicenter retrospective study

BACKGROUND

Acute ischemic stroke (AIS) due to intracranial atherosclerotic disease (ICAD) carries a high risk of recurrence despite aggressive medical management. The aim of our study is to present our initial experience with the Onyx Frontier™ balloon-mounted drug-eluting stent (Medtronic, Santa Rosa, CA) for AIS due to ICAD.

METHODS

We conducted a multicenter retrospective cohort study describing the technical feasibility, safety, and performance of using the Onyx Frontier™ balloon-mounted drug-eluting stent in patients with acute intracranial vessel occlusion due to ICAD across three comprehensive stroke centers in the United States.

RESULTS

We included 23 patients in our study (mean age 67.3 [10.7]; females: n = 13/23, 56.5%). Most patients were Black (n = 14/23, 60.9%). The most common site of vessel occlusion was the M1 branch of the middle cerebral artery (MCA) (n = 14/23, 60.9%), followed by the vertebrobasilar system (n = 5/23, 21.7%), and the internal carotid artery (n = 3/23, 13.0%). Treatment with the Onyx Frontier™ stent was associated with a final mTICI score ≥2b for 100% of patients, with no vessel perforations or distal embolization. None of the patients had any restenosis or re-treatment over a median follow-up of 3.5 months (interquartile range [IQR] 7.8). All cases required a single stent except for one, where two were deployed. Transfemoral access was used in most cases (n = 18/23, 78.3%), with one in-hospital death due to access site complication (n = 1/23, 4.3%).

CONCLUSIONS

This is the largest multicenter cohort study demonstrating the feasibility and safety of using the Onyx Frontier™ balloon-mounted zotarolimus-eluting stent to treat symptomatic AIS due to ICAD.

Future of Endovascular and Surgical Treatments of Atherosclerotic Intracranial Stenosis

Intracranial atherosclerotic disease and resultant intracranial stenosis is a global leading cause of stroke, and poses an ongoing treatment challenge. Among patients with intracranial stenosis, those with hemodynamic compromise are at high risk for recurrent stroke despite medical therapy and risk factor modification. Revascularization of the hypoperfused territory is the most plausible treatment strategy for these high-risk patients, yet surgical and endovascular therapies have not yet shown to be sufficiently safe and effective in randomized controlled trials. Advances in diagnostic and therapeutic technologies have led to a resurgence of interest in surgical and endovascular treatment strategies, with a growing body of evidence to support their further evaluation in the treatment of select patient populations. This review outlines the current and emerging endovascular and surgical treatments and highlights promising future management strategies.

Single-center outcomes of Onyx Frontier™ and Resolute Onyx™ drug-eluting balloon-mounted stents for rescue stenting for acute large vessel occlusion

BACKGROUND

In cases where mechanical thrombectomy (MT) fails, rescue stenting may be necessary to achieve reperfusion; however, the lack of standardized techniques or devices poses a challenge. This series aims to present our early experience with the Onyx Frontier™ and Resolute Onyx™ balloon-mounted drug-eluting stents for rescue stenting.

METHODS

A retrospective chart review was performed of all patients who underwent rescue stenting, in the setting of failed MT, using Onyx Frontier™ or Resolute Onyx™ stents at a single institution. Technical details, procedural complications, and patient outcomes were recorded for each case.

RESULTS

Twenty-two Onyx Frontier™ and Resolute Onyx™ stents were deployed in 18 patients undergoing rescue stenting. Stent locations included the middle cerebral artery (36.4%), internal carotid artery (18.2%), vertebral artery (22.7%), and basilar artery (22.7%). The average National Institutes of Health Stroke Scale score before MT was 13.8 (range 0-31). The median initial modified Rankin Scale (mRS) score was zero, while the median mRS score at follow-up was three. Successful reperfusion, as assessed by TICI scores, was achieved in 43.8% of patients for TICI 3, 43.8% for TICI 2C, and 12.5% for TICI 2B. Post-revascularization, 16.7% of patients experienced hemorrhage, of which one patient (5.6%) had symptomatic hemorrhage.

CONCLUSIONS

Onyx Frontier™ and Resolute Onyx™ stents are well suited for rescue stenting in cases of failed MT. These balloon-mounted drug-eluting stents exhibit excellent navigability, rendering them appropriate for rescue revascularization procedures. Our findings demonstrate that these stents confer a high degree of technical success.

Novel usage of everolimus-eluting coronary stent for intracranial atherosclerotic disease: a technical report and case series

Objectives

This report describes the use of an Everolimus-eluting stent (Xience Skypoint stent) for the treatment of medically-refractory ICAD.

Design

Retrospective, case-series.

Setting

In-hospital patients.

Participants

All patients in this report had a history of stroke secondary to ICAD. All patients failed aggressive medical treatments and had recurrence of symptoms despite anticoagulation or dual-antiplatelet therapy plus a statin. Diagnostic angiogram in each case showed severe vessel stenosis, therefore patients were recommended for intracranial artery stenting.

Main outcome measures

Technical feasibility of deploying Xience Skypoint stent for treatmet of ICAD.

Results

The Xience Skypoint stent was safely and effectively deployed in the vertebral artery (x1) and the internal carotid artery (x2) using trans-ulnar (x1), trans-radial (x1), and trans-femoral (x1) approaches without the use of an intermediate catheter.

Conclusion

Second-generation EES such as Xience Skypoint may be utilized for treatment of medically-refractory ICAD. This technical report serves as a proof of concept for further studies analysing long-term safety and efficacy of such stents for treatment of ICAD.