Preliminary Experience With Proximal Flow Reversal During Intracranial Balloon Angioplasty and Stenting for Symptomatic, Severe Intracranial Stenosis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Branden J Cord ◽  
Corrado Santarosa ◽  
Nanthiya Sujijantarat ◽  
Adam Kundishora ◽  
Guido Falcone ◽  
...  
Keyword(s):  
Balloon Angioplasty ◽  
Recurrent Stroke ◽  
Carotid Bifurcation ◽  
Flow Reversal ◽  
Intracranial Stenosis ◽  
Artery Embolism ◽  
Proximal Protection ◽  
Maximal Medical Therapy ◽  
A Minor ◽  
Angioplasty And Stenting

Abstract INTRODUCTION The frequency of balloon-angioplasty and stenting for symptomatic intracranial stenosis was drastically reduced after publication of the negative SAMMPRIS trial. In part, this was due to a higher than expected periprocedural complication rate (14.7% 30-d stroke or death) compared to maximal medical therapy (5.8%). Although the cause of periprocedural stroke was not defined, intraprocedural artery-to-artery embolism is a likely contributor. The Silk Road ENROUTE Transcarotid Neuroprotection System (TCNS) was designed as an alternative revascularization strategy for carotid bifurcation disease. It provides direct transcarotid access and proximal protection through flow reversal. We adapted this system as a proximal protection strategy for balloon angioplasty and stenting of severe, symptomatic intracranial stenosis. METHODS From May-2017 to May-2019, 7 patients underwent intracranial balloon angioplasty and stenting for symptomatic intracranial stenosis using the TCNS. Baseline demographics, comorbidities, procedure-related parameters, and outcomes were assessed. RESULTS A total of 7 patients (mean age 63, SEM 4.7 yr, 57% female) with severe (84% +/− 5%) supraclinoid internal carotid artery (ICA) and/or M1 stenosis presented with recurrent strokes (86% left sided) despite dual antiplatelet therapy (DAPT). Angiographically, cessation or reversal of flow was seen in the supraclinoid ICA in all patients, with confirmation by transcranial doppler in selected cases, after the institution of flow reversal by the TCNS. A noncompliant balloon was used to perform submaximal angioplasty, followed by stenting with intracranial stents. All procedures were technically successful with no evidence of periprocedural thromboembolic complications. Follow-up ranged from 6 to 12 mo. One patient suffered a fatal reperfusion hemorrhage on POD 3. One patient suffered from a minor recurrent stroke at 7 mo (after the cessation of DAPT) and was restarted on DAPT. CONCLUSION Traditional methods of intracranial balloon angioplasty and stenting suffer from high periprocedural ischemic stroke rates. TCNS can be adapted to provide a means of proximal protection during the treatment of these high-risk lesions. This procedural innovation warrants further investigation.

Abstract 81: Recurrent Stroke Risk After Angioplasty and Stenting for Symptomatic Intracranial Stenosis: Data From the SAMMPRIS Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Colin Derdeyn ◽  
David Fiorella ◽  
Tanya Turan ◽  
Jean Montgomery ◽  
Bethany Lane ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Primary Endpoint ◽  
Imaging Modality ◽  
Recurrent Stroke ◽  
Intracranial Stenosis ◽  
Stent Restenosis ◽  
Primary Endpoints ◽  
Angioplasty And Stenting ◽  
In Stent Restenosis

Purpose: To investigate the incidence and clinical characteristics of recurrent stroke beyond 30 days after uncomplicated angioplasty and stenting for symptomatic intracranial stenosis. Methods: Primary endpoints in SAMMPRIS (Stenting and Aggressive Medical Management for the Prevention of Recurrent Ischemic Stroke) after 30 days past enrollment were defined as ischemic stroke in the territory or any stroke or death within 30 days of a subsequent revascularization procedure. Endpoints were independently and blindly adjudicated. Study records and imaging studies of subjects randomized to the stent arm with post-30 day primary endpoints were reviewed. Instent restenosis (ISR) was categorized as severe (>70%), moderate (50-69%) or mild (< 50%) based on consensus of two reviewers. Findings were categorized as definite, probable, or indeterminate based on imaging modality and study quality. Results: 224 subjects were randomized to the stent arm and 33 suffered a primary endpoint within 30 days of enrollment. Nineteen of the remaining 191 subjects (9.9%) suffered a primary endpoint during follow up (median follow up of 32.4 months). Eighteen had an ischemic stroke in the territory and one had a symptomatic intracranial hemorrhage after repeat angioplasty for in stent restenosis (ISR). In the 18 patients with ischemic stroke, the vascular imaging findings were: complete stent occlusion in 2 (1 of these was acutely revascularized and severe underlying ISR was identified), severe ISR by catheter angiography in 5, severe ISR or occlusion by computed tomographic angiography (CTA) in 1, probable ISR by CTA or magnetic resonance angiography (MRA) in 3, moderate stenosis on angiography in 2 (1 with ISR and 1 with a residual stenosis), indeterminate in 2, normal in 2, and not done in 1. Lesion locations included: distal internal carotid (6), petrous carotid (1), basilar (5), middle cerebral (6), and vertebral (1) arteries. Median time to recurrent stroke was 7.7 months from enrollment (2.2 to 28.2 months). Conclusions: The incidence of recurrent stroke beyond 30 days after uncomplicated angioplasty and stenting in the SAMMPRIS trial was nearly 10% over a mean follow-up of almost 3 years. In stent restenosis was associated with the majority of recurrent strokes.

Transcervical Carotid Stenting with Flow Reversal for Neuroprotection: Technique, Results, Advantages, and Limitations

Vascular ◽  
2006 ◽  
Vol 14 (5) ◽  
pp. 245-255 ◽  
Author(s):  
Iraklis I. Pipinos ◽  
Matias Bruzoni ◽  
Jason M. Johanning ◽  
G. Matthew Longo ◽  
Thomas G. Lynch
Keyword(s):  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Carotid Bifurcation ◽  
Carotid Stenting ◽  
Flow Reversal ◽  
Transcervical Approach ◽  
Weighted Magnetic Resonance Imaging ◽  
Carotid Occlusive Disease ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Carotid angioplasty and stenting are progressively earning a role as a less invasive alternative in the treatment of carotid occlusive disease. The most common approach for carotid artery stenting involves transfemoral access and use of a filter or balloon device for neuroprotection. This approach has limitations related to both the site of access and the method of neuroprotection. Specifically, an aortoiliac segment with advanced occlusive or aneurysmal disease or an anatomically unfavorable or atheromatous arch and arch branches can significantly limit the safety of the retrograde transfemoral pathway to the carotid bifurcation. Additionally, data provided by the use of transcranial Doppler monitoring and diffusion-weighted magnetic resonance imaging in patients undergoing filter- or balloon-protected carotid artery stenting demonstrate that currently available devices are associated with a considerable incidence of cerebral embolization. To address these limitations, we, along with others, have employed a direct transcervical approach for carotid artery stenting that incorporates the principle of flow reversal for neuroprotection. The technique bypasses all of the anatomic limitations of transfemoral access and simplifies the application of flow reversal, which is one of the safest neuroprotection techniques. The purpose of this review is to describe our method of transcervical carotid artery stenting, review the accumulating outcomes data, and discuss the clinical advantages of and indications for this increasingly popular technique.

scholarly journals Stenting for intracranial stenosis: potential future for the prevention of disabling or fatal stroke

2018 ◽  
Vol 3 (3) ◽  
pp. 140-146 ◽  
Author(s):  
Wengui Yu ◽  
Wei-Jian Jiang
Keyword(s):  
Medical Management ◽  
Recurrent Stroke ◽  
Group Versus ◽  
Intracranial Stenosis ◽  
Medical Group ◽  
Intracranial Stenting ◽  
Fatal Stroke ◽  
Stent System ◽  
Post Market ◽  
Angioplasty And Stenting

Intracranial stenosis is a common cause of ischaemic strokes, in particular, in the Asian, African and Hispanic populations. The randomised multicentre study Stenting and Aggressive Medical Management for the Prevention of Recurrent stroke in Intracranial Stenosis (SAMMPRIS) showed 14.7% risk of stroke or death in the stenting group versus 5.8% in the medical group at 30 days, and 23% in the stenting group versus 15% in the medical group at a median follow-up of 32.4 months. The results demonstrated superiority of medical management over stenting and have almost put the intracranial stenting to rest in recent years. Of note, 16 patients (7.1%) in the stenting group had disabling or fatal stroke within 30 days mostly due to periprocedural complications as compared with 4 patients (1.8%) in the medical group. In contrast, 5 patients (2.2%) in the stenting group and 14 patients (6.2%) in the medical group had a disabling or fatal stroke beyond 30 days, indicating significant benefit of stenting if periprocedural complications can be reduced. Recently, the results of the Chinese Angioplasty and Stenting for Symptomatic Intracranial Severe Stenosis trial and the Wingspan Stent System Post Market Surveillance Study (WEAVE trial) showed 2%–2.7% periprocedural complications. It is time to evaluate the role of intracranial stenting for the prevention of disabling or fatal stroke.

scholarly journals Surgery and Neurointervention for Intracranial Atherosclerotic Steno-occlusive Disease

2013 ◽  
Vol 8 (2) ◽  
pp. 170
Author(s):  
Sepideh Amin-Hanjani ◽  
Simon Chun Ho Yu ◽  
Fady Charbel ◽  
Joji Inamasu ◽  
Yoko Kato ◽  
...  
Keyword(s):  
Medical Therapy ◽  
Recurrent Stroke ◽  
High Volume ◽  
Occlusive Disease ◽  
Carotid Occlusion ◽  
Intracranial Stenosis ◽  
Ischaemic Event ◽  
Operative Morbidity ◽  
Maximal Medical Therapy

Neurosurgeons and neurointerventionists interested in cerebral revascularisation to prevent stroke from intracranial atherosclerotic steno-occlusive disease were disappointed in 2011 with the closure of two important negative studies: the Carotid Occlusion Surgery Study (COSS) and Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study. Debates are centred on what causes these failures. While extracranial-intracranial (EC-IC) bypass and neurointervention (angioplasty and/ or stenting) cannot be considered a routine intervention for patients presenting with initial ischaemic event in the setting of atherosclerotic steno-occlusive disease, selected patients with severe haemodynamic impairment and/or recurrent symptoms despite maximal medical therapy may still benefit from surgery and neurointervention at high-volume centres, which can offer the procedure with low peri-operative morbidity.

Abstract 1122‐000095: Revisiting the Role of Angioplasty and Stenting for Symptomatic Intracranial Stenosis ‐ A Case Series

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Dylan G Jones ◽  
Dylan G Jones ◽  
Neil V Patel ◽  
Johanna Helenius ◽  
Ajay Wakhloo ◽  
...  
Keyword(s):  
Medical Therapy ◽  
Medical Management ◽  
Therapeutic Option ◽  
Case Series ◽  
Intracranial Stenosis ◽  
Long Term Results ◽  
High Grade ◽  
Ct Angiogram ◽  
Maximal Medical Therapy ◽  
Angioplasty And Stenting

Introduction : Early and long‐term results of the SAMMPRIS trial showed superiority of aggressive medical management over stenting in patients with symptomatic intracranial stenosis, in part due to the high risk of periprocedural complications. However, even with maximal medical management, the risk of recurrent TIA or stroke in patients with high‐grade stenosis often remains elevated. Methods : A review of our stroke database was conducted, identifying three relevant cases. Results : CASE 1: A 69 year‐old man with multiple vascular risk factors and atrial fibrillation on apixaban presented with several months of multiple stereotyped episodes of limb‐shaking TIAs affecting the left leg, often leading to falls. CT angiogram revealed 70–80% stenosis of A2 segment of right ACA. Symptoms completely resolved after stenting with Neuroform Atlas stent. Repeat angiogram at 6 months showed excellent vessel caliber. CASE 2: A 78 year‐old man with hypertension, DM, CAD, and known left ICA occlusion presented with recurrent episodes of aphasia and right arm weakness while on maximal medical therapy. CT angiogram showed severe right supraclinoid ICA stenosis which was corrected with Resolute Onyx DES stent with improvement of symptoms. CASE 3: A 77 year‐old with hypertension, DM, CAD and aortic dissection on dual antiplatelet therapy and high‐intensity statin was admitted with stereotyped, blood pressure‐dependent episodes of aphasia and right face/arm weakness secondary to high‐grade stenosis of both M2 divisions of the left MCA. Successful angioplasty and Y‐stenting with Neuroform EZ and Wingspan stents led to complete resolution of symptoms. Conclusions : At high‐volume centers and with newer interventional devices and techniques, intracranial angioplasty and stenting should be considered as a valuable therapeutic option in patients with symptomatic intracranial stenosis refractory to maximal medical therapy.

scholarly journals Carotid Stenting without Angioplasty

2002 ◽  
Vol 29 (2) ◽  
pp. 175-179 ◽  
Author(s):  
S. Men ◽  
S.P. Lownie ◽  
D.M. Pelz
Keyword(s):  
Balloon Angioplasty ◽  
Plain Film ◽  
Carotid Bifurcation ◽  
Carotid Stenting ◽  
Vessel Diameter ◽  
Moderate Increase ◽  
Atherosclerotic Stenosis ◽  
Hemodynamic Improvement ◽  
Angioplasty And Stenting ◽  
Carotid Angioplasty And Stenting

Abstract:Background:Carotid angioplasty and stenting is gaining popularity as an alternative to carotid endarterectomy for the treatment of carotid bifurcation stenosis. The major concern with the procedure is the risk of embolic stroke which may be initiated by balloon angioplasty of friable atherosclerotic plaque. Elimination of angioplasty may result in a lower incidence of embolic complications.Method:We describe a case in which a self-expanding stent alone, without balloon angioplasty, was used to successfully dilate an atherosclerotic stenosis of the carotid bifurcation.Results:A moderate increase in vessel diameter, from 75% to 50%, was immediately observed after stent placement alone. No embolic complications were observed and follow-up plain film and ultrasound examinations showed progressive stent enlargement with excellent anatomic and hemodynamic results.Conclusions:In this case of severe carotid stenosis, the use of a self-expanding stent alone, without balloon angioplasty, resulted in excellent anatomic and hemodynamic improvement.

Current concepts of the interventional treatment of proximal supraaortic vessel stenosis

VASA ◽  
2012 ◽  
Vol 41 (5) ◽  
pp. 313-318 ◽  
Author(s):  
Ernemann ◽  
Bender ◽  
Melms ◽  
Brechtel ◽  
Kobba ◽  
...  
Keyword(s):  
Treatment Strategies ◽  
Carotid Bifurcation ◽  
Current Treatment ◽  
Long Term Results ◽  
Clinical Indication ◽  
Interventional Treatment ◽  
Special Focus ◽  
Brachiocephalic Artery ◽  
Treatment Concepts ◽  
Angioplasty And Stenting

Interventional therapies using angioplasty and stenting of symptomatic stenosis of the proximal supraaortic vessels have evolved as safe and effective treatment strategies. The aim of this paper is to summarize the current treatment concepts for stenosis in the subclavian and brachiocephalic artery with regard to clinical indication, interventional technique including selection of the appropriate vascular approach and type of stent, angiographic and clinical short-term and long-term results and follow-up. The role of hybrid interventions for tandem stenoses of the carotid bifurcation and brachiocephalic artery is analysed. A systematic review of data for angioplasty and stenting of symptomatic extracranial vertebral artery stenosis is discussed with a special focus on restenosis rate.

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