Drug-Eluting Stents for the Treatment of Intracranial Atherosclerosis

Abstract

Background and Purpose-Intracranial stenting is associated with a 32% rate of restenosis. Drug-eluting stents (DES) have revolutionized the treatment of coronary artery disease and have greatly reduced the risk of in-stent stenosis. We present our experience with the feasibility and safety of using DES for patients with symptomatic intracranial atherosclerosis. Methods-All of the patients had Ͼ70% stenoses and had failed maximal medical therapy. They were pretreated with aspirin, clopidogrel, and intraprocedural heparin. All of the lesions were predilated, and balloons and stents were slightly undersized. Clopidogrel and aspirin were continued for 1 year, and patients had clinical follow-up and vascular imaging at 30 days, 6 months, and 1 year. Results-Eight patients with intracranial internal carotid artery (3), middle cerebral (2), basilar (2), and vertebral artery (1) stenoses were successfully treated with 4 Cypher (Cordis Corp) and 4 Taxus (Boston Scientific Inc) stents. The mean stenosis severity was reduced from 84.4%Ϯ10.2% to 2.5%Ϯ4.6%. One patient had an intraprocedural retinal embolism, but there were no other complications. Over a mean follow-up of 11.1Ϯ4.9 months (range, 2 to 17.3 months), patients have had repeat angiography (5)

Durability of Endovascular Therapy for Symptomatic Intracranial Atherosclerosis

“…However, this situation (symptomatic restenosis after angioplasty) represented a low proportion of target-vessel revascularizations (2.9% in our series) and has to be balanced with the difficulties in stent delivery, which was not possible in 10% of the procedures that included coronary equipment. Although DESs have been reported to be safe and effective with minimal restenosis rates, [12][13][14] data from the literature on coronary cases suggest that stent thrombosis with DESs may occur very late during follow-up, when many patients have discontinued their antiplatelet therapy. 15 These findings suggest a potential concern with the widespread use of DESs in the intracranial vasculature.…”

Local Paclitaxel Delivery for Treatment of Peripheral Arterial Disease

“…[17][18][19][20][21][22][23][24][25] These studies were not randomized and did not have control groups for comparison. For vertebral interventions, reported procedural success rates exceed 95%, with only 3% of subjects having periprocedural complications.…”

Reporting Standards for Angioplasty and Stent-Assisted Angioplasty for Intracranial Atherosclerosis

“…Angioplasty or stent-assisted angioplasty of cerebral arteries has been performed successfully under general anesthesia 2,54,59,61,70,83,84,87,113,129 or local anesthesia. 2,60,61,83,91,96,97,114,119,131,132 General anesthesia has the advantage of maximal reduction of motion artifacts. Procedure times may be reduced using general anesthesia.…”

“…The postangioplasty stenosis grade defining technical success varies from Յ20% residual stenosis, 70 Յ30% residual stenosis, 96 but most commonly Յ50% residual stenosis. 2,54,58,60,68,94,119 Most importantly, technical success should be heralded by freedom from ipsilateral ischemic or hemorrhagic strokes in the distribution of the treated target stenosis.…”