Use of Heparin-coated Stents in Neurovascular Interventional Procedures: Preliminary Experience with 10 Patients

Neurosurgery ◽  
2006 ◽  
Vol 59 (4) ◽  
pp. 812-821 ◽  
Author(s):  
Richard J. Parkinson ◽  
Christopher P. Demers ◽  
Joseph G. Adel ◽  
Elad I. Levy ◽  
Eric Sauvageau ◽  
...  
Keyword(s):  
Clinical Symptoms ◽  
Cerebrovascular Circulation ◽  
Clinical History ◽  
Published Data ◽  
Anterior Circulation ◽  
Stent Deployment ◽  
Stent Restenosis ◽  
Intracranial Atherosclerotic Disease ◽  
Small Series

Abstract OBJECTIVE: Currently, there is minimal published data on the use of heparin-coated stents in the neurovasculature; however, these stents have a proven clinical record in the treatment of coronary disease. This article details our experience with the safety and technical aspects of stent deployment in the first 10 patients who had heparin-coated stents placed in the intracranial and cervical vasculature and the preliminary follow-up in most cases. METHODS: We retrospectively reviewed the clinical history, intra- and periprocedural data, and imaging for the patients who received heparin-coated stents in the cervical and intracranial vasculature for cerebrovascular disease between October 2002 and October 2003. RESULTS: Thirteen heparin-coated stents were placed in 10 patients. Seven out of the 10 patients had heparin-coated stents placed in the posterior circulation; the remaining three patients had stents placed in the anterior circulation. Four patients had stents placed intracranially. There was no acute or subacute in-stent thrombosis and no procedure-related complications. Follow-up was performed on most patients, with no clinical symptoms attributable to restenosis in any patient. CONCLUSION: This small series suggests that heparin-coated stents are safe for use in the treatment of cervical and intracranial atherosclerotic disease. Longer-term follow-up is needed to study the heparin coating effect on in-stent restenosis rates and to assess the long-term durability and clinical efficacy of this stent. The use of drug-coated stents in the cerebrovascular circulation is an area that warrants further investigation.

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

2015 ◽  
Vol 22 (2) ◽  
pp. 187-195 ◽  
Author(s):  
Kun-Yu Lee ◽  
David Yen-Ting Chen ◽  
Hui-Ling Hsu ◽  
Chi-Jen Chen ◽  
Ying-Chi Tseng
Keyword(s):  
Medical Therapy ◽  
Arterial Stenosis ◽  
Modified Rankin Scale ◽  
Intracranial Arterial Stenosis ◽  
Stent Deployment ◽  
Technical Success Rate ◽  
Stent Restenosis ◽  
Intracranial Atherosclerotic Disease ◽  
Stenotic Lesions

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.

scholarly journals Stent Deployment as an Emergency Alternative Treatment for Acute Stroke. Case Series

2019 ◽  
Vol 29 (3) ◽  
pp. 517-522
Author(s):  
Roberto Crosa ◽  
Alejandro M. Spiotta
Keyword(s):  
Mechanical Thrombectomy ◽  
Case Series ◽  
Large Vessel Occlusion ◽  
Good Clinical Outcome ◽  
Vessel Occlusion ◽  
Stent Deployment ◽  
Small Series ◽  
Treatment Variant

Introduction. Acute ischemic stroke due to large vessel occlusion refractory to aspiration or mechanical thrombectomy is a therapeuticchallenge. Objective. A treatment variant is in order. Methods. In the last three years, we admitted seven patients with refractory largevessel occlusions, for all of whose aspiration and mechanical thrombectomy had failed. A Solitaire AB stent was deployed as a rescuemeasure. Results. Data was retrospectively analyzed. Six out of seven patients had a good clinical outcome as measured by mTICIand mRS twelve months after the procedure. One patient died after the first follow-up visit, one month after endovascular therapy.Conclusion. Results of this small series support the role of stent deployment as a rescue measure for such challenging patients.

WINGSPAN IN-STENT RESTENOSIS AND THROMBOSIS

Neurosurgery ◽  
2007 ◽  
Vol 61 (3) ◽  
pp. 644-651 ◽  
Author(s):  
◽  
Elad I. Levy ◽  
Aquilla S. Turk ◽  
Felipe C. Albuquerque ◽  
David B. Niemann ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Anterior Circulation ◽  
Target Vessel Revascularization ◽  
Computed Tomographic ◽  
Stent Restenosis ◽  
Current Series ◽  
Complete Thrombosis ◽  
Ischemic Attack ◽  
In Stent Restenosis

Abstract OBJECTIVE Wingspan (Boston Scientific, Fremont, CA) is a self-expanding stent designed specifically for the treatment of symptomatic intracranial atheromatous disease. The current series reports the observed incidence of in-stent restenosis (ISR) and thrombosis on angiographic follow-up. METHODS A prospective, intent-to-treat registry of patients in whom the Wingspan stent system was used to treat symptomatic intracranial atheromatous disease was maintained at five participating institutions. Clinical and angiographic follow-up results were recorded. ISR was defined as stenosis greater than 50% within or immediately adjacent (within 5 mm) to the implanted stents and absolute luminal loss greater than 20%. RESULTS To date, follow-up imaging (average duration, 5.9 mo; range, 1.5–15.5 mo) is available for 84 lesions treated with the Wingspan stent (78 patients). Follow-up examinations consisted of 65 conventional angiograms, 17 computed tomographic angiograms, and two magnetic resonance angiograms. Of these lesions with follow-up, ISR was documented in 25 and complete thrombosis in four. Two of the 4 patients with stent thrombosis had lengthy lesions requiring more than one stent to bridge the diseased segment. ISR was more frequent (odds ratio, 4.7; 95% confidence intervals, 1.4–15.5) within the anterior circulation (42%) than the posterior circulation (13%). Of the 29 patients with ISR or thrombosis, eight were symptomatic (four with stroke, four with transient ischemic attack) and 15 were retreated. Of the retreatments, four were complicated by clinically silent in-stent dissections, two of which required the placement of a second stent. One was complicated by a postprocedural reperfusion hemorrhage. CONCLUSION The ISR rate with the Wingspan stent is higher in our series than previously reported, occurring in 29.7% of patients. ISR was more frequent within the anterior circulation than the posterior circulation. Although typically asymptomatic (76% of patients in our series), ISR can cause neurological symptoms and may require target vessel revascularization.

Abstract 1122‐000218: Flow Reversal After Stent Diversion Causes In‐Stent Thrombosis and Anemia‐Driven Ischemia

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Adam R Blanden ◽  
Karan Philip ◽  
Hesham E Masoud
Keyword(s):  
Flow Reversal ◽  
Attractive Alternative ◽  
Anterior Circulation ◽  
Stent Deployment ◽  
Doppler Study ◽  
Risk Of Rupture ◽  
Flow Through ◽  
Carotid Aneurysms ◽  
Flow Diverting Stent

Introduction : Large symptomatic ICA aneurysms are rare, but present a life threatening risk of rupture that increases with size, female sex, and age >50 at the time of diagnosis, among other risk factors. Historically, large carotid aneurysms have been treated with intentional carotid sacrifice, requiring recruitment of contralateral, posterior, and ECA‐supplied collaterals to provide flow to the anterior circulation previously supplied by the sacrificed ICA, lest the patient experience an iatrogenic stroke. While still a viable option in some cases, flow diverting stents provide an attractive alternative to vessel sacrifice. By providing a channel for blood to bypass the aneurysm, the stent can effectively exclude the aneurism from active circulation while preserving a path for blood to travel to the anterior cerebral circulation it currently provides. Methods : Here, we present a case of a 1.3 cm symptomatic left cavernous ICA aneurysm treated with such a flow diverting stent. Results : The patient presented to the emergency department with left sided ptosis. CTA head and neck revealed the 1.3 cm left sided cavernous ICA aneurysm. She was treated endovascularly under general anesthesia with continuous intra‐operative monitoring. The procedure was complicated by iatrogenic flow reversal through the Circle of Willis at the time of stent deployment and resultant in situ thrombosis of the stent without alteration in electrical signals recorded at the scalp – thus creating a de facto carotid sacrifice without intra‐operative complication. Follow up doppler study revealed a loss of flow through the left ICA and reversal of flow through the ophthalmic artery on the left side, thus confirming ECA collateral supply to the area. Post‐op course was complicated by extensive bleeding from the scalp electrode sites used for intraoperative monitoring due to hyper‐response to aspirin‐ticagrelor dual‐antiplatelet therapy. This gave rise to a symptomatic anemia that manifested as pressure‐dependent left‐sided circulatory failure on exam – specifically hemiparesis and aphasia. The symptoms ultimately resolved with pressure augmentation, blood transfusion, and supportive care in the Neuro ICU. The patient was successfully transitioned to a general neurology floor with subsequent resolution of the anemia and, correspondingly, the symptoms. Conclusions : The patient was discharged to rehab and at 4‐month follow‐up is again living independently with no residual deficits. This case has significance for pre‐operative anti‐platelet optimization for flow diverting stents, management of post‐operative complications of flow‐diverting stent placement including thrombosis and bleeding, and optimal critical care support for patients with pressure‐dependent ischemia. Specifically, the course of the patient’s symptoms and anemia raise the question of optimal hemoglobin targets in the subset of patients with pressure‐dependent ischemia, and how to best reach those targets.

scholarly journals First-line lesional aspiration in acute stroke thrombectomy using a novel intermediate catheter: Initial experiences with the SOFIA

2016 ◽  
Vol 22 (3) ◽  
pp. 333-339 ◽  
Author(s):  
C Kabbasch ◽  
M Möhlenbruch ◽  
S Stampfl ◽  
A Mpotsaris ◽  
D Behme ◽  
...  
Keyword(s):  
Median Time ◽  
Clinical Status ◽  
Multimodality Treatment ◽  
Published Data ◽  
First Line ◽  
Anterior Circulation ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Clot Aspiration ◽  
Major Stroke

Introduction Five randomized controlled trials (RCTs) on endovascular therapy (EVT) of stroke have proven a clinical benefit over conservative treatment or IV-thrombolysis alone. Lesional clot aspiration with a dedicated system can achieve revascularization without an additional retriever (a direct-aspiration first-pass technique, ADAPT), and the SOFIA has been shown to be both safe and efficacious in a multicentric retrospective study. We have evaluated a subset of these data acquired in two major stroke centers with regard to using the SOFIA for first-line lesional aspiration. Methods Thirty patients with large-vessel occlusions treated with first-line lesional aspiration were identified. Procedural data, clot length, reperfusion success (mTICI), procedural timings, complications, and clinical status at admission, discharge and at 90 days were analyzed. Results The median baseline NIHSS was 16. IV thrombolysis was administered in 15/30 patients. Ninety-three percent of occlusions were in the anterior circulation. TICI ≥ 2b was achieved in 90% of multimodality treatments; lesional aspiration was successful in 67% within a median time of 20 minutes. The highest first-attempt success rate was in MCA occlusions (median time to recanalization 10 minutes). There were no device-related events. Symptomatic intracerebral hemorrhage (sICH) occurred in 10%, but never with sole lesional aspiration. Embolization to new territories was recorded in 1/30 (3%). Median discharge NIHSS was 7; 30% were mRS ≤ 2 at discharge and 43% at 90-day follow-up. Conclusions Lesional aspiration with SOFIA is in line with published data. The SOFIA may be used as a first-line device, aiming at fast recanalization by sole aspiration with good safety and efficacy. If unsuccessful, it converts into part of a stent retriever-based multimodality treatment.

scholarly journals Restenosis after stenting in symptomatic vertebral arterial orifice disease and considerations for better outcome

2017 ◽  
Vol 23 (2) ◽  
pp. 180-185 ◽  
Author(s):  
Jun Young Chang ◽  
Hyun Park ◽  
Oki Kwon ◽  
Moon-Ku Han
Keyword(s):  
Clinical Symptoms ◽  
Bare Metal Stents ◽  
Metal Stents ◽  
Anterior Circulation ◽  
Stent Restenosis ◽  
Vertebrobasilar Ischemia ◽  
Drug Eluting ◽  
The Common ◽  
Revascularization Therapy ◽  
In Stent Restenosis

We have performed stenting in 11 patients with symptomatic vertebral arterial orifice stenosis refractory to medical treatment or impairment in anterior circulation. Three of the 11 patients experienced asymptomatic severe in-stent restenosis or occlusion. Bare metal stents were used in those three patients, two of whom received revascularization therapy. Development of sufficient cervical collateral channels reconstituting the distal vertebral artery was the common feature in patients with asymptomatic in-stent restenosis. In selecting appropriate stents, consideration of mechanical strength and drug-eluting properties of a stent according to characteristics of the target vessel is important to reduce the risk of in-stent restenosis. Any decision to perform revascularization should be based on the presence of abundant cervical collaterals as well as clinical symptoms of vertebrobasilar ischemia.

Drug-coated balloons for the treatment of symptomatic intracranial atherosclerosis: initial experience and follow-up outcome

2018 ◽  
Vol 11 (6) ◽  
pp. 569-573 ◽  
Author(s):  
Ju Han ◽  
Jun Zhang ◽  
Xiao Zhang ◽  
Jinping Zhang ◽  
Yun Song ◽  
...  
Keyword(s):  
De Novo ◽  
Perioperative Complications ◽  
Vascular Imaging ◽  
Atherosclerotic Disease ◽  
Total Occlusion ◽  
Stent Restenosis ◽  
Intracranial Atherosclerotic Disease ◽  
Artery Disease ◽  
Angioplasty And Stenting

BackgroundThe optimal treatment for patients with symptomatic severe intracranial atherosclerotic disease is not well established. Angioplasty and stenting have been attempted, with controversial results, mainly attributed to perioperative complications and a high incidence of restenosis or in-stent restenosis. Drug-coated balloons (DCBs) have shown encouraging results for coronary and peripheral artery disease, without convincing data for intracranial vasculature.ObjectivesTo assess the feasibility, clinical and angiographic outcomes of DCBs for patients with intracranial de novo atherosclerotic disease.MethodsBetween September 2016 and September 2017, details of 30 patients with 31 arteries treated with DCBs for symptomatic severe intracranial atherosclerotic disease (≥70% stenosis or chronic total occlusion) were retrospectively collected in our centre. All lesions were predilated with conventional balloons. Periprocedural complications and clinical and vascular imaging follow-up outcomes were analysed.ResultsAll arteries were successfully dilated with DCBs and 29 (93.5%) arteries achieved good antegrade perfusion, with remedial stenting for two arteries. Two patients presented with new ischemic stroke after the procedure. Over a mean follow-up of 9.8±2.6 months, no patient had recurrent ischemic symptoms. Repeat vascular imaging was performed at 7.0±1.1 months, with cerebral angiography in 24 patients (25 arteries) and MR angiography in six patients (six arteries). Only one (3.2%) artery presented with angiographic asymptomatic restenosis.ConclusionsThis study suggests that DCB dilatation may be a safe and effective alternative for intracranial de novo atherosclerotic disease.

scholarly journals Microsurgical clipping and endovascular flow diversion of ruptured anterior circulation blood blister-like aneurysms

2018 ◽  
Vol 24 (6) ◽  
pp. 615-623 ◽  
Author(s):  
V Hellstern ◽  
M Aguilar-Pérez ◽  
M AlMatter ◽  
P Bhogal ◽  
E Henkes ◽  
...  
Keyword(s):  
Acute Phase ◽  
Clinical Symptoms ◽  
Demographic Data ◽  
Flow Diversion ◽  
Parent Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Microsurgical Clipping ◽  
Safety Margins

Background Detection and treatment of blister-like intracranial aneurysms as a source of subarachnoid hemorrhage (SAH) can be challenging. In the past the results of both microsurgical and endovascular treatment were difficult. We present our experience with the treatment of blister-like aneurysms in the acute phase of SAH using microsurgical clipping, endovascular parent vessel occlusion or flow diversion. Methods A retrospective analysis of the cases of eight consecutive patients presenting in the acute phase after SAH from an intracranial blister aneurysm was performed. The demographic data of the patients, aneurysm characteristics, the clinical results of the treatment and the follow-up examinations were recorded. Procedural safety margins and aneurysm occlusion on follow-up digital subtraction angiography were the main interest of this evaluation. Results Between January 2012 and November 2017 a total of eight ruptured blister aneurysms were treated in our center, six patients endovascularly. Five patients were treated in the acute phase of SAH, four by flow diversion. All endovascular procedures were feasible and no procedure-related complications were observed, especially no recurrent hemorrhage. In the first angiographic follow-up all blood blister-like aneurysms were completely occluded; two of the six patients treated by flow diverter implantation showed mild, transient intimal hyperplasia without clinical symptoms or the need for treatment. Conclusions Endovascular flow diversion is a viable option in the acute phase after SAH due to the rupture of a blister aneurysm. Implants with reduced thrombogenicity, obviating dual-platelet function inhibition, and flow diverters for vessel bifurcations would extend the indications for this treatment modality.

Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience

2021 ◽  
pp. neurintsurg-2021-017818
Author(s):  
Mahmoud H Mohammaden ◽  
Raul G Nogueira ◽  
Wondwossen Tekle ◽  
Santiago Ortega-Gutierrez ◽  
Mudassir Farooqui ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Medical Management ◽  
Randomized Clinical Trials ◽  
Recurrent Stroke ◽  
Atherosclerotic Disease ◽  
Anterior Circulation ◽  
Safety And Efficacy ◽  
Intracranial Atherosclerotic Disease ◽  
Long Term Follow Up

BackgroundRandomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications.ObjectiveTo study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD.MethodsProspectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up.ResultsA total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2–20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3–14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke.ConclusionOur study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.

scholarly journals Stent-Assisted Coil Embolization of Complex Wide-Necked Bifurcation Cerebral Aneurysms Using the “Waffle Cone” Technique

2012 ◽  
Vol 18 (1) ◽  
pp. 20-28 ◽  
Author(s):  
W. Liu ◽  
D.K. Kung ◽  
B. Policeni ◽  
J.D. Rossen ◽  
P.M. Jabbour ◽  
...  
Keyword(s):  
Cerebral Aneurysms ◽  
Aneurysm Rupture ◽  
Published Data ◽  
Catheter Angiography ◽  
Follow Up Study ◽  
Small Series ◽  
Relative Safety ◽  
Aneurysm Occlusion ◽  
Ischemic Attack

Endovascular treatment of complex, wide-necked bifurcation cerebral aneurysms is challenging. Intra/extra-aneurysmal stent placement, the “waffle cone” technique, has the advantage of using a single stent to prevent coil herniation without the need to deliver the stent to the efferent vessel. The published data on the use of this technique is limited. We present our initial and follow-up experience with the waffle cone stent-assisted coiling (SAC) of aneurysms to evaluate the durability of the technique. We retrospectively identified ten consecutive patients who underwent SAC of an aneurysm using the waffle cone technique from July 2009 to March 2011. Clinical and angiographic outcomes after initial treatment and follow-up were evaluated. Raymond Class I or II occlusion of the aneurysm was achieved in all cases with the waffle cone technique. No intraoperative aneurysm rupture was noted. The parent arteries were patent at procedure completion. Clinical follow-up in nine patients (median 12.9 months) revealed no aneurysm rupture. Two patients had a transient embolic ischemic attack at 18 hours and three months after treatment, respectively. Catheter angiography or MRA at six-month follow-up demonstrated persistent occlusions of aneurysms in seven out of eight patients. Another patient had stable aneurysm occlusion at three-month follow-up study. Our experience in the small series suggests the waffle cone technique could be performed on complex, wide-necked aneurysms with relative safety, and it allowed satisfactory occlusions of the aneurysms at six months in most cases.

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