Undersized angioplasty and stenting of symptomatic intracranial tight stenosis with Enterprise: Evaluation of clinical and vascular outcome

Abstract

Background: Severe intracranial arterial stenosis results in more than 10% incidence of stroke and transient ischemic attack. Using undersized angioplasty with off-label closed-cell Enterprise stent may be a feasible alternative option for treating patients with intracranial atherosclerotic disease who fail dual-antiplatelet medical therapy. The results of the authors' study are presented in this paper.

Materials and methods: Between January 2013 and July 2014, 24 symptomatic patients with a total of 30 intracranial arterial stenotic lesions refractory to medical therapy, who underwent undersized angioplasty and Enterprise stenting, were retrospectively reviewed in the authors' institution. The results evaluated include technical success rate, clinical outcome measured as modified Rankin Scale at presentation and follow-up, peri-procedural morbidity within 30 days and 1 year, and follow-up vessel patency.

Results: Stent deployment was successfully achieved in all stenotic lesions (30/30). Mean pre-stent and post-stent diameter residual stenosis was 81% and 18%, respectively. The peri-procedural complication rate during 30 days after stenting was 10% per lesion (3/30), including intracranial hemorrhage, in-stent thrombosis and ischemic stroke. No further thromboembolic event or complication occurred in any patient more than 30 days after stenting. Modified Rankin scale ≤ 2 was observed in 64% and 83% of patients at initial presentation and follow-up (mean 15.8 months), respectively. Imaging follow-up was available in 17 of 24 patients (70.8%) and 20 of 30 treated lesions (66.6%) with a mean follow-up period of 15.4 months. Only one asymptomatic in-stent restenosis occurred in 20 available lesions (5.0%).

Conclusion: This preliminary study suggests that using undersized angioplasty and Enterprise stenting may effectively treat high-degree symptomatic intracranial arterial stenosis with favorable clinical and angiographic outcome.

Keywords: Enterprise; Intracranial stent; angioplasty; intracranial arterial stenosis; stroke.

© The Author(s) 2015.

Figures

Figure 1.

Representative angiographic images of pre-stenting, post-stenting and follow-up CTA image in cases of high-grade intracranial arterial stenosis. (a) MCA, (b) intracranial VA, and (c) BA treated with PTA and Enterprise stent deployment. [Typesetter: please change A, B, C, D to (a), (b), (c), (d) in Figures].

Figure 2.

A high-grade right MCA stenosis. (a) Pre-stenting right ICA angiogram reveals tight stenosis (99%) of M1 segment. (b) First-time post-stenting right ICA angiogram reveals resolution of the critical stenosis. (c) The follow-up (3 days) right ICA angiogram shows complete in-stent thrombosis. (d) After thrombolytic recanalization and balloon-expandable Helistent (2.5 × 7 mm) deployment, right ICA angiogram shows patent flow with some minimal filling defects representing thrombotic debris.

Figure 3.

Modified Rankin Scale (mRS) score for all patients evaluated at initial presentation (pre-stent) and after stenting follow-up of mean 15.8 months (24 patients).

Figure 4.

A high-grade right MCA stenosis. (a) Pre-stenting right ICA angiogram shows right proximal M2 stenosis (90%). (b) Undersized PTA was performed by using a Rafale balloon (1.5 × 10 mm) for the M2 stenotic lesion. (c) Post-stenting angiogram after Enterprise stent (4.5 × 22 mm) deployment shows less than 10% diameter stenosis of right M2 segment. (d) Follow-up CTA 18 months after PTAS demonstrates in-stent restenosis with nearly 55% luminal narrowing.