Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis

View More View Less
  • 1 Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object. Medically refractory symptomatic vertebrobasilar atherosclerotic disease has a poor prognosis. Studies have shown that longer (≥ 10 mm), eccentric, high-grade (> 70%) stenoses portend increased procedure-related morbidity. The authors reviewed their experience to determine whether a staged procedure consisting of angioplasty followed by delayed (≥ 1 month later) repeated angioplasty and stent placement reduces the morbidity associated with endovascular treatment of symptomatic basilar and/or intracranial vertebral artery (VA) stenoses.

Methods. The authors retrospectively reviewed the medical records in a consecutive series of eight patients who underwent planned stent-assisted angioplasty for medically refractory, symptomatic atherosclerotic disease of the intracranial posterior circulation between February 1999 and January 2002. Staged stent-assisted angioplasty was planned for these patients because the extent and degree of stenosis of the VA and/or basilar artery (BA) lesion portended an excessive procedure-related risk. The degree of stenosis, recent onset of symptoms (unstable plaque), vessel tortuosity, and lesion length and morphological features were contributing factors in determining procedure-related risk. Patient records were analyzed for location and degree of stenosis, preprocedural regimen of antiplatelet and/or anticoagulation agents, devices used, procedure-related complications, and clinical and radiographic outcomes.

Among the patients in whom staged stent-assisted angioplasty was planned, vessel dissection, which necessitated immediate stent placement, occurred during passage of the balloon in one of them. In a second patient, the stent could not be maneuvered through the tortuous VA. In a third patient, the VA and BAs remained widely patent after angioplasty alone, and therefore stent placement was not required. Significant complications among the eight patients included transient aphasia and hemiparesis in one and a groin hematoma that necessitated surgical intervention in another; there was no permanent neurological morbidity. The mean stenosis before treatment was 78%, which fell to 54% after angioplasty, and the mean residual stenosis after stent placement was 30%. At the last follow-up examination, none of the treated patients had further symptoms attributable to the treated stenosis.

Conclusions. The novel combination of initial angioplasty followed by delayed endoluminal stent placement may reduce the neurological morbidity associated with endovascular treatment of long, high-grade stenotic lesions. Attempting to cross high-grade stenoses with higher-profile devices such as stents may result in an embolic shower. Furthermore, neointimal proliferation and scar formation after angioplasty result in a thickened fibrous layer, which may be protective during delayed stent deployment. Larger-scale studies involving multiple centers are needed to elucidate further the lesion morphological characteristics and patient population most likely to benefit from staged procedures.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: L. Nelson Hopkins, M.D., Neurosurgery, University at Buffalo, 3 Gates Circle, Buffalo, New York 14209–1194. email: dzbuffns@aol.com.
  • 1.

    Ahuja A, , Guterman LR, & Hopkins LN: Angioplasty for basilar artery atherosclerosis. Case report. J Neurosurg 77:941944, 1992 Ahuja A, Guterman LR, Hopkins LN: Angioplasty for basilar artery atherosclerosis. Case report. J Neurosurg 77:941–944, 1992

    • Search Google Scholar
    • Export Citation
  • 2.

    Al-Mubarak N, , Gomez CR, & Vitek JJ, et al: Stenting of symptomatic stenosis of the intracranial internal carotid artery. AJNR 19:19491951, 1998 Al-Mubarak N, Gomez CR, Vitek JJ, et al: Stenting of symptomatic stenosis of the intracranial internal carotid artery. AJNR 19:1949–1951, 1998

    • Search Google Scholar
    • Export Citation
  • 3.

    Anderson PG, , Boerth NJ, & Liu M, et al: Cyclic GMP-dependent protein kinase expression in coronary arterial smooth muscle in response to balloon catheter injury. Arterioscler Thromb Vasc Biol 20:21922197, 2000 Anderson PG, Boerth NJ, Liu M, et al: Cyclic GMP-dependent protein kinase expression in coronary arterial smooth muscle in response to balloon catheter injury. Arterioscler Thromb Vasc Biol 20:2192–2197, 2000

    • Search Google Scholar
    • Export Citation
  • 4.

    Anonymous: Prognosis of patients with symptomatic vertebral or basilar artery stenosis. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study Group. Stroke 29:13891392, 1998 Anonymous: Prognosis of patients with symptomatic vertebral or basilar artery stenosis. The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Study Group. Stroke 29:1389–1392, 1998

    • Search Google Scholar
    • Export Citation
  • 5.

    Ausman JI, , Shrontz CE, & Pearce JE, et al: Vertebrobasilar insufficiency. A review. Arch Neurol 42:803808, 1985 Ausman JI, Shrontz CE, Pearce JE, et al: Vertebrobasilar insufficiency. A review. Arch Neurol 42:803–808, 1985

    • Search Google Scholar
    • Export Citation
  • 6.

    Callahan AS III, & Berger BL: Balloon angioplasty of intracranial arteries for stroke prevention. J Neuroimaging 7:232235, 1997 Callahan AS III, Berger BL: Balloon angioplasty of intracranial arteries for stroke prevention. J Neuroimaging 7:232–235, 1997

    • Search Google Scholar
    • Export Citation
  • 7.

    Callahan AS III, , Berger BL, & Beuter MJ, et al: Possible short-term amelioration of basilar plaque by high-dose atorvastatin: use of reductase inhibitors for intracranial plaque stabilization. J Neuroimaging 11:202204, 2001 Callahan AS III, Berger BL, Beuter MJ, et al: Possible short-term amelioration of basilar plaque by high-dose atorvastatin: use of reductase inhibitors for intracranial plaque stabilization. J Neuroimaging 11:202–204, 2001

    • Search Google Scholar
    • Export Citation
  • 8.

    Chimowitz MI, , Kokkinos J, & Strong J, et al: The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 45:14881493, 1995 Chimowitz MI, Kokkinos J, Strong J, et al: The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 45:1488–1493, 1995

    • Search Google Scholar
    • Export Citation
  • 9.

    Connors JJ III, & Wojak JC: Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg 91:415423, 1999 Connors JJ III, Wojak JC: Percutaneous transluminal angioplasty for intracranial atherosclerotic lesions: evolution of technique and short-term results. J Neurosurg 91:415–423, 1999

    • Search Google Scholar
    • Export Citation
  • 10.

    Derdeyn CP, , Cross DT III, & Moran CJ, et al: Reversal of focal misery perfusion after intracranial angioplasty: case report. Neurosurgery 48:436440, 2001 Derdeyn CP, Cross DT III, Moran CJ, et al: Reversal of focal misery perfusion after intracranial angioplasty: case report. Neurosurgery 48:436–440, 2001

    • Search Google Scholar
    • Export Citation
  • 11.

    George CJ, , Baim DS, & Brinker JA, et al: One-year follow-up of the Stent Restenosis (STRESS I) Study. Am J Cardiol 81:860865, 1998 George CJ, Baim DS, Brinker JA, et al: One-year follow-up of the Stent Restenosis (STRESS I) Study. Am J Cardiol 81:860–865, 1998

    • Search Google Scholar
    • Export Citation
  • 12.

    Gomez CR, , Misra VK, & Campbell MS, et al: Elective stenting of symptomatic middle cerebral artery stenosis. AJNR 21:971973, 2000 Gomez CR, Misra VK, Campbell MS, et al: Elective stenting of symptomatic middle cerebral artery stenosis. AJNR 21:971–973, 2000

    • Search Google Scholar
    • Export Citation
  • 13.

    Gomez CR, , Misra VK, & Liu MW, et al: Elective stenting of symptomatic basilar artery stenosis. Stroke 31:9599, 2000 Gomez CR, Misra VK, Liu MW, et al: Elective stenting of symptomatic basilar artery stenosis. Stroke 31:95–99, 2000

    • Search Google Scholar
    • Export Citation
  • 14.

    Grubb RL Jr, & Powers WJ: Risks of stroke and current indications for cerebral revascularization in patients with carotid occlusion. Neurosurg Clin N Am 12:473487, 2001 Grubb RL Jr, Powers WJ: Risks of stroke and current indications for cerebral revascularization in patients with carotid occlusion. Neurosurg Clin N Am 12:473–487, 2001

    • Search Google Scholar
    • Export Citation
  • 15.

    Hopkins LN, & Budny JL: Complications of intracranial bypass for vertebrobasilar insufficiency. J Neurosurg 70:207211, 1989 Hopkins LN, Budny JL: Complications of intracranial bypass for vertebrobasilar insufficiency. J Neurosurg 70:207–211, 1989

    • Search Google Scholar
    • Export Citation
  • 16.

    Hopkins LN, , Budny JL, & Castellani D: Extracranial-intracranial arterial bypass and basilar artery ligation in the treatment of giant basilar artery aneurysms. Neurosurgery 13:189194, 1983 Hopkins LN, Budny JL, Castellani D: Extracranial-intracranial arterial bypass and basilar artery ligation in the treatment of giant basilar artery aneurysms. Neurosurgery 13:189–194, 1983

    • Search Google Scholar
    • Export Citation
  • 17.

    Hopkins LN, , Martin NA, & Hadley MN, et al: Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease. J Neurosurg 66:662674, 1987 Hopkins LN, Martin NA, Hadley MN, et al: Vertebrobasilar insufficiency. Part 2. Microsurgical treatment of intracranial vertebrobasilar disease. J Neurosurg 66:662–674, 1987

    • Search Google Scholar
    • Export Citation
  • 18.

    Horowitz MB, , Pride GL, & Graybeal DF, et al: Percutaneous transluminal angioplasty and stenting of midbasilar stenoses: three technical case reports and literature review. Neurosurgery 45:925931, 1999 Horowitz MB, Pride GL, Graybeal DF, et al: Percutaneous transluminal angioplasty and stenting of midbasilar stenoses: three technical case reports and literature review. Neurosurgery 45:925–931, 1999

    • Search Google Scholar
    • Export Citation
  • 19.

    Houdart E, , Ricolfi F, & Brugieres P, et al: Percutaneous transluminal angioplasty of atherosclerotic basilar artery stenosis. Neuroradiology 38:383385, 1996 Houdart E, Ricolfi F, Brugieres P, et al: Percutaneous transluminal angioplasty of atherosclerotic basilar artery stenosis. Neuroradiology 38:383–385, 1996

    • Search Google Scholar
    • Export Citation
  • 20.

    Huang P, , Levin T, & Kabour A, et al: Acute and late outcome after use of 2.5-mm intracoronary stents in small (< 2.5 mm) coronary arteries. Catheter Cardiovasc Interv 49:121126, 2000 Huang P, Levin T, Kabour A, et al: Acute and late outcome after use of 2.5-mm intracoronary stents in small (< 2.5 mm) coronary arteries. Catheter Cardiovasc Interv 49:121–126, 2000

    • Search Google Scholar
    • Export Citation
  • 21.

    Kapadia SR, , Bajzer CT, & Ziada KM, et al: Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy. Stroke 32:23282332, 2001 Kapadia SR, Bajzer CT, Ziada KM, et al: Initial experience of platelet glycoprotein IIb/IIIa inhibition with abciximab during carotid stenting: a safe and effective adjunctive therapy. Stroke 32:2328–2332, 2001

    • Search Google Scholar
    • Export Citation
  • 22.

    Lanzino G, , Fessler RD, & Miletich RS, et al: Angioplasty and stenting of basilar artery stenosis: technical case report. Neurosurgery 45:404408, 1999 Lanzino G, Fessler RD, Miletich RS, et al: Angioplasty and stenting of basilar artery stenosis: technical case report. Neurosurgery 45:404–408, 1999

    • Search Google Scholar
    • Export Citation
  • 23.

    Lanzino G, , Mericle RA, & Lopes DK, et al: Percutaneous transluminal angioplasty and stent placement for recurrent carotid artery stenosis. J Neurosurg 90:688694, 1999 Lanzino G, Mericle RA, Lopes DK, et al: Percutaneous transluminal angioplasty and stent placement for recurrent carotid artery stenosis. J Neurosurg 90:688–694, 1999

    • Search Google Scholar
    • Export Citation
  • 24.

    Levy EI, , Horowitz MB, & Koebbe CJ, et al: Transluminal stent-assisted angioplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results. Neurosurgery 48:12151223, 2001 Levy EI, Horowitz MB, Koebbe CJ, et al: Transluminal stent-assisted angioplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results. Neurosurgery 48:1215–1223, 2001

    • Search Google Scholar
    • Export Citation
  • 25.

    Marks MP, , Marcellus M, & Norbash AM, et al: Outcome of angioplasty for atherosclerotic intracranial stenosis. Stroke 30:10651069, 1999 Marks MP, Marcellus M, Norbash AM, et al: Outcome of angioplasty for atherosclerotic intracranial stenosis. Stroke 30:1065–1069, 1999

    • Search Google Scholar
    • Export Citation
  • 26.

    Mori T, , Fukuoka M, & Kazita K, et al: Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. AJNR 19:15251533, 1998 Mori T, Fukuoka M, Kazita K, et al: Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. AJNR 19:1525–1533, 1998

    • Search Google Scholar
    • Export Citation
  • 27.

    Mori T, , Kazita K, & Chokyu K, et al: Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR 21:249254, 2000 Mori T, Kazita K, Chokyu K, et al: Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR 21:249–254, 2000

    • Search Google Scholar
    • Export Citation
  • 28.

    Mori T, , Kazita K, & Mori K: Cerebral angioplasty and stenting for intracranial vertebral atherosclerotic stenosis. AJNR 20:787789, 1999 Mori T, Kazita K, Mori K: Cerebral angioplasty and stenting for intracranial vertebral atherosclerotic stenosis. AJNR 20:787–789, 1999

    • Search Google Scholar
    • Export Citation
  • 29.

    Mori T, , Mori K, & Fukuoka M, et al: Percutaneous transluminal cerebral angioplasty: serial angiographic follow-up after successful dilatation. Neuroradiology 39:111116, 1997 Mori T, Mori K, Fukuoka M, et al: Percutaneous transluminal cerebral angioplasty: serial angiographic follow-up after successful dilatation. Neuroradiology 39:111–116, 1997

    • Search Google Scholar
    • Export Citation
  • 30.

    Morice MC, , Bradai R, & Lefevre T, et al: Stenting small coronary arteries. J Invasive Cardiol 11:337340, 1999 Morice MC, Bradai R, Lefevre T, et al: Stenting small coronary arteries. J Invasive Cardiol 11:337–340, 1999

    • Search Google Scholar
    • Export Citation
  • 31.

    Nahser HC, , Henkes H, & Weber W, et al: Intracranial vertebrobasilar stenosis: angioplasty and follow-up. AJNR 21:12931301, 2000 Nahser HC, Henkes H, Weber W, et al: Intracranial vertebrobasilar stenosis: angioplasty and follow-up. AJNR 21:1293–1301, 2000

    • Search Google Scholar
    • Export Citation
  • 32.

    Rasmussen PA, , Perl J II, & Barr JD, et al: Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: an initial experience. J Neurosurg 92:771778, 2000 Rasmussen PA, Perl J II, Barr JD, et al: Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: an initial experience. J Neurosurg 92:771–778, 2000

    • Search Google Scholar
    • Export Citation
  • 33.

    Schneiderman J, , Morag B, & Gerniak A, et al: Abciximab in carotid stenting for postsurgical carotid restenosis: intermediate results. J Endovasc Ther 7:263272, 2000 Schneiderman J, Morag B, Gerniak A, et al: Abciximab in carotid stenting for postsurgical carotid restenosis: intermediate results. J Endovasc Ther 7:263–272, 2000

    • Search Google Scholar
    • Export Citation
  • 34.

    Schwartz SM, , deBlois D, & O'Brien ER: The intima. Soil for atherosclerosis and restenosis. Circ Res 77:445465, 1995 Schwartz SM, deBlois D, O'Brien ER: The intima. Soil for atherosclerosis and restenosis. Circ Res 77:445–465, 1995

    • Search Google Scholar
    • Export Citation
  • 35.

    Sousa JE, , Costa MA, & Abizaid A, et al: Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 103:192195, 2001 Sousa JE, Costa MA, Abizaid A, et al: Lack of neointimal proliferation after implantation of sirolimus-coated stents in human coronary arteries: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 103:192–195, 2001

    • Search Google Scholar
    • Export Citation
  • 36.

    Stary HC, , Chandler AB, & Dinsmore RE, et al: A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 92:13551374, 1995 Stary HC, Chandler AB, Dinsmore RE, et al: A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association. Circulation 92:1355–1374, 1995

    • Search Google Scholar
    • Export Citation
  • 37.

    Sundt TM Jr, , Smith HC, & Campbell JK, et al: Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc 55:673680, 1980 Sundt TM Jr, Smith HC, Campbell JK, et al: Transluminal angioplasty for basilar artery stenosis. Mayo Clin Proc 55:673–680, 1980

    • Search Google Scholar
    • Export Citation
  • 38.

    Takis C, , Kwan ES, & Pessin MS, et al: Intracranial angioplasty: experience and complications. AJNR 18:16611668, 1997 Takis C, Kwan ES, Pessin MS, et al: Intracranial angioplasty: experience and complications. AJNR 18:1661–1668, 1997

    • Search Google Scholar
    • Export Citation
  • 39.

    Tanaka H, , Sukhova GK, & Swanson SJ, et al: Sustained activation of vascular cells and leukocytes in the rabbit aorta after balloon injury. Circulation 88:17881803, 1993 Tanaka H, Sukhova GK, Swanson SJ, et al: Sustained activation of vascular cells and leukocytes in the rabbit aorta after balloon injury. Circulation 88:1788–1803, 1993

    • Search Google Scholar
    • Export Citation
  • 40.

    Terada T, , Higashida RT, & Halbach VV, et al: Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries. J Neurol Neurosurg Psychiatry 60:377381, 1996 Terada T, Higashida RT, Halbach VV, et al: Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries. J Neurol Neurosurg Psychiatry 60:377–381, 1996

    • Search Google Scholar
    • Export Citation
  • 41.

    Terada T, , Nakai E, & Tsuura M, et al: Combined surgery and endovascular stenting for basilar artery stenosis refractory to balloon angioplasty: technical case report. Acta Neurochir 143:511516, 2001 Terada T, Nakai E, Tsuura M, et al: Combined surgery and endovascular stenting for basilar artery stenosis refractory to balloon angioplasty: technical case report. Acta Neurochir 143:511–516, 2001

    • Search Google Scholar
    • Export Citation
  • 42.

    Thijs VN, & Albers GW: Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 55:490497, 2000 Thijs VN, Albers GW: Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 55:490–497, 2000

    • Search Google Scholar
    • Export Citation
  • 43.

    Uchiyama N, , Kida S, & Watanabe T, et al: Improved cerebral perfusion and metabolism after stenting for basilar artery stenosis: technical case report. Neurosurgery 48:13861392, 2001 Uchiyama N, Kida S, Watanabe T, et al: Improved cerebral perfusion and metabolism after stenting for basilar artery stenosis: technical case report. Neurosurgery 48:1386–1392, 2001

    • Search Google Scholar
    • Export Citation
  • 44.

    Wainwright CL, , Miller AM, & Wadsworth RM: Inflammation as a key event in the development of neointima following vascular balloon injury. Clin Exp Pharmacol Physiol 28:891895, 2001 Wainwright CL, Miller AM, Wadsworth RM: Inflammation as a key event in the development of neointima following vascular balloon injury. Clin Exp Pharmacol Physiol 28:891–895, 2001

    • Search Google Scholar
    • Export Citation
  • 45.

    Yokote H, , Terada T, & Ryujin K, et al: Percutaneous transluminal angioplasty for intracranial arteriosclerotic lesions. Neuroradiology 40:590596, 1998 Yokote H, Terada T, Ryujin K, et al: Percutaneous transluminal angioplasty for intracranial arteriosclerotic lesions. Neuroradiology 40:590–596, 1998

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 564 188 20
Full Text Views 145 4 1
PDF Downloads 83 2 0
EPUB Downloads 0 0 0