Percutaneous Transluminal Angioplasty And Stenting Research Articles

Abstract 225: Rescue Stenting for Posterior Circulation Strokes

Introduction Intracranial atherosclerotic disease (ICAD) is associated with up to 32% of posterior circulation strokes.1 ICAD‐related strokes are at high risk for re‐occlusion following MT. Rescue treatment with stenting, balloon angioplasty, and/or intraarterial thrombolysis or antiplatelets are often required to treat the underlying stenosis. However, these rescue treatments are associated with their own risks.2,3 The SAMMPRIS trial reported that percutaneous transluminal angioplasty and stenting (PTAS) was associated with inferior outcomes compared to aggressive medical management alone but it is unclear whether these findings are generalizable to LVO strokes.4 Recent literature has reported clinical benefits associated with rescue stenting in the setting of ICAD‐related MT‐refractory strokes.5 However, most of the existing literature focuses on anterior circulation. This meta‐analysis aims to analyze the literature regarding the efficacy and safety of post‐thrombectomy PTAS in ICAD‐related posterior circulation strokes. Methods The search strategy was developed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines.6 Using the common evidence medicine framework PICOS (Patient Population, Intervention, Control/Comparison, Outcome, and Study type), we specified our research question: “In patients with posterior circulation AIS who underwent endovascular thrombectomy but failed to recanalize or who had severe stenosis, is PTAS an effective and safe rescue treatment option?” An electronic search of PubMed, EMBASE, Cochrane and OVID databases was performed from date of database inception to March 2023. Data was collected and analyzed using “Meta” package in RStudio.7 Outcomes of interest included 90 day modified Rankin score (mRS) and 90‐day mortality. Results A total of 10 studies were collected, but only 7 double‐arm studies involving 965 participants were included in this analysis. Among these patients, 544 underwent rescue stenting, while 421 were control patients. In a common effects meta‐analysis, patients who underwent stenting were more likely to have an mRS ≤ 2 at 90 days (OR 1.73, 95% CI [1.25 – 2.37]; p < 0.001) and lower odds of mortality at 90 days (OR 0.31, 95% CI [0.23 – 0.42]; p < 0.001). Additionally, patients undergoing stenting were less likely to have symptomatic intracranial hemorrhage (sICH) (OR 0.34, 95% CI [0.17 ‐ 0.67]; p = 0.002). Furthermore, the stenting group showed significantly higher odds of achieving a modified treatment in cerebral ischemia score (mTICI) of 2b‐3 when compared to the control group (OR 11.32, 95% CI [6.54 ‐ 19.59]; p < 0.001). Conclusion PTAS appears to be an effective and safe treatment for ICAD after MT in the posterior circulation both improving likelihood of good outcomes and overall survival. Given the uncertainty of applying the results of the SAMMPRIS trial to LVOs, further research is needed to better assess the efficacy and safety of PTAS in this patient population.

Abstract 190: Patient Selection for Intracranial Stenting: Impact on Clinical Outcomes and Procedural Success Rates

Introduction Intracranial atherosclerosis (ICAS) is a leading global cause of stroke. The role of intracranial stenting in ICAS remains uncertain. In the SAMMPRIS trial, patients who had experienced recent TIA/CVA secondary to 70‐99% ICAS demonstrated an increased risk of recurrent stroke when treated with angioplasty and stenting compared to medical therapy alone [1]. The VISSIT trial found an increased 12‐month risk of TIA/CVA in the same territory, as well as an increased 30‐day risk of any TIA/CVA, when a stenting was used in patients with ICAS [2]. Additionally, the recent CASSISS trial demonstrated that adding percutaneous transluminal angioplasty and stenting (PTAS) to medical therapy did not significantly affect the risk of stroke or death within 30 days or stroke beyond 30 days through 1 year in patients TIA/CVA secondary to symptomatic ICAS [3]. However, the WEAVE trial demonstrated that using the Wingspan stent for ICAS resulted in a low periprocedural complication rate and excellent safety profile [4]. Subsequently, the WOVEN study provided a 1‐year follow‐up to WEAVE. It presented a more homogeneous patient group than in prior studies, and demonstrated a relatively low 8.5% 1‐year rate of stroke and death in stented patients [5]. Currently underway, the Angioplasty and Stenting for Patients With Symptomatic Intracranial Atherosclerosis Clinical trial (NCT02689037) aims to determine whether PTAS combined with medical treatment is superior to medical treatment alone in preventing stroke and death events in patients with symptomatic ICAS [6]. The purpose of this case series is to provide an overview of the procedural and clinical outcomes of patients who underwent stenting for symptomatic ICAS. Methods We reviewed a database of all interventional procedures conducted at our institution to identify patients who underwent intracranial stenting from 2013 and 2022 for symptomatic ICAS. Electronic medical records were assessed, and data on patient demographics, comorbidities, lesion characteristics, and clinical outcomes were extracted. The outcomes of interest included successful stent placement, restoration of blood flow, procedural complications, symptomatic improvement, change in NIHSS, and mortality and stroke within one year. Descriptive statistics were used, summarizing continuous variables as means and standard deviations, and categorical variables as frequencies and ranges. Results Between 2013 and 2022, 35 patients underwent intracranial stenting for symptomatic ICAS. Procedurally, all patients had successful stent placement and restoration of blood flow. Six patients (17.1%) experienced perioperative complications including stent occlusion, bradycardia, and hematoma. Regarding clinical outcomes, 25 patients (71.4%) showed improvement in their TIA/CVA symptoms, including dizziness, weakness, and speech difficulties. Furthermore, 21 patients (60%) had improved NIHSS scores by discharge, 9 patients (25.7%) remained stable, and 4 patients (11.4%) deteriorated. One unrelated mortality was recorded at 1‐year post‐procedure. Conclusion This case series demonstrates the successful and effective restoration of distal blood flow through intracranial stenting for symptomatic ICAS. The low rates of perioperative complications and potential improvements in patients' clinical outcomes suggest the need for further investigation into the patient selection, safety, and effectiveness of intracranial stenting for managing symptomatic ICAS.

Angiography-based hemodynamic features predict recurrent ischemic events after angioplasty and stenting of intracranial vertebrobasilar atherosclerotic stenosis

ObjectivesTo assess the predictive value of hemodynamic features for stroke relapse in patients with intracranial vertebrobasilar atherosclerotic stenosis treated with percutaneous transluminal angioplasty and stenting (PTAS) using quantitative digital subtraction angiography (q-DSA).MethodsIn this retrospective longitudinal study, patients with intracranial vertebrobasilar atherosclerotic stenosis and who underwent PTAS treatment between January 2012 and May 2020 were enrolled. The q-DSA assessment was performed before and after PTAS. ROIs 1–4 were placed along the vertebral artery, proximal and distal basilar artery, and posterior cerebral artery; ROIs 5–8 were in 5 mm and 10 mm proximal and distal to the lesion, respectively. Relative time to peak (rTTP) was defined as the difference in TTP between ROIs. Cox regression analyses were performed to determine risk factors for recurrent stroke.ResultsA total of 137 patients (mean age, 62 years ± 10 [standard deviation], 83.2% males) were included, and 26 (19.0%) patients had stroke relapse during follow-up (median time of 42.6 months [interquartile range, 19.7–60.7]). Preprocedural rTTP4-1 (adjusted hazard ratio (HR) = 2.270; 95% CI 1.371–3.758; p = 0.001) and preprocedural rTTP8-5 (adjusted HR = 0.240; 95% CI 0.088–0.658; p = 0.006) were independently associated with the recurrent stroke. These hemodynamic parameters provided an incremental prognostic value for stroke relapse (AUC, 0.817 [0.704–0.931]; the net reclassification index, 0.431 [0.057–0.625]; and the integrated discrimination index, 0.140 [0.035–0.292]).ConclusionsIn patients with intracranial vertebrobasilar atherosclerosis treated with PTAS, preprocedural prolonged TTP of the target vessel and shortened trans-stenotic TTP difference were associated with stroke relapse. Q-DSA-defined hemodynamic parameters provided incremental predictive value over conventional parameters for stroke recurrence.Clinical relevance statementQuantitative DSA analysis enables intuitive observation and semi-quantitative evaluation of peri-therapeutic cerebral blood flow. More importantly, quantitative DSA–defined hemodynamic parameters have the potential for risk stratification of patients with intracranial atherosclerotic stenosis.Key PointsSemi-quantitative angiography-based parameters can reflect pre- and postprocedural subtle changes in blood flow in patients with intracranial atherosclerotic stenosis.Although angioplasty procedures can significantly improve blood flow status, patients with more restricted baseline blood flow still show a higher risk of stroke recurrence.Angiography-based hemodynamic features possess prognostic value and can serve as clinical markers to assess stroke risk of patients with intracranial atherosclerotic stenosis.

Stent reconstruction in intracranial atherosclerotic disease related acute ischemic stroke results in high revascularization rates

ObjectivesIntracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our study aimed to analyze the effect of percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAD undergoing rescue treatment in terms of functional outcome and mortality rate at 90 days and compare the results to LVO with thromboembolic origins. Materials and methodsA retrospective review of a mechanical thrombectomy (MT) single center database from 01/2019 to 09/2021 was carried out using chart review and angiogram analysis. From 469 acute stroke patients, 361 patients were enroled in the study, of whom twenty-four (6.6%) were diagnosed with underlying ICAD and treated with angioplasty and stent reconstruction (PTAS) with a standardized medication protocol. Successful reperfusion, peri-procedural complications, and functional independence at 90 days were collected as outcomes. ResultsThere was no difference in age or admission National Institutes of Health Stroke Scale (NIHSS). Onset to groin puncture (median 460 vs 277 min, P = 0.019) was significantly longer in the ICAD group. The procedure time (median 73 vs 60 min, P = 0.137) did not differ. Successful reperfusion was achieved in 95.8% of ICAD and 91.1% of the remaining patients (P = 0.445). Functional independence (mRS ≤ 2) at 90 days was achieved in 45.8% (11/24) and 42.7% (144/337, (P = 0.767)). The mortality rates (mRS 6) at 90 days were similar (29.2% vs 29.4% (P = 0.983)). ConclusionDespite significantly longer treatment delays, the outcome and revascularization rates of ICAD patients were similar to the thromboembolic cohort. Our proposed protocol of PTAS and medication protocol in ICAD was effective with a similar safety profile as MT in general.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery: A matched case-control study

BackgroundAlthough radiotherapy is common for head/neck and chest cancers (HNCC), it can result in post-irradiation stenosis of the subclavian artery (PISSA). The efficacy of percutaneous transluminal angioplasty and stenting (PTAS) to treat severe PISSA is not well-clarified. AimsTo compare the technical safety and outcomes of PTAS between patients with severe PISSA (RT group) and radiation-naïve counterparts (non-RT group). MethodsDuring 2000 and 2021, we retrospectively enrolled patients with severe symptomatic stenosis (>60%) of the subclavian artery who underwent PTAS. The rate of new recent vertebrobasilar ischaemic lesions (NRVBIL), diagnosed on diffusion-weight imaging (DWI) within 24 h of postprocedural brain MRI; symptom relief; and long-term stent patency were compared between the two groups. ResultsTechnical success was achieved in all 61 patients in the two groups. Compared with the non-RT group (44 cases, 44 lesions), the RT group (17 cases, 18 lesions) had longer stenoses (22.1 vs 11.1 mm, P = 0.003), more ulcerative plaques (38.9% vs 9.1%, P = 0.010), and more medial- or distal-segment stenoses (44.4% vs 9.1%, P<0.001). The technical safety and outcome between the non-RT group and the RT group were NRVBIL on DWI of periprocedural brain MRI 30.0% vs 23.1%, P = 0.727; symptom recurrence rate (mean follow-up 67.1 ± 50.0 months) 2.3% vs 11.8%, P = 0.185; and significant in-stent restenosis rate (>50%) 2.3% vs 11.1%, P = 0.200. ConclusionThe technical safety and outcome of PTAS for PISSA were not inferior to those of radiation-naïve counterparts. PTAS for PISSA is an effective treatment for medically refractory ischaemic symptoms of HNCC patients with PISSA.

Length and location of post-PIRCS predict percutaneous transluminal angioplasty and stenting-related restenosis in nasopharyngeal cancer

PurposePost-irradiated carotid stenosis (PIRCS) commonly occurs in patients with nasopharyngeal cancer (NPC) after receiving radiotherapy. A high in-stent restenosis (ISR) is observed in these patients after percutaneous transluminal angioplasty and stenting (PTAS) for PIRCS. Risk factors for ISR in these patients remain unclear. MethodsData were retrospectively analyzed from 68 NPC patients with 70 lesions treated with PTAS for PIRCS. The median follow-up was 40 months (range: 4–120). Evaluations of demographic and clinical characteristics included stenotic severity, stenotic lesion length (SLL), stenotic lesion location, and ISR-related stroke during follow-up. The risk for ISR was evaluated using multiple Cox regression analysis. ResultsThe median age of the patients was 61 (35–80) years and 94.1% were male. The median stenosis was 80% (60–99%) and the median SLL was 2.6 cm (0.6–12.0 cm) before PTAS. Compared to those without ISR, patients with longer SLL were at significantly greater risk of developing significant ISR, defined as > 50% after PTAS (hazard ratio [HR] and 95% confidence interval [CI]: 2.06 [1.30–3.28]). PTAS for lesions from the internal carotid artery (ICA) to common carotid artery (CCA) was associated with a significantly greater risk of ISR than lesions located only in the ICA (HR: 9.58 [1.79–51.34]). The baseline cut-off value for SLL that best predicted significant ISR was 1.6 cm (area under the curve 0.700, sensitivity 83.3% and specificity 62.5%). ConclusionStenotic lesions located from the ICA to CCA with longer SLL at baseline appear to predict ISR in NPC patients with PIRCS after PTAS. Intensive post-procedural follow-up is advised for this patient population.

Percutaneous transluminal angioplasty and stenting vs aggressive medical management on stroke or intracranial atherosclerotic stenosis: a systematic review and meta-analysis

There are currently two main treatment strategies mainly for high-risk patients: percutaneous transluminal angioplasty and stenting (PTAS) and aggressive medical management (AMM). However, the choice between PTAS or AMM remains controversial for patients with stroke or intracranial atherosclerotic stenosis (ICAS). The investigators searched the PubMed, Web of Science, Embase, Scopus, and Cochrane library databases. Randomized controlled trial (RCT) comparing PTAS and AMM for patients with stroke or ICAS were selected. RevMan 5.3 was used to analyze the results and assess risk of bias. The primary endpoints are stroke and death within 30 days after enrollment, or ischemic stroke in the territory of the qualifying artery beyond 30 days, and entire follow-up endpoints. The secondary outcomes were the disabling or fatal stroke, and incidence of death within 3 years. Four studies, 989 patients were included in this article. The AMM group was superior in the entire follow-up endpoint (OR 0.56; 95% CI 0.40, 0.79). The AMM also better in primary endpoint within 30 days (OR 0.32; 95% CI 0.17, 0.61). There was no significant difference beyond 30 days (OR 1.08; 95% CI 0.63, 1.86). The remaining outcomes, such as stroke and death, were not significantly different (P > 0.05). This meta-analysis shows AMM is significantly more effective than PTAS in subjects with ICAS due to the high rate of periprocedural stroke (OR 0.32; 95% CI 0.17, 0.61) and stroke during the entire follow-up (OR 0.56; 95% CI 0.40, 0.79) associated with PTAS. Furthermore, PTAS offers no additional benefits over AMM beyond 30 days (OR 1.08; 95% CI 0.63, 1.86).

Abstract Number ‐ 145: Impact of Landmark Trials on Intracranial Stenting Utilization for Intracranial Atherosclerotic Disease in the US

Introduction The Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial published in 2010 showed aggressive medical therapy is superior to percutaneous transluminal angioplasty and stenting (PTAS) for intracranial atherosclerotic disease (ICAD). Following the pivotal positive mechanical thrombectomy (MT) trials in 2015, MT utilization in the United States (US) has increased. Rescue ICAD stenting may be needed in MT patients with underlying ICAD but it remains uncertain whether PTAS use for ICAD has changed over this time. The aim of this study is to describe national trends in the utilization of PTAS for ICAD in the US before and after SAMMPRIS and following the pivotal MT trials. Methods We used a constellation of International Classification of Diseases ninth and tenth revision diagnostic/procedural codes to identify all elective and non‐elective adult (&gt; = 18 years) ICAD admissions with or without infarction containing concomitant codes for PTAS in the 2007–2019 National Inpatient Sample. Admissions containing codes for subarachnoid hemorrhage, unruptured intracranial aneurysms or benign intracranial hypertension were excluded. We combined weighted counts of PTAS admissions with annual US adult census data to obtain prevalence of PTAS. We used joinpoint regression to evaluate trends in PTAS use over time. Results Across the study period, there were 16,477 weighted admissions for ICAD undergoing PTAS in the US. 52.4% of these admissions were in patients 60–79years and 43.2% were in women. 74.3% of these admissions were non‐elective and this proportion increased over time (P = 0.019). 26.5% of all admissions had concurrent codes for MT but this proportion increased by almost ten‐fold over time from 4.3% in 2007 to 40.0% in 2019. On join point regression, PTAS utilization increased but insignificantly from 3.0/million population in 2007 to 5.7/million population in 2010 (Annualized percentage change, APC 11.2%, 95%CI ‐11.8 to 40.3, p = 0.290), declined also insignificantly from 2010–2013 (APC ‐13.2, 95%CI ‐48.4 to 45.8, p = 0.514) and increased significantly from 3.55/million in 2013 to 3.80/million in 2014 and exponentially across the rest of the period to 8.4 cases/million in 2019 (APC 15.4, 95%CI 9.2 to 22.0, p = 0.001). Upon stratification by admission type, most of the increase across the period 2013/2014 to 2019 occurred in non‐elective admissions (Figure 1). Utilization in elective admissions varied from 0.92 to 1.96 cases per million population but this did not change significantly across the study period. Conclusions PTAS utilization for ICAD declined in the US after SAMMPRIS but has increased following publication of pivotal MT trials mainly in non‐elective admissions. PTAS utilization increased significantly following publication of pivotal MT trials likely in ICAD patients who required rescue stenting.. Additional prospective studies are needed to determine the long‐term outcomes of concurrent PTAS and MT as this is not a group of patients that was studied in SAMMPRIS.

Abstract Number ‐ 36: Acute Angioplasty And/or Stenting Posterior Circulation Intracranial Atherosclerotic Disease Related Large Vessel Occlusion

Introduction With prior studies showing the value of percutaneous transluminal angioplasty and stenting (PTAS) for rescue of acute large vessel occlusions (LVO) of anterior circulation in patients with underlying intracranial atherosclerotic disease (ICAD), we investigated the safety and efficacy of PTAS in posterior circulation intracranial atherosclerosis‐related occlusions (ICAS‐O). Methods By utilizing a prospectively collected endovascular database at a comprehensive stroke center from January 2016‐May 2022, variables such as demographics, co‐morbid conditions, symptomatic intracerebral hemorrhage (ICH), mortality rate at discharge, recanalization rate, modified thrombolysis in cerebral infarction score (mTICI) and favorable clinical outcome via modified Rankin Scale (mRS) were examined. The outcomes between acute PTAS + MT in the anterior and posterior circulation groups were then compared and analyzed. Results Within a group of 75 acute ischemic stroke (AIS) patients who underwent rescue PTAS, 15 (20.0 %) belonged to the posterior circulation ICAS‐O group. Baseline characteristics between the posterior and anterior groups were similar, except for gender (6.7% vs 45.0%) and atrial fibrillation (21.7% vs 0.0%). While there was no statistical difference in discharge NIH Stroke Scale(18% vs 23%, P = 0.860) or favorable outcome (modified Rankin Scale ≤ 2) at 90 days (46.7% vs 38.7 %, P = 0.477) between the posterior and anterior ICAS‐O groups respectively, symptomatic ICH rate was higher in the anterior group (11.7 vs 6.7%, P = 0.495). Conclusions Rescue angioplasty and stenting seems to be a safe and efficacious treatment option for ICAS‐related LVO of posterior circulation. Future larger, multicenter prospective studies would provide further analysis and allow for corroboration of the results of our study.

Percutaneous transluminal angioplasty and stenting of post-irradiation stenosis of the vertebral artery

BackgroundThe outcomes of percutaneous transluminal angioplasty and stenting (PTAS) in patients with medically refractory post-irradiation stenosis of the vertebral artery (PISVA) have not been clarified. AimThis retrospective study evaluated the safety and outcomes of PTAS in patients with severe PISVA compared with their radiation-naïve counterparts (non-RT group). MethodsPatients with medically refractory severe symptomatic vertebral artery stenosis and undergoing PTAS between 2000 and 2021 were classified as the PISVA group or the non-RT group. The periprocedural neurological complications, periprocedural brain magnetic resonance imaging, the extent of symptom relief, and long-term stent patency were compared. ResultsAs compared with the non-RT group (22 cases, 24 lesions), the PISVA group (10 cases, 10 lesions) was younger (62.0 ± 8.6 vs 72.4 ± 9.7 years, P = 0.006) and less frequently had hypertension (40.0% vs 86.4%, P = 0.013) and diabetes mellitus (10.0% vs 54.6%, P = 0.024). Periprocedural embolic infarction was not significantly different between the non-RT group and the PISVA group (37.5% vs 35.7%, P = 1.000). At a mean follow-up of 72.1 ± 58.7 (3–244) months, there was no significant between-group differences in the symptom recurrence rate (0.00% vs 4.55%, P = 1.000) and in-stent restenosis rate (10.0% vs 12.5%, P = 1.000). ConclusionPTAS of severe medically refractory PISVA is effective in the management of vertebrobasilar ischemic symptoms in head and neck cancer patients. Technical safety and outcome of the procedure were like those features in radiation-naïve patients.

Hemodynamic and Geometric Risk Factors for In-Stent Restenosis in Patients with Intracranial Atherosclerotic Stenosis.

Methods Severe ICAS patients managed with percutaneous transluminal angioplasty and stenting (PTAS) were included in the retrospective cohort study and were divided into two groups according to whether ISR occurred at follow-up (ISR group and no-ISR group). Computational fluid dynamics models were built based on digital subtraction angiography before and after PTAS to simulate blood flow and quantify hemodynamic parameters. The associations between vessel geometry, hemodynamics, and ISR in ICAS patients were investigated. Results Among 39 patients, ISR occurred in seven patients (17.95%) after a mean follow-up period of 6.69 ± 3.24 months. Stenting decreased vessel angulation (51.11° [40.07°–67.27°] vs. 15.97° [0.00°–36.16°], P = 0.000) and vessel tortuosity (0.09 [0.06–0.13] vs. 0.01 [0.00–0.03], P = 0.000). Meanwhile, the translational pressure ratio (PR) dramatically increased (0.07 [0.00–0.31] vs. 0.62 [0.41–0.82], P = 0.000) with the wall shear stress ratio decreased (13.93 [8.37–40.30] vs. 2.90 [1.69–4.48], P = 0.000). In the multivariate analysis, smaller Δ tortuosity (P = 0.038) was independently associated with the occurrence of ISR, and smaller post-PTAS translesional PR was also a predictive factor of marginal significance (P = 0.059). Conclusion PTAS decreased vessel angulation, vessel tortuosity, and translesional wall shear stress ratio while it increased translesional pressure ratio (PR) dramatically in ICAS patients. Smaller Δ tortuosity was found to be a risk factor for ISR, and smaller post-PTAS translesional PR was also a predictive factor of marginal significance, indicating that both geometric and hemodynamic parameters played important roles in the occurrence of ISR after PTAS.

Influence of angioplasty and stenting on intracranial artery stenosis: preliminary results of high-resolution vessel wall imaging evaluation.

To investigate whether the imaging changes on high-resolution vessel wall imaging (HR-VWI) in patients before and after percutaneous transluminal angioplasty and stenting (PTAS) contribute to predicting the clinical outcome. The study included 24 severe intracranial artery stenosis (SICAS) patients undergoing PTAS with Wingspan Stent between 2018 and 2020 and had a 1-year follow-up. Three HR-VWI sessions (preprocedural, early [within 24 h], and delayed postprocedural [134.7 ± 27.1 days)]) in each subject were performed with 3-Tesla MRI. We evaluated periprocedural HR-VWI changes in patients with and without recurrent cerebral ischemic symptoms (RCIS) within 1-year follow-up. On CE-T1WI of the patients without RCIS, a significant decrease in enhanced area was observed on early postprocedural (0.04 ± 0.02 cm2, p = 0.001) and delayed postprocedural (0.04 ± 0.02 cm2; p = 0.001) HR-VWI compared to preprocedural (0.07 ± 0.02 cm2) HR-VWI. Patients with RCIS demonstrated no significant loss of enhanced area on CE-T1WI of early postprocedural HR-VWI (p = 0.180). Significant decreases in calibrated T1 signals were observed in both presence (1.77 ± 0.70 vs. 0.79 ± 0.52; p = 0.018) and absence (1.42 ± 0.62 vs. 0.83 ± 0.40; p = 0.001) of RCIS in early postprocedural HR-VWI. The preliminary results showed the presence of reduced contrast enhancement immediately after PTAS may indicate less recurrent stroke events within 1 year. Further studies are necessary to confirm the phenomena in a longer observation period. • Early postprocedural high-resolution vessel imaging (HR-VWI) within 24 h can effectively predict a 1-year outcome following intracranial stenting. • For stenotic lesions after stenting without reduced contrast enhancement on HR-VWI within 24 h may need closer clinical surveillance for potentially higher risk of stroke events within 1 year.

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.

Long-term clinical and angiographic outcome from angioplasty and stenting for intracranial stenosis.

Severe intracranial atherosclerotic stenosis (ICAS) is a major cause of stroke. Although percutaneous transluminal angioplasty and stenting (PTAS) treatment methods have increased over the last decade as alternative therapies, there is debate regarding the best method of treatment, with medical and surgical therapies often suggested. We analyzed the long-term follow-up results from 5years of intracranial stenting for intracranial stenosis from three stroke centers. The primary endpoints were early stroke complications or death within 30days after stent insertion, and the secondary endpoint was a recurrent stroke between 30days and 60months. Correlating factors and Kaplan-Meier survival curves for recurrent stroke and in-stent restenosis (ISR) were also obtained. Seventy-three PTAS in 71 patients were examined in this study. The primary and secondary endpoints were all 8.2% (n = 6), and restenosis was 13.7% (n = 10) during the 5-year follow-up. The primary endpoints were significantly frequent in the high National Institutes of Health Stroke Scale (NIHSS) and early stent (≤ 7days after dual antiplatelet medication) groups. Secondary endpoint and ISR were identically frequent in the younger age group and in the presence of tandem stenosis in other major intracranial arteries. The cumulative probability of recurrent stroke and ISR at 60months was 16.4% and 14.1%, respectively. This study shows that PTAS is safe and effective for major ICAS. Reducing the early complication rate is still an important factor, despite the fact that long-term stroke recurrence was low.

Intracranial Atherosclerotic Disease: Current Concepts in Medical and Surgical Management.

This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery. Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT. ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.

Percutaneous transluminal angioplasty and stenting of post-irradiated stenosis of subclavian artery

The therapeutic efficacy of percutaneous transluminal angioplasty and stenting (PTAS) of post-irradiated stenosis of subclavian artery (PISSA) was not well clarified. This retrospective study was designed to evaluate the technical safety and outcome of the patients of severe symptomatic PISSA accepted PTAS. Between 2000 and 2019, 16 cases with 17 lesions of symptomatic and medically refractory PISSA accepted PTAS were included. We evaluated their technical success, peri-procedural complications and diffusion-weight imaging (DWI) of brain magnetic resonance imaging (MRI), results of symptom relief, and long-term stent patency. The stenosis of the 17 stenotic lesions were 81.2±11.1%. The most common symptom of the 16 patients was dizziness (14/16, 87.5%). All successfully accepted PTAS without neurological complication and had symptom relief after PTAS (17/17, 100%). Of the 12 patients accepted pre-procedural and early post-procedural MRI follow-up, 2 patients had an asymptomatic tiny acute embolic infarct in the territory of vertebrobasilar system. In a 51.9±54.9 months follow-up, all patients had no severe restenosis and no recurrent vertebrobasilar ischemic symptoms. For patients with PISSA and medically refractory ischemic symptoms, PTAS can be an effective alternative management.

Diagnosis of extracranial carotid stenosis by MRA of the brain

Severe extracranial carotid stenosis (SECS) patients may present with nonspecific neurological symptoms that require intracranial magnetic resonance imaging (MRI) and time-of-flight (TOF)-MR angiography (MRA) to exclude intracranial pathology. Recognition of SECS on intracranial TOF-MRA findings is beneficial to provide a prompt carotid imaging study and aggressive stroke prevention. Patients with SECS (January 2016 to May 2019) undergoing percutaneous transluminal angioplasty and stenting (PTAS) were included. Differences in normalized signal intensities (SRICA) and diameters (DICA) between bilateral petrous internal carotid arteries (ICAs) were calculated 1 cm from the orifice. A hypothesized criterion describing the opacification grades (GOPH) of bilateral ophthalmic arteries was proposed. We correlated SRICA (p = 0.041), DICA (p = 0.001) and GOPH (p = 0.012), with the severity of extracranial carotid stenosis on digital subtractive angiography (DSA) in the examined group (n = 113), and all showed statistical significance in predicting percentages of ICA stenosis. The results were further validated in another patient group with SECS after radiation therapy (n = 20; p = 0.704 between the actual and predicted stenosis grades). Our findings support the evaluation of the signal ratio and diameter of intracranial ICA on TOF-MRA to achieve early diagnosis and provide appropriate management of SECS.

A Retrospective Study Comparison Between Stenting and Standardized Medical Treatment for Intracranial Vertebrobasilar Stenosis in a Real-World Chinese Cohort.

Background: To date, there has been no consensus regarding the benefits of percutaneous transluminal angioplasty and stenting (PTAS) vs. those of standardized medical treatment (SMT) for patients with symptomatic intracranial vertebrobasilar stenosis (IVBS). The purpose of this retrospective study was to compare the effects of PTAS or SMT on symptomatic IVBS in a real-world Chinese population.Methods: We included 238 patients with ischemic stroke caused by IVBS stenosis who were admitted to Shandong Provincial Hospital Affiliated to Shandong University between September 2012 and May 2018; 62 of these patients were treated with SMT and 176 underwent PTAS. Ischemic stroke in the territory of the responsible artery, hemorrhage, and death within 1 year were recorded as primary endpoints. Secondary endpoints included assessment of stroke severity and the incidence of re-stenosis. The primary endpoint rates were compared between the PTAS and SMT groups at 7 days, 1, 6 months, and 1 year.Results: In the PTAS group, the success rate of stent placement was 98.9%. During the entire trial, except for 7 days, the SMT group had a higher frequency of primary endpoint events than did the PTAS group. The primary endpoint was 17.7% (11/62) vs. 8.6% (15/174) at 1 month (p = 0.049), 29% (18/62) vs. 14.4% (25/174) at 6 months (p = 0.01), and 32.2% (20/62) vs. 17.2% (30/174) at 1 year (p = 0.013). The restenosis rate of the target lesion was 13.8%; 60% were symptomatic restenosis and 40% were asymptomatic restenosis. The rate of severe stroke at 1 year after PTAS was 0%, while that in the SMT group was 9.7%.Conclusions: In a real-world Chinese cohort, PTAS for patients might be superior to SMT, and provide better long-term neurological function recovery and lower disability rate.

Angioplasty and stenting for symptomatic stenosis of the left subclavian artery complicated with aortic dissection.

Aortic dissection is a rare but severe complication of percutaneous transluminal angioplasty and stenting (PTAS) for stenosis of the subclavian artery (SA). This retrospective study was designed to evaluate the risk factors and outcomes of patients with severe stenosis of the SA who underwent PTAS complicated by aortic dissection. Between 1999 and 2018, 169 cases of severe symptomatic stenosis of the SA underwent PTAS at our institute. Of them, six cases complicated by aortic dissection were included in this study. We evaluated the demographic features, technical factors of PTAS, and clinical outcomes in these six patients. Aortic dissection occurred in 5.3% (6/113) of all left SA stenting cases but in none of the right SA stenting cases. All patients had hypertension and a high severity of SA stenosis (85.0 ± 13.0%, 60%-95%). Five of the six patients received balloon-expandable stents (83.3%). All patients had spontaneous resolution of the aortic dissection with conservative treatment. In a 63.33 ± 33.07 (7-118) month follow-up, five of the six patients (83.3%) had long-term symptom relief and stent patency. Aortic dissection occurred in patients who underwent PTAS for severe stenosis of the left SA, mainly with balloon-expandable stents. We suggest using self-expandable stents and angioplasty with an undersized balloon during PTAS for severe stenosis of the left proximal SA to prevent aortic dissection.

Dual Antiplatelet Therapy Beyond 90 days in Symptomatic Intracranial Stenosis in the SAMMPRIS Trial

BackgroundThe safety and efficacy of dual antiplatelet use for symptomatic intracranial atherosclerosis beyond 90 days is unknown. Data from SAMMPRIS was used to determine if dual antiplatelet therapy (DAPT) beyond 90 days impacted the risk of ischemic stroke and hemorrhage. MethodsThis post hoc exploratory analysis from SAMMPRIS included patients who did not have a primary endpoint within 90 days after enrollment (n = 397). Patients in both the aggressive medical management (AMM) and percutaneous transluminal angioplasty and stenting (PTAS) arms were included. Baseline features and outcomes during follow-up were compared between patients who remained on DAPT beyond 90 days (on clopidogrel) and patients who discontinued clopidogrel and remained on aspirin alone at 90 days (off clopidogrel) using Fisher's exact tests. ResultsThe stroke rate was numerically lower in the group on clopidogrel vs off clopidogrel among both the AMM alone arm (6.0% versus 10.8%, p = 0.31) and the PTAS arm (8.7% versus 9.8%; p = 0.82), but the difference was not significant. The major hemorrhage rates were numerically higher in the group on clopidogrel vs. off clopidogrel group among both the AMM alone arm (4.0% versus 2.5%; p = 0.67) and the PTAS arm (10.9% versus 3.5%; p = 0.08), but were not significant. ConclusionThis exploratory analysis suggests that prolonged DAPT use may lower the risk of stroke in medically treated patients with intracranial stenosis but may increase the risk of major hemorrhage.