In-stent Stenosis after p64 Flow Diverter Treatment

M Aguilar Pérez, P Bhogal, E Henkes, O Ganslandt, H Bäzner, H Henkes, M Aguilar Pérez, P Bhogal, E Henkes, O Ganslandt, H Bäzner, H Henkes

Abstract

Purpose: There is limited information available on the incidence of in-stent stenosis (ISS) secondary to the use of flow-diverting stents in the intracranial vasculature. We sought to determine the incidence, severity, and clinical course of ISS on angiographic follow-up after treatment of saccular aneurysms with p64.

Methods: We retrospectively reviewed all patients who underwent treatment of a saccular (ruptured and unruptured) intracranial aneurysm with ≥1 p64 between 2011 and 2015. Fusiform aneurysms and dissections were excluded. Aneurysms with prior or concomitant saccular treatment (e. g., coiling, clipping) were included. Extradural targets and aneurysms with parent vessel implants other than p64 were excluded. ISS was assessed on follow-up angiography and defined as <50% (mild), 50-75% (moderate), or >75% (severe).

Results: In total, 205 patients (147 female, 71.7%; median age 57 years), with 223 saccular aneurysms were treated with p64 and had at least 9 months of digital subtraction angiography (DSA) follow-up completed. There was no DSA follow-up available in 8 patients. ISS of any degree at any time was recognized in 65/223 (29.1%) of all target aneurysms. The maximal degree of lumen loss was <50% in 40 lesions (17.9%), 50-75% in 19 lesions (8.5%), and >75% in 6 lesions (2.7%). ISS did not cause a focal neurological deficit in any patient. No progression from stenosis to occlusion was observed. Balloon angioplasty was performed in 1 lesion and was well tolerated. In 56 lesions (84.8%), a significant reduction of ISS occurred spontaneously, 2 mild stenoses remained stable, and for 6 lesions the long-term follow-up is pending.

Conclusion: Treatment with p64 is associated with an overall rate of 8.5% moderate ISS (50-75%) and 2.7% severe ISS (>75%), which is comparable with the rate of ISS reported in the literature for other flow diverting stents. There is a tendency for ISS to spontaneously improve over time.

Keywords: Aneurysm; Flow diverter; In stent stenosis; Stent; p64.

Conflict of interest statement

M. Aguilar Pérez and P. Bhogal serve as proctors and consultants for phenox GmbH, with moderate financial compensation. H. Henkes is a cofounder and shareholder of phenox GmbH. E. Henkes, O. Ganslandt, and H. Bäzner declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
A patient treated with a single p64 flow diverter for an aneurysm related to the superior hypophyseal artery (a). A follow-up angiogram at 4 months (b) showed severe in-stent stenosis (arrow). She underwent balloon angioplasty. A delayed angiogram 12 months after this balloon angioplasty shows only mild residual stenosis with no flow limitation

References

    1. Saatci I, Yavuz K, Ozer C, Geyik S, Cekirge HS. Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results. AJNR Am J Neuroradiol. 2012;33:1436–1446. doi: 10.3174/ajnr.A3246.
    1. Pistocchi S, Blanc R, Bartolini B, Piotin M. Flow diverters at and beyond the level of the circle of willis for the treatment of intracranial aneurysms. Stroke. 2012;43:1032–1038. doi: 10.1161/STROKEAHA.111.636019.
    1. Chalouhi N, Tjoumakaris S, Starke RM, Gonzalez LF, Randazzo C, Hasan D, McMahon JF, Singhal S, Moukarzel LA, Dumont AS, Rosenwasser R, Jabbour P. Comparison of flow diversion and coiling in large unruptured intracranial saccular aneurysms. Stroke. 2013;44:2150–2154. doi: 10.1161/STROKEAHA.113.001785.
    1. Chalouhi N, Starke RM, Yang S, Bovenzi CD, Tjoumakaris S, Hasan D, Gonzalez LF, Rosenwasser R, Jabbour P. Extending the indications of flow diversion to small, unruptured, saccular aneurysms of the anterior circulation. Stroke. 2014;45:54–58. doi: 10.1161/STROKEAHA.113.003038.
    1. Tomasello A, Romero N, Aixut S, Miquel MA, Macho JM, Castaño C, Coscojuela P, Lemus M, Aja L, San Roman L, Blasco J, Rovira A. Endovascular treatment of intracraneal aneurysm with pipeline embolization device: experience in four centres in Barcelona. Neurol Res. 2016;38:381–388. doi: 10.1080/01616412.2016.1155335.
    1. Brinjikji W, Murad MH, Lanzino G, Cloft HJ, Kallmes DF. Endovascular treatment of intracranial aneurysms with flow diverters: a meta-analysis. Stroke. 2013;44:442–447. doi: 10.1161/STROKEAHA.112.678151.
    1. Wang CB, Shi WW, Zhang GX, Lu HC, Ma J. Flow diverter treatment of posterior circulation aneurysms. A meta-analysis. Neuroradiology. 2016;58:391–400. doi: 10.1007/s00234-016-1649-2.
    1. Cohen JE, Gomori JM, Moscovici S, Leker RR, Itshayek E. Delayed complications after flow-diverter stenting: reactive in-stent stenosis and creeping stents. J Clin Neurosci. 2014;21:1116–1122. doi: 10.1016/j.jocn.2013.11.010.
    1. John S, Bain MD, Hui FK, Hussain MS, Masaryk TJ, Rasmussen PA, Toth G. Long-term follow-up of in-stent stenosis after pipeline flow diversion treatment of Intracranial aneurysms. Neurosurgery. 2016;78:862–867. doi: 10.1227/NEU.0000000000001146.
    1. Lubicz B, Van der Elst O, Collignon L, Mine B, Alghamdi F. Silk flow-diverter stent for the treatment of intracranial aneurysms: a series of 58 patients with emphasis on long-term results. AJNR Am J Neuroradiol. 2015;36:542–546. doi: 10.3174/ajnr.A4143.
    1. Mitra AK, Agrawal DK. In stent restenosis: bane of the stent era. J Clin Pathol. 2006;59:232–239. doi: 10.1136/jcp.2005.025742.
    1. Grewe PH, Deneke T, Machraoui A, Barmeyer J, Müller KM. Acute and chronic tissue response to coronary stent implantation: pathologic findings in human specimen. J Am Coll Cardiol. 2000;35:157–163. doi: 10.1016/S0735-1097(99)00486-6.
    1. Inoue T, Croce K, Morooka T, Sakuma M, Node K, Simon DI. Vascular inflammation and repair: implications for re-endothelialization, restenosis, and stent thrombosis. JACC Cardiovasc Interv. 2011;4:1057–1066. doi: 10.1016/j.jcin.2011.05.025.
    1. Welt FG, Tso C, Edelman ER, Kjelsberg MA, Paolini JF, Seifert P, Rogers C. Leukocyte recruitment and expression of chemokines following different forms of vascular injury. Vasc Med. 2003;8:1–7. doi: 10.1191/1358863x03vm462oa.
    1. Otsuka F, Finn AV, Yazdani SK, Nakano M, Kolodgie FD, Virmani R. The importance of the endothelium in atherothrombosis and coronary stenting. Nat Rev Cardiol. 2012;9:439–453. doi: 10.1038/nrcardio.2012.64.
    1. Chaabane C, Otsuka F, Virmani R, Bochaton-Piallat ML. Biological responses in stented arteries. Cardiovasc Res. 2013;99:353–363. doi: 10.1093/cvr/cvt115.
    1. Campbell JH, Campbell GR. Smooth muscle phenotypic modulation – a personal experience. Arterioscler Thromb Vasc Biol. 2012;32:1784–1789. doi: 10.1161/ATVBAHA.111.243212.
    1. Kadirvel R, Ding YH, Dai D, Rezek I, Lewis DA, Kallmes DF. Cellular mechanisms of aneurysm occlusion after treatment with a flow diverter. Radiology. 2014;270:394–399. doi: 10.1148/radiol.13130796.
    1. De Vries J, Boogaarts J, Van Norden A, Wakhloo AK. New generation of flow diverter (surpass) for unruptured Intracranial aneurysms: a prospective single-center study in 37 patients. Stroke. 2013;44:1567–1577. doi: 10.1161/STROKEAHA.111.000434.
    1. Cook S, Wenaweser P, Togni M, Billinger M, Morger C, Seiler C, Vogel R, Hess O, Meier B, Windecker S. Incomplete stent apposition and very late stent thrombosis after drug-eluting stent implantation. Circulation. 2007;115:2426–2434. doi: 10.1161/CIRCULATIONAHA.106.658237.
    1. Klisch J, Turk A, Turner R, Woo HH, Fiorella D. Very late thrombosis of flow-diverting constructs after the treatment of large fusiform posterior circulation aneurysms. AJNR Am J Neuroradiol. 2011;32:627–632. doi: 10.3174/ajnr.A2571.
    1. Pierot L, Wakhloo AK. Endovascular treatment of intracranial aneurysms: current status. Stroke. 2013;44:2046–2054. doi: 10.1161/STROKEAHA.113.000733.
    1. Carneiro A, Rane N, Küker W, Cellerini M, Corkill R, Byrne JV. Volume changes of extremely large and giant intracranial aneurysms after treatment with flow diverter stents. Neuroradiology. 2014;56:51–58. doi: 10.1007/s00234-013-1304-0.
    1. Mattingly T, Van Adel B, Dyer E, Lopez-Ojeda P, Pelz DM, Lownie SP, Marotta T, Boulton M. Failure of aneurysm occlusion by flow diverter: a role for surgical bypass and parent artery occlusion. J Neurointerv Surg. 2015;7:e13. doi: 10.1136/neurintsurg-2013-011062.
    1. Flood TF, van der Bom IM, Strittmatter L, Puri AS, Hendricks GM, Wakhloo AK, Gounis MJ. Quantitative analysis of high-resolution, contrast-enhanced, cone-beam CT for the detection of intracranial in-stent hyperplasia. J Neurointerv Surg. 2015;7:118–125. doi: 10.1136/neurintsurg-2013-010950.
    1. van der Marel K, Gounis MJ, Weaver JP, de Korte AM, King RM, Arends JM, Brooks OW, Wakhloo AK, Puri AS. Grading of regional apposition after flow-diverter treatment (GRAFT): a comparative evaluation of vasoCT and intravascular OCT. J Neurointerv Surg. 2016;8:847–852. doi: 10.1136/neurintsurg-2015-011843.
    1. Berg P, Iosif C, Ponsonnard S, Yardin C, Janiga G, Mounayer C. Endothelialization of over- and undersized flow-diverter stents at covered vessel side branches: an in vivo and in silico study. J Biomech. 2016;49:4–12. doi: 10.1016/j.jbiomech.2015.10.047.
    1. Benard N, Coisne D, Donal E, Perrault R. Experimental study of laminar blood flow through an artery treated by a stent implantation: characterisation of intra-stent wall shear stress. J Biomech. 2003;36:991–998. doi: 10.1016/S0021-9290(03)00068-X.
    1. Adam Z, Turley A, Mason JM, Kasim AS, Newby D, Mills N, Padfield G, Thompson L, Morley R, Hall JA, Wright RA, Muir DF, Sutton AG, Swanson N, Carter J, Bilous R, Jones S, de Belder MA. The SSTARS (STeroids and Stents Against Re-Stenosis) trial: different stent alloys and the use of peri-procedural oral corticosteroids to prevent in-segment restenosis after percutaneous coronary intervention. Int J Cardiol. 2016;216:1–8. doi: 10.1016/j.ijcard.2016.04.105.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere