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Long-term Outcome of Angioplasty Using a Wingspan Stent, Post-Stent Balloon Dilation and Aggressive Restenosis Management for Intracranial Arterial Stenosis

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Abstract

Purpose

To investigate the long-term outcome of stent angioplasty for symptomatic severe intracranial artery stenosis.

Method

In this study 95 consecutive patients with intracranial atherosclerotic stenosis (>70%) underwent stent angioplasty using Wingspan stents. The primary endpoints were stroke or death within 30 days of the procedure and subsequent stroke attributed to the stented vessel. Disabling stroke was defined as stroke with a modified Rankin scale > 3. Secondary endpoints included transient ischemic attacks, contralateral stroke, nonstroke death, and other events. Patients underwent prestent balloon dilation with or without poststent balloon dilation, close restenosis follow-up, and selective retreatment, as required.

Result

The mean follow-up duration was 34.9 ± 23.3 months. Primary endpoint events occurred in 23% of the patients. The median infarction volume was 2.6 ml, and 11 (68%) of 16 infarctions were <5 ml in volume. Disabling stroke occurred in 3% of patients. The primary endpoint rates were 17.9% within 30 days and 2.1% from 30 days to 1 year. Secondary endpoint events occurred in 27.3% of the patients. Mean stenosis was reduced from 76.8 ± 6.1% to 7.5 ± 13.4%. Of 80 patients who underwent angiographic follow-up, 11 (14%) experienced restenosis (≥50%) and 7 (9%) exhibited restenosis-related symptoms of transient ischemic attack. The rate of symptomatic restenosis was significantly higher in patients who underwent prestent balloon dilation alone than in patients who underwent prestent and poststent balloon dilation (p = 0.016).

Conclusion

The postprocedural stroke rate was similar to that observed in the SAMMPRIS study. Symptomatic restenosis may be reduced by poststent dilation, close angiographic follow-up, and retreatment.

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Change history

  • 07 February 2020

    <Emphasis Type="Bold">Correction to:</Emphasis>

    <Emphasis Type="Bold">Clin Neuroradiol 2019</Emphasis>

    https://doi.org/10.1007/s00062-019-00793-1

    The original version of this article unfortunately contained some mistakes. The Institutional Review Board number was given wrongly in the Methods/Participants section and in the Compliance with ethical guidelines/Ethical

Abbreviations

DSA:

Digital subtraction angiography

PreB:

Prestent ballooning

PrePostB:

Prestent and poststent ballooning

TIA:

Transient ischemic attack

References

  1. 1.

    Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ; SAMMPRIS Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993–1003.

  2. 2.

    Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, Levine SR, Chaturvedi S, Kasner SE, Benesch CG, Sila CA, Jovin TG, Romano JG; Warfarin-Aspirin Symptomatic Intracranial Disease Trial Investigators. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005;352:1305–16.

  3. 3.

    Zaidat OO, Klucznik R, Alexander MJ, Chaloupka J, Lutsep H, Barnwell S, Mawad M, Lane B, Lynn MJ, Chimowitz M; NIH Multi-center Wingspan Intracranial Stent Registry Study Group. The NIH registry on use of the Wingspan stent for symptomatic 70–99% intracranial arterial stenosis. Neurology. 2008;70:1518–24.

  4. 4.

    Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Hanel RA, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke. 2007;38:881–7.

  5. 5.

    Bose A, Hartmann M, Henkes H, Liu HM, Teng MM, Szikora I, Berlis A, Reul J, Yu SC, Forsting M, Lui M, Lim W, Sit SP. A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 2007;38:1531–7.

  6. 6.

    Zhang L, Huang Q, Zhang Y, Deng B, Liu J, Hong B, Xu Y, Zhao W. A single-center study of Wingspan stents for symptomatic atherosclerotic stenosis of the middle cerebral artery. J Clin Neurosci. 2013;20:362–6.

  7. 7.

    Levy EI1, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, Pride L, Purdy P, Welch B, Woo H, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ. Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery. 2007;61:644–50. discussion 50–1.

  8. 8.

    Dorn F, Prothmann S, Wunderlich S, Liebig T. Stent angioplasty of intracranial stenosis: single center experience of 54 cases. Clin Neuroradiol. 2012;22:149–56.

  9. 9.

    Zaidat OO, Fitzsimmons BF, Woodward BK, Wang Z, Killer-Oberpfalzer M, Wakhloo A, Gupta R, Kirshner H, Megerian JT, Lesko J, Pitzer P, Ramos J, Castonguay AC, Barnwell S, Smith WS, Gress DR; VISSIT Trial Investigators. Effect of a balloon-expandable intracranial stent vs medical therapy on risk of stroke in patients with symptomatic intracranial stenosis: the VISSIT randomized clinical trial. JAMA. 2015;313:1240–8.

  10. 10.

    Marks MP, Marcellus ML, Do HM, Schraedley-Desmond PK, Steinberg GK, Tong DC, Albers GW. Intracranial angioplasty without stenting for symptomatic atherosclerotic stenosis: long-term follow-up. AJNR Am J Neuroradiol. 2005;26:525–30.

  11. 11.

    Jiang WJ, Wang YJ, Du B, Wang SX, Wang GH, Jin M, Dai JP. Stenting of symptomatic M1 stenosis of middle cerebral artery: an initial experience of 40 patients. Stroke. 2004;35:1375–80.

  12. 12.

    Shin YS, Kim BM, Suh SH, Jeon P, Kim DJ, Kim DI, Kim BS, Kim KH, Heo JH, Nam HS, Kim YD. Wingspan stenting for intracranial atherosclerotic stenosis: clinical outcomes and risk factors for in-stent restenosis. Neurosurgery. 2013;72:596–604. discussion 604.

  13. 13.

    Jiang WJ, Yu W, Du B, Gao F, Cui LY. Outcome of patients with ≥70% symptomatic intracranial stenosis after Wingspan stenting. Stroke. 2011;42:1971–5.

  14. 14.

    Yu SC, Leung TW, Lee KT, Hui JW, Wong LK. Angioplasty and stenting of atherosclerotic middle cerebral arteries with Wingspan: evaluation of clinical outcome, restenosis, and procedure outcome. AJNR Am J Neuroradiol. 2011;32:753–8.

  15. 15.

    Li TX, Gao BL, Cai DY, Wang ZL, Zhu LF, Xue JY, Bai WX, He YK, Li L. Wingspan Stenting for severe symptomatic Intracranial atherosclerotic Stenosis in 433 patients treated at a single medical center. PLoS ONE. 2015;10:e139377.

  16. 16.

    Turk AS, Levy EI, Albuquerque FC, Pride GL Jr, Woo H, Welch BG, Niemann DB, Purdy PD, Aagaard-Kienitz B, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella D. Influence of patient age and stenosis location on wingspan in-stent restenosis. AJNR Am J Neuroradiol. 2008;29:23–7.

  17. 17.

    Derdeyn CP, Fiorella D, Lynn MJ, Turan TN, Cotsonis GA, Lane BF, Montgomery J, Janis LS, Chimowitz MI; SAMMPRIS Investigators. Nonprocedural symptomatic infarction and in-Stent Restenosis after Intracranial Angioplasty and Stenting in the SAMMPRIS trial (Stenting and aggressive medical management for the prevention of recurrent stroke in Intracranial Stenosis). Stroke. 2017;48:1501–6.

  18. 18.

    Vajda Z, Güthe T, Perez MA, Heuschmid A, Schmid E, Bäzner H, Henkes H. Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons. AJNR Am J Neuroradiol. 2011;32:1942–7.

  19. 19.

    Chimowitz MI, Lynn MJ, Turan TN, Fiorella D, Lane BF, Janis S, Derdeyn CP; SAMMPRIS Investigators. Design of the stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis trial. J Stroke Cerebrovasc Dis. 2011;20:357–68.

  20. 20.

    Connors JJ 3rd, Wojak JC. Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg. 1999;91:415–23.

  21. 21.

    Yu J, Wang L, Deng JP; JLi, Gao L, Zhang T, Zhao ZW, Gao GD. Treatment of symptomatic intracranial atherosclerotic stenosis with a normal-sized gateway() balloon and wingspan() stent. J Int Med Res. 2010;38:1968–74.

  22. 22.

    Albuquerque FC, Levy EI, Turk AS, Niemann DB, Aagaard-Kienitz B, Pride GL Jr, Purdy PD, Welch BG, Woo HH, Rasmussen PA, Hopkins LN, Masaryk TJ, McDougall CG, Fiorella DJ. Angiographic patterns of Wingspan in-stent restenosis. Neurosurgery. 2008;63:23–7. discussion 27–8.

  23. 23.

    Zhang L, Huang Q, Zhang Y, Liu J, Hong B, Xu Y, Zhao W. Wingspan stents for the treatment of symptomatic atherosclerotic stenosis in small intracranial vessels: safety and efficacy evaluation. AJNR Am J Neuroradiol. 2012;33:343–7.

  24. 24.

    Berkefeld J, Zanella FE. Intracranial stenting of atherosclerotic stenoses. Clin Neuroradiol. 2009;19:38–44.

  25. 25.

    Shin YS, Kim SY, Bang OY, Jeon P, Yoon SH, Cho KH, Cho KG. Early experiences of elective stenting for symptomatic stenosis of the M1 segment of the middle cerebral artery: reports of three cases and review of the literature. J Clin Neurosci. 2003;10:53–9.

  26. 26.

    Brodie BR, Cooper C, Jones M, Fitzgerald P, Cummins F; Postdilatation Clinical Compartative Study (POSTIT) Investigators. Is adjunctive balloon postdilatation necessary after coronary stent deployment? Final results from the POSTIT trial. Catheter Cardiovasc Interv. 2003;59:184–92.

  27. 27.

    Siddiq F, Chaudhry SA, Khatri R, Rodriguez GJ, Tummala R, Suri MF, Qureshi AI. Rate of postprocedural stroke and death in SAMMPRIS trial-eligible patients treated with intracranial angioplasty and/or stent placement in practice. Neurosurgery. 2012;71:68–73.

  28. 28.

    Derdeyn CP, Fiorella D, Lynn MJ, Barnwell SL, Zaidat OO, Meyers PM, Gobin YP, Dion J, Lane BF, Turan TN, Janis LS, Chimowitz MI; SAMMPRIS Trial Investigators. Impact of operator and site experience on outcomes after angioplasty and stenting in the SAMMPRIS trial. J Neurointerv Surg. 2013;5:528–33.

  29. 29.

    Tarlov N, Jahan R, Saver JL, Sayre JW, Ali LK, Kim D, et al.Tarlov N1, Jahan R, Saver JL, Sayre JW, Ali LK, Kim D, Duckwiler GR, Tateshima S, Viñuela F, Liebeskind DS.Tarlov N, Jahan R, Saver JL, Sayre JW, Ali LK, Kim D, et al.reatment of high risk symptomatic intracranial atherosclerosis with balloon mounted coronary stents and Wingspan stents: single center experience over a 10 year period. J Neurointerv Surg. 2012;4:34–9.

  30. 30.

    Habib A, Finn AV. Endothelialization of drug eluting stents and its impact on dual anti-platelet therapy duration. Pharmacol Res. 2015;93:22–7.

  31. 31.

    Costalat V, Maldonado IL, Vendrell JF, Riquelme C, Machi P, Arteaga C, Turjman F, Desal H, Sedat J, Bonafé A. Endovascular treatment of symptomatic intracranial stenosis with the Wingspan stent system and Gateway PTA balloon: a multicenter series of 60 patients with acute and midterm results. J Neurosurg. 2011;115:686–93.

  32. 32.

    Samuels OB, Joseph GJ, Lynn MJ, Smith HA, Chimowitz MI. A standardized method for measuring intracranial arterial stenosis. AJNR Am J Neuroradiol. 2000;21:643–6.

  33. 33.

    Obeid T, Arnaoutakis DJ, Arhuidese I, Qazi U, Abularrage CJ, Black J, Perler B, Malas M. Poststent ballooning is associated with increased periprocedural stroke and death rate in carotid artery stenting. J Vasc Surg. 2015;62:616–23.

  34. 34.

    Zhang ZJ, Marroquin OC, Stone RA, Weissfeld JL, Mulukutla SR, Selzer F, Kip KE. Differential effects of post-dilation after stent deployment in patients presenting with and without acute myocardial infarction. Am Heart J. 2010;160:979–86.

  35. 35.

    Blackman DJ, Porto I, Shirodaria C, Channon KM, Banning AP. Usefulness of high-pressure post-dilatation to optimize deployment of drug-eluting stents for the treatment of diffuse in-stent coronary restenosis. Am J Cardiol. 2004;94:922–5.

  36. 36.

    Zhang ZJ, Ma L, Wan J, Kip KE. Stent post-dilation for patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Catheter Cardiovasc Interv. 2014;84:682–3.

  37. 37.

    von Schoenfeldt P, Krützelmann A, Bußmeyer M, Mpotsaris A, Rosenkranz M, Fiehler J, Weber W, Buhk JH. Elective treatment of intracranial stenosis with the balloon-expandable Pharos Vitesse stent: 30-day stroke rate and complications. J Neurointerv Surg. 2015;7:188–93.

  38. 38.

    Kessler IM, Mounayer C, Piotin M, Spelle L, Vanzin JR, Moret J. The use of balloon-expandable stents in the management of intracranial arterial diseases: a 5-year single-center experience. AJNR Am J Neuroradiol. 2005;26:2342–8.

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Acknowledgements

This study was supported by Gangneung Asan Hospital research grant 2018-b09.

Author information

All authors made substantial contribution to the design of the study and analysis and interpretation of the data in this work. All authors drafted and/or critically revised the manuscript, provided final approval of the version to be published, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Correspondence to Seung-Hoon You.

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Conflict of interest

S.-C. Park, S.H. Cho, M.-K. Kim, J.-E. Kim, W.-Y. Jang, M.-K. Lee, K.-D. Jo and S.-H. You declare that they have no competing interests.

Ethical standards

All procedures performed in studies involving human participants or on human tissue were in accordance with the ethical standards of the institutional and/or national research committee and with the 1975 Helsinki declaration and its later amendments or comparable ethical standards. Written patient consent was waived by the local ethics committee due to the retrospective design. Gangneung Asan Hospital Institutional Review Board (certification number: 010-3595-9706).

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Park, S., Cho, S.H., Kim, M. et al. Long-term Outcome of Angioplasty Using a Wingspan Stent, Post-Stent Balloon Dilation and Aggressive Restenosis Management for Intracranial Arterial Stenosis. Clin Neuroradiol (2019). https://doi.org/10.1007/s00062-019-00793-1

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Keywords

  • Intracranial atherosclerosis
  • Infarction
  • Ischemic attack, transient
  • Retreatment
  • Stroke