Stenting for a Symptomatic Posterior Cerebral Artery Stenosis

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Evolvement of endovascular devices and increase of operator expertise have made angioplasty and stenting in intracranial vessels technically possible. Stenting has been reported in treating stenosis in middle and anterior cerebral arteries with favorable outcomes. However, the feasibility of stenting for stenosis in posterior cerebral artery (PCA) has not been established. We report a patient with progressive focal cerebral ischemic symptoms, which were arrested after reconstruction of the associated PCA stenosis with stenting.

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... Recently, SAMMPRIS, the only randomized controlled trial for endovascular treatment of ICAD, demonstrated the superiority of aggressive medical therapy over PTAS, as stroke recurrence occurred within the first year in 12.2 versus 20.9% of patients in the medical and PTAS arms, respectively. SAMMPRIS studied ICAD only in large intracranial arteries (2-4.5 mm); unfortunately, small-artery ICAD has not been studied extensively, and endovascular treatment may be a valuable alternative in medically refractory patients as large-and small-artery ICAD could possibly represent two distinct entities, with a different natural history and response to medical and interventional treatments ( table 2 ) [14][15][16][17] . ...
... In our study, all 10 patients had symptomatic small-artery ICAD (mean stenosis of 79%) refractory to medical therapy, and treatment with either primary balloon angioplasty or PTAS (Wingspan Stent System) yielded a 100% technical success rate. This is comparable with other small-artery ICAD studies with reported success rates of 98.1-100%, with the only technical difficulty due to failure of Wingspan stent deployment in a tortuous M2 lesion [14][15][16][17] . Furthermore, there were no periprocedural complications in our patients, which is also similar to previously published case series ( table 2 ). ...
... In other smallartery ICAD publications, the overall restenosis rate for primary angioplasty was 40.0% (all Table 2. Comparison of current data on endovascular treatment of small-artery ICAD [14][15][16][17] symptomatic) and 27.7% for PTAS (only 5.6% symptomatic) [14][15][16][17] . Studies examining large-artery ICAD have stated a variable in-stent restenosis rate for the Wingspan Stent System. ...
Background: Intracranial atherosclerotic disease (ICAD) is a common cause of stroke with a poor natural history despite medical therapy. Few studies have investigated endovascular therapies for the treatment of symptomatic ICAD in distal intracranial arteries. Here, we present the feasibility and safety of balloon angioplasty with and without stenting in patients with medically refractory small artery symptomatic ICAD. Method: Personal logs were reviewed to identify patients who were treated for small artery ICAD (stenosis > 50%) using angioplasty ± stenting. Small cerebral arteries were defined by a diameter ≤ 2 mm or any branch distal to a large intracranial vessel (i.e. distal to ICA, M1, A1, Vertebrobasilar trunk). Patient characteristics, clinical manifestations, treatment, hospital course, and follow up data was collected and analyzed. Results: Ten patients (12 arteries) were treated with either primary balloon angioplasty (58.3%) or angioplasty with stenting (41.6 %) with 100% technical success rate. Mean pre-treatment stenosis was 79.9% while mean post-treatment stenosis was 19.0%. There were no major peri-procedural complications including symptomatic intracranial hemorrhage or mortality; three cases were complicated by groin hematoma. Patients were followed for a mean total of 18.6 months with only one symptomatic restenosis which was re-treated successfully. All patients had good functional outcome with a mRS of either 0 (80%) or 1 (20%) on follow up. Conclusion: In our case series, treatment of symptomatic small artery ICAD with angioplasty ± stenting was safe and effective. These interventions should be considered as an alternative treatment for ICAD patients refractory to medical therapy.
... As a reconstructive rather than deconstructive approach, stentassisted coiling has become the first choice for managing most cerebral aneurysms, especially at the P1 and P2 segments, because it can keep the parent artery unobstructed without affecting small perforating arteries (19,20). However, this type of treatment may have higher recurrence and bleeding rates in treating PCA aneurysms (21)(22)(23). In our study, the only bleeding complication occurred in one of the patients treated with stent-assisted coiling. ...
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Purpose: To investigate the safety and efficacy of endovascular embolization of cerebral aneurysms at the P1–P3 segments of the posterior cerebral artery (PCA). Materials and Methods: Seventy-seven patients with 77 PCA aneurysms who were treated with endovascular embolization were enrolled, including 35 (45.5%) patients with ruptured aneurysms and 42 (54.5%) with unruptured ones. The pretreatment clinical data and aneurysm occlusion status after treatment and at follow-up were analyzed. Results: All patients were successfully treated endovascularly, including coiling alone in 10 (13.0%) patients, stent-assisted coiling in 18 (23.4%), parent artery occlusion in 25 (32.5%), and pipeline embolization device (PED) in 24 (31.2%). Complete occlusion was achieved in 48 (62.3%) aneurysms, residual neck in 4 (5.2%), and residual aneurysm in the other 25 (32.5%) at the end of embolization. Periprocedural complications occurred in eight patients, including acute thrombosis in seven (9.1%) and intraprocedural subarachnoid hemorrhage in one (1.3%), with the total complication rate of 10.4%. Follow-up was performed in 60 patients (77.9%) for 42 ± 11 months; the mRS score was 0–2 in 55 (91.7%) patients, three in four patients (6.7%), and six in one patient (1.7%). Fifty-three (88.3%) patients (53 aneurysms) had stable or complete occlusion, and seven (11.7%) patients had aneurysm recurrence or residual aneurysm. Among 19 patients treated with PED at follow-up, 15 aneurysms (78.9%) proceeded to complete occlusion while four (21.1%) aneurysms showed residual aneurysm. Conclusion: Endovascular embolization remains a good choice of treatment with high safety and efficacy for posterior cerebral artery aneurysms.
... The balloon-mounted coronary stents previously used for intracranial aneurysms had a high profile and stiffness with stent struts outside the balloon, which made it risky and technically difficult to apply coronary stents in PCA especially across an aneurysm. Up to now, only five cases with the application of balloonmounted stents in PCAs were reported in the literature, one of which was used for PCA stenosis [17][18][19]. ...
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Objective: To investigate the safety and efficacy of stenting with coil in the endovascular treatment of complex posterior cerebral artery (PCA) aneurysms. Methods: The data on PCA aneurysms treated with stents were retrospectively reviewed from a prospectively collected intervention database. The literature was reviewed concerning the use of stents for PCA aneurysms. Results: Seven cases with complex PCA aneurysms (male: female = 6:1; ruptured: unruptured = 4:3) were retrieved from our database. Three aneurysms were localized at the junction of P1 and P2 segments (P1-2), two at P1, and two at P2A. Four were wide-necked saccular aneurysms, while the other three were dissecting ones. A total of nine stents (one Neuroform and eight Enterprise stents) were successfully deployed. Two aneurysms were totally eliminated, three were with neck residues and two were partially occluded. No procedure-related complications occurred. All patients recovered well. Angiographic follow-ups (FU) showed that three aneurysms achieved total obliterations, one got improved, two remained stable, and one recurred. The recurred aneurysm caused no symptom and was treated with two stents. Clinical FU demonstrated no neurological deterioration or bleeding. In literature review, the procedure-related mortality is 5.3 % (2/38). The incidence of permanent neurologic deficit is 2.6 % (1/38). Three (3/23) aneurysms recurred, of which one caused rebleeding. Four (4/23) in-stent stenoses were all asymptomatic. No other hemorrhagic or ischemic event occurred in clinical FU. Conclusion: Stent offers a therapeutic alternative for complex PCA aneurysms especially when PVO cannot be tolerated. Long-term therapeutic efficacy requires further observations in clinical series with larger case numbers.
Angioplasty and stenting in symptomatic intracranial stenosis is technically possible and may reduce the risk of stroke in patients with symptomatic arterial stenosis. We report a patient with P1 segment stenosis of posterior cerebral artery treated successfully with angioplasty and stenting with a favorable outcome. He had 5 years of clinical and imaging follow-up and no in-stent stenosis or new ischemic event was observed.
As is the case in many vascular territories, endovascular treatment of extracranial carotid artery disease is becoming a rival alternative to surgery. Results of carotid artery stenting (CAS) are improving with the introduction of embolic protection devices, improved technology, and increasing operator experience. Multiple clinical studies have shown results in favor of CAS as opposed to carotid endartrectomy (CEA) in patients considered at high risk for surgery. Current ongoing trials are examining both treatment options in low and intermediate risk patients in prospective randomized protocols. With the recent FDA approval of carotid stent systems, we are entering a new era in the treatment of carotid artery disease. An update of modern carotid stent studies, as well as stent versus surgery studies in the current era is needed. © 2006 Wiley-Liss, Inc.
We studied 100 consecutive acute stroke patients in a Chinese population with transcranial Doppler and CT. Twenty patients had intracerebral hemorrhage and 14 patients did not have adequate temporal windows for transcranial Doppler examination. Among the remaining 66 patients, 22 patients (33%) had intracranial occlusive diseases and 3 (6%) had extracranial carotid stenosis. Our data showed that intracranial occlusive disease is the most commonly found vascular lesion in our acute stroke patients.
We conducted a retrospective, multicenter study to compare the efficacy of warfarin with aspirin for the prevention of major vascular events (ischemic stroke, myocardial infarction, or sudden death) in patients with symptomatic stenosis of a major intracranial artery. Patients with 50 to 99% stenosis of an intracranial artery (carotid; anterior, middle, or posterior cerebral; vertebral; or basilar) were identified by reviewing the results of consecutive angiograms performed at participating centers between 1985 and 1991. Only patients with TIA or stroke in the territory of the stenotic artery qualified for inclusion in the study. Patients were prescribed warfarin or aspirin according to local physician preference and were followed by chart review and personal or telephone interview. Seven centers enrolled 151 patients; 88 were treated with warfarin and 63 were treated with aspirin. Median follow-up was 14.7 months (warfarin group) and 19.3 months (aspirin group). Vascular risk factors and mean percent stenosis of the symptomatic artery were similar in the two groups, yet the rates of major vascular events were 18.1 per 100 patient-years of follow-up in the aspirin group (stroke rate, 10.4/100 patient-years; myocardial infarction or sudden death rate, 7.7/100 patient-years) compared with 8.4 per 100 patient-years of follow-up in the warfarin group (stroke rate, 3.6/100 patient-years; myocardial infarction or sudden death rate, 4.8/100 patient-years). Kaplan-Meier analysis showed a significantly higher percentage of patients free of major vascular events among patients treated with warfarin (p = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
It is becoming clear that the complete management of cerebro-vascular disease requires practitioners who possess endovascular skills. Ever increasing numbers of vascular neurosurgeons are seeking interventional training, and the growing field of interventional stroke neurology is attracting many young neurologists. The American Society of Interventional and Therapeutic Neuroradiology has established guidelines to ensure that these candidates receive a good grounding in the underlying radiological sciences. The discipline of interventional neuroradiology may become the model of a fruitful collaboration between multiple specialties working together for maximum patient benefit.
lthough the traditional use of intravenous (IV) thrombolytics is restricted to within 3 hours of stroke onset, the use of intra-arterial (IA) therapy is proving to be more flexible, with the ultimate time window yet to be determined. Anecdotal evidence suggests that thrombectomy may be effective beyond the 6-hour window in properly selected patients.1 Clinical success and the incidence of complications may be more dependent on the results of perfusion-imaging and the presence of large-vessel occlusion and less on an arbitrary time window. Multimodality strategies are becoming more popular. A combination of me- chanical clot retrieval and adjunctive thrombolytic therapies in 111 patients participating in the Multi MERCI trial resulted in successful recanalization in 69% of vessels versus 54% with the retriever alone.2 The preliminary results of the IMS II trial indicate that the MicroLysus ultrasound device (EKOS Corp) may improve recanalization rates compared with standard mi- crocatheter techniques.3,4 Multimodal therapy combining IV or IA abciximab and intracranial angioplasty has been reported to achieve high recanalization rates,5 and preliminary experience with intracranial stenting in acute stroke suggests that this may be an attractive adjunct to IA thrombolytics.6,7 A retrospective review of 168 patients treated with a combination of IA thrombolytics and mechanical interventions reported recanaliza- tion in 63% and improvement in NIHSS of at least 4 points in 21% of patients at 24-hour follow-up,8 with the highest recana- lization rates seen in patients in whom 3 or more IA modalities were used. Not surprisingly, however, the rate of symptomatic intracranial hemorrhage was 14%.8 The high morbidity and mortality rates that continue to complicate IA therapies may be attributable to the inherent selection bias toward large-vessel occlusions and the resultant initial severity of these strokes. Angioplasty and Stenting for Atherosclerosis of Extracranial and Intracranial Arteries Over the past year, the results of 4 large extracranial carotid angioplasty (CAS) investigations have been reported. The industry supported ARCHeR and BEACH registries of non- randomized, symptomatic and asymptomatic patients at high risk for carotid endarterectomy found 30-day stroke or death rates of 6.9% and 5.8% respectively, and ARCHeR reported a 1 year composite outcome including myocardial infarction of 9.6%.9,10 The European EVA-3S11 and SPACE12 investi- gators reported on symptomatic patients randomized to re- ceive either CAS or carotid endarterectomy. EVA-3S was stopped prematurely when the 30-day rate of stroke or death was significantly higher in the CAS group (9.6%) than in the carotid endarterectomy group (3.9%). In the SPACE trial, the 30-day stroke or death rate was 6.8% after CAS, and 6.3% after carotid endarterectomy, with slightly higher complica- tion rates when embolic protection devices were used during CAS. Cerebrovascular embolization and hemodynamic changes after CAS continue to be investigated. Changes on diffusion-weighted MR images are seen less often with the use of embolic protection devices, but can still be seen in up to 42% of patients in the distribution of the stented artery.13-16 CT perfusion, MR volume flow quantification and transcra- nial Doppler ultrasound methods have all shown improve- ment in cerebral blood flow parameters post-CAS.17,18,19 Transient hemodynamic instability, including bradycardia and hypotension after CAS remains common, but may be persistent in up to 17% of patients and may occasionally require a pacemaker.20 Preprocedural use of statins in CAS patients may lower the 30-day risk of stroke, myocardial infarction or death.21 Drug-eluting and heparin-coated stents are being used to reduce the risk of restenosis after angio- plasty for intracranial and extracranial atherosclerosis,22,23,24 but there are as yet no long-term results or direct comparisons with bare metal stents. No randomized controlled trials have evaluated angioplasty and/or stenting for intracranial arterial stenosis. A recent review of the 79 published case series found an overall perioperative stroke rate of 7.9% and stroke or death rate of 9.5%.25 Perforator strokes after intracranial angioplasty and stenting were found in 3% of patients, and those with pre-existing strokes adjacent to the stenotic seg- ments were at greatest risk of symptom exacerbation.26 A new, self-expanding intracranial stent for atherosclerosis treatment (Wingspan, Boston Scientific) has shown initial promise in small numbers of patients.27
he year 2007 brought further understanding of the risk for subgroups of patients undergoing carotid artery stenting (CAS). For symptomatic patients, both increasing age and treatment within 2 weeks of neurological symptoms were associated with increased risk of perioperative stroke or death.1 Unfavorable anatomic factors for CAS among octo- genarians included aortic arch elongation, calcification, great vessel origin stenosis, tortuosity, and severity of lesion stenosis,2 and the combined perioperative stroke/ myocardial infarction/death rate was 10.8% for this group.2 Diabetic patients 75 years undergoing CAS have 4.3 greater risk for any stroke/death and 12.0 greater risk for major stroke/ death, whereas diabetics 75 years have no increased risk.3 Increasing age was also associated with higher rates of in-hospital stroke or death.4 There was no significant differ- ence in periprocedural complications after CAS for patients with previous ipsilateral carotid endarterectomy (CEA).5 In an attempt to aid decision-making for surgical versus endovascular treatment of carotid artery disease, a single community-based hospital reviewed its contemporary expe- rience with CEAs in 1900 patients.6 High-surgical-risk pa- tients comprised 54% of the total. The perioperative stroke/ death rate for this cohort was 1.6% compared with 1.3% for all patients. The 30-day stroke/myocardial infarction/death rate was 3.4%. Severe coronary artery disease and previous ipsilateral CEA were associated with increased risk for complications.6 A prospective randomized trial of CAS versus CEA for symptomatic patients reported that despite increased diffusion-weighted imaging lesions on brain MRI after CAS, similar numbers of patients in each treatment group experi- enced cognitive changes.7 A study evaluating brain MRI before and after CAS found diffusion-weighted imaging lesions in 41.5%, with no association between microscopic debris captured in the distal embolic protection device and new lesions on MRI.8 A pre-/post-MRI study of diffusion- weighted imaging changes after CAS with distal embolic protection device or CEA found lesions in 70% of CAS-distal embolic protection device patients and in none of the CEA patients.9 Among the CAS patients, diffusion-weighted im- aging lesions relative to the vessel treated were either bilateral (36%), ipsilateral (47%), or contralateral (16%), and neurological symptoms lasting 36 hours occurred in 11%.9 A protocol for comprehensive blood pressure management initiated in conjunction with CAS was shown to significantly reduce the incidence of intracerebral hemorrhage in all patients and both hyperperfusion syndrome and intracerebral hemorrhage in high-risk patients.10 A number of industry supported registries continue to supply interesting data. Carotid artery stenting with emboli protection surveillance post-marketing study (CASES-PMS) demonstrated a 30-day stroke/myocardial infarction/death rate of 5.0% for a mixed group of symptomatic and asymp- tomatic patients.11 The Carotid ACCULINK/ACCUNET Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) postapproval registry reported a 30-day stroke/ myocardial infarction/death rate of 6.3%, and both registries have shown no difference in outcomes based on level of operator experience.12 Complication rates in both were sim- ilar to Asymptomatic Carotid Atherosclerosis Study (ACAS) and North American Symptomatic Carotid Endarterectomy Trial (NASCET), and there was some relationship to CAS operator experience. Three-year follow-up data from regis- tries using Boston Scientific devices confirmed higher risk of CAS in octogenarians, symptomatic patients, and those with medical comorbidities. In these high-risk cohorts, the inci- dence of perioperative stroke was up to 7.7%.13 Primary stenting consists of carotid stent placement with- out embolic protection or intentional use of balloon angio- plasty. Results among 87 consecutive patients with carotid stenosis treated with primary stent placement revealed 98% procedural success, 2% stroke/death, and 5% with periproce- dural transient ischemic attacks.14
Malignant posterior cerebral artery infarction 748 Xu et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd
  • T Pfefferkorn
  • A Deutschlaender
  • E Riedel
  • M Wiesmann
  • Dichgans
Pfefferkorn T, Deutschlaender A, Riedel E, Wiesmann M, Dichgans M. Malignant posterior cerebral artery infarction. J Neurol 2006;253:1640–1641. 748 Xu et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI)
  • Xu
748 Xu et al. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).