J Cerebrovasc Endovasc Neurosurg.  2013 Jun;15(2):85-95. 10.7461/jcen.2013.15.2.85.

Comparison of Drug-eluting Coronary Stents, Bare Coronary Stents and Self-expanding Stents in Angioplasty of Middle Cerebral Artery Stenoses

• Lee JH
• Jo SM
• Jo KD
• Kim MK
• Lee SY
• You SH

• KMID: 1980434
• DOI: http://doi.org/10.7461/jcen.2013.15.2.85

Abstract

OBJECTIVE
The purpose of this study is to investigate the results of treatment using stent-angioplasty for symptomatic middle cerebral arterial (MCA) stenosis and comparison of in-stent restenosis between drug-eluting stents (DES), bare metal coronary stents (BMS) and self-expanding stents (SES).
MATERIALS AND METHODS
From Jan. 2007 to June. 2012, 34 patients (mean age +/- standard deviation: 62.9 +/- 13.6 years) with MCA stenosis were treated. Inclusion criteria were acute infarction or transient ischemic attacks (TIAs) and angiographically proven symptom related severe stenosis. Stents used for treatment were DES (n = 8), BMS (n = 13) and SES (n = 13). National Institutes of Health Stroke Scale (NIHSS) at admission was 2.5 +/- 3.1 and mean stenosis rate was 79.0 +/- 8.2%. Assessment of clinical and angiographic results was performed retrospectively.
RESULTS
Among 34 patients, periprocedural complications occurred in four cases (11.8%), however, only two cases (6.0%) were symptomatic. All patients were followed clinically (mean follow-up period; 40.7 +/- 17.7 months) and 31 were followed angiographically (91.2%. 13.4 +/- 8.5 months). There was no occurrence of repeat stroke in all patients; however, mild TIAs related to restenosis occurred in three of 34 patients (8.8%). The mean NIHSS after stent-angioplasty was 1.7 +/- 2.9 and 0.8 +/- 1.1 at discharge. The modified Rankin score (mRS) at discharge was 0.5 +/- 0.9 and 0.3 +/- 0.8 at the last clinical follow-up. In-stent restenosis over 50% occurred in five of 31 angiographically followed cases (16.1%), however, all of these events occurred only in patients who were treated with BMS or SES. Restenosis rate was 0.0% in the DES group and 20.8% in the other group (p = 0.562); it did not differ between BMS and SES (2/11 18.2%, 3/13 23.1%, p = 1.000).
CONCLUSION
Stent-angioplasty appears to be effective for symptomatic MCA stenosis. As for restenosis, in our study, DES was presumed to be more effective than BMS and SES; meanwhile, the results did not differ between the BMS and SES groups.

Keyword

Intracranial stenosis; Middle cerebral artery; Restenosis; Stent-angioplasty; Drug-eluting stent; Self-expanding stent

MeSH Terms

Angioplasty
Constriction, Pathologic
Drug-Eluting Stents
Follow-Up Studies
Humans
Infarction
Ischemic Attack, Transient
Middle Cerebral Artery
National Institutes of Health (U.S.)
Stents
Stroke

Figure

• 

  Fig. 1 Catheter angiograms of a 66-year-old male patient who presented with repeated transient ischemic attacks of left arm weakness. (A) Preoperative right internal cerebral artery (ICA) angiogram demonstrates severe stenosis at the right middle cerebral artery (MCA) and flow compromise of the MCA territory. (B) Right MCA was fully recanalized after Wingspan stent (Boston Scientific, Natick, MA, USA) deployment. (C) Follow-up angiogram three months after stent-angioplasty. M1 segment in which stent was implanted is more remodeled than immediately after stent-angioplasty. (D) Follow-up angiogram 13 months after stent-angioplasty. No change is seen when compared with the three month follow-up angiogram.

• 

  Fig. 2 Catheter angiograms of a 68-year-old female patient who presented with MCA borderzone infarct. (A) Preoperative left ICA angiogram demonstrates severe stenosis at M1 segment and definite flow compromise caused by the stenosis. (B) Postoperative angiogram after stent-angioplasty with a drug-eluting coronary stent (Endeavor, Medtronic Vascular, Santa Rosa, CA) shows no residual stenosis and fully recovered MCA flow. (C) One year follow-up angiogram shows no restenosis compared with immediate postoperative angiogram.

• 

  Fig. 3 Catheter angiograms of a 47-year-old male patient who presented with right MCA borderzone infarct. (A) Preoperative right ICA angiogram demonstrates MCA occlusion. (B) Postoperative angiogram after stent-angioplasty with a bare metal coronary stent (Coroflex, B. Braun, DE) shows no residual stenosis and fully recovered MCA flow. (C) Three month follow-up angiogram shows severe in-stent restenosis up to 80% with mild flow compromise. (D) Follow-up angiogram immediately after retreatment (balloon angioplasty) with a drug-eluting balloon (SeQuent® Please, B.Braun, DE) shows fully recovered MCA flow compromise, but insignificant residual stenosis remained. (E) One year follow-up angiogram after retreatment demonstrates a fully dilated M1 segment without any residual stenosis or restenosis.

Reference

1. Abou-Chebl A, Bashir Q, Yadav JS. Drug-eluting stents for the treatment of intracranial atherosclerosis: initial experience and midterm angiographic follow-up. Stroke. 2005; 12. 36(12):e165–e168. PMID: 16282539.

2. Albuquerque FC, Levy EI, Turk AS, Niemann DB, Aagaard-Kienitz B, Pride GL Jr, et al. Angiographic patterns of Wingspan in-stent restenosis. Neurosurgery. 2008; 7. 63(1):23–27. PMID: 18728565.

3. Al Hasan M, Murugan R. Stenting versus aggressive medical therapy for intracranial arterial stenosis: more harm than good. Crit Care. 2012; 5. 16(3):310. PMID: 22574950.

4. Arenillas JF, Molina CA, Montaner J, Abilleira S, González-Sánchez MA, Alvarez-Sabín J. Progression and clinical recurrence of symptomatic middle cerebral artery stenosis: a long-term follow-up transcranial Doppler ultrasound study. Stroke. 2001; 12. 32(12):2898–2904. PMID: 11739993.

5. Bose A, Hartmann M, Henkes H, Liu HM, Teng MM, Szikora I, et al. A novel, self-expanding, nitinol stent in medically refractory intracranial atherosclerotic stenoses: the Wingspan study. Stroke. 2007; 5. 38(5):1531–1537. PMID: 17395864.

6. Boulos AS, Agner C, Deshaies EM. Preliminary evidence supporting the safety of drug-eluting stents in neurovascular disease. Neurol Res. 2005; 27(Suppl 1):S95–S102. PMID: 16197833.

7. Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011; 9. 365(11):993–1003. PMID: 21899409.

8. Derdeyn CP, Fiorella D, Lynn MJ, Barnwell SL, Zaidat OO, Meyers PM, et al. Impact of operator and site experience on outcomes after angioplasty and stenting in the SAMMPRIS trial. J Neurointerv Surg. 2012; 9. 12.

9. De Rochemont Rdu M, Turowski B, Buchkremer M, Sitzer M, Zanella FE, Berkefeld J. Recurrent symptomatic high-grade intracranial stenoses: safety and efficacy of undersized stents-initial experience. Radiology. 2004; 4. 231(1):45–49. PMID: 15068940.

10. De Silva DA, Woon FP, Lee MP, Chen CP, Chang HM, Wong MC. South Asian patients with ischemic stroke: intracranial large arteries are the predominant site of disease. Stroke. 2007; 9. 38(9):2592–2594. PMID: 17656660.

11. Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, et al. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke. 2007; 3. 38(3):881–887. PMID: 17290030.

12. Fiorella D, Levy EI, Turk AS, Albuquerque FC, Pride GL Jr, Woo HH, et al. Target lesion revascularization after wingspan: assessment of safety and durability. Stroke. 2009; 1. 40(1):106–110. PMID: 18927447.

13. Gröschel K, Schnaudigel S, Pilgram SM, Wasser K, Kastrup A. A systematic review on outcome after stenting for intracranial atherosclerosis. Stroke. 2009; 5. 40(5):e340–e347. PMID: 19182081.

14. Henkes H, Miloslavski E, Lowens S, Reinartz J, Liebig T, Kühne D. Treatment of intracranial atherosclerotic stenoses with balloon dilatation and self-expanding stent deployment (Wingspan). Neuroradiology. 2005; 3. 47(3):222–228. PMID: 15912418.

15. Jiang WJ, Du B, Leung TW, Xu XT, Jin M, Dong KH. Symptomatic Intracranial Stenosis: cerebrovascular complications from elective stent placement. Radiology. 2007; 4. 243(1):188–197. PMID: 17392253.

16. Kim JS, You SH, Kim SR, Kim SD, Kim YW, Park IK, et al. Usefulness of drug-eluting stents in angioplasty and stenting of the vertebral artery origin: comparison with bare stents. Korean J Cerebrovasc Surg. 2005; 7(2):135–142.

17. Lee J, Kwon S, Lee JH, Suh DC, Kim JS. Percutaneous transluminal angioplasty for symptomatic middle cerebral artery stenosis: long-term follow-up. Cerebrovasc Dis. 2003; 15(1-2):90–97. PMID: 12499717.

18. Lee JH, Yun JK, Kim DW, Kang SD. Clinical and angiographic outcomes of Wingspan stent placement for treatment of symptomatic intracranial stenosis: single center experience with 19 cases. J Cerebrovasc Endovasc Neurosurg. 2012; 9. 14(3):157–163. PMID: 23210041.

19. Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagard-Kienitz B, Pride L, et al. Wingspan in-stent restenosis and thrombosis: incidence, clinical presentation, and management. Neurosurgery. 2007; 9. 61(3):644–650. discussion 650-1. PMID: 17881980.

20. Marks MP, Marcellus ML, Do HM, Schraedley-Desmond PK, Steinberg GK, Tong DC, et al. Intracranial angioplasty without stenting for symptomatic atherosclerotic stenosis: long-term follow-up. AJNR Am J Neuroradiol. 2005; 3. 26(3):525–530. PMID: 15760860.

21. Marks MP, Marcellus M, Norbash AM, Steinberg GK, Tong D, Albers GW. Outcome of angioplasty for atherosclerotic intracranial stenosis. Stroke. 1999; 5. 30(5):1065–1069. PMID: 10229745.

22. Marks MP, Wojak JC, Al-Ali F, Jayaraman M, Marcellus ML, Connors JJ, et al. Angioplasty for symptomatic intracranial stenosis: clinical outcome. Stroke. 2006; 4. 37(4):1016–1020. PMID: 16497979.

23. Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M, et al. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med. 2002; 6. 346(23):1773–1780. PMID: 12050336.

24. Park S, Lee DG, Chung WJ, Lee DH, Suh DC. Long-term outcomes of drug-eluting stents in symptomatic intracranial stenosis. Neurointervention. 2013; 2. 8(1):9–14. PMID: 23515851.

25. Scheller B, Hehrlein C, Bocksch W, Rutsch W, Haghi D, Dietz U, et al. Two year follow-up after treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. Clin Res Cardiol. 2008; 10. 97(10):773–781. PMID: 18536865.

26. Shin YS, Kim BM, Suh SH, Jeon P, Kim DJ, Kim DI, et al. Wingspan stenting for intracranial atherosclerotic stenosis: clinical outcomes and risk factors for in-stent restenosis. Neurosurgery. 2013; 4. 72(4):596–604. discussion 604. PMID: 23277374.

27. Steinfort B, Ng PP, Faulder K, Harrington T, Grinnell V, Sorby W, et al. Midterm outcomes of paclitaxel-eluting stents for the treatment of intracranial posterior circulation stenoses. J Neurosurg. 2007; 2. 106(2):222–225. PMID: 17410703.

28. Stettler C, Wandel S, Allemann S, Kastrati A, Morice MC, Schömig A, et al. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis. Lancet. 2007; 9. 370(9591):937–948. PMID: 17869634.

29. Stone GW, Ellis SG, Cox DA, Hermiller J, OShaughnessy C, Mann JT, et al. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med. 2004; 1. 350(3):221–231. PMID: 14724301.

30. Tarlov N, Jahan R, Saver JL, Sayre JW, Ali LK, Kim D, et al. Treatment of high risk symptomatic intracranial atherosclerosis with balloon mounted coronary stents and Wingspan stents: single center experience over a 10 year period. J Neurointerv Surg. 2012; 1. 4(1):34–39. PMID: 21990460.

31. The SSYLVIA Study Investigators. Stenting of symptomatic atherosclerotic lesions in the vertebral or intracranial arteries (SSYLVIA): study results. Stroke. 2004; 6. 35(6):1388–1392. PMID: 15105508.

32. Turk AS, Levy EI, Albuquerque FC, Pride GL Jr, Woo H, Welch BG, et al. Influence of patient age and stenosis location on wingspan in-stent restenosis. AJNR Am J Neuroradiol. 2008; 1. 29(1):23–27. PMID: 17989366.

33. Vajda Z, Aguilar M, Göhringer T, Horváth-Rizea D, Bäzner H, Henkes H. Treatment of intracranial athero sclerotic disease with a balloon-expandable paclitaxel eluting stent: procedural safety, efficacy and mid-term patency. Clin Neuroradiol. 2012; 9. 22(3):227–233. PMID: 22252289.

34. Vajda Z, Güthe T, Perez MA, Heuschmid A, Schmid E, Bäzner H, et al. Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons. AJNR Am J Neuroradiol. 2011; Nov-Dec. 32(10):1942–1947. PMID: 21885715.

35. Vajda Z, Güthe T, Perez MA, Kurre W, Schmid E, Bäzner H, et al. Prevention of intracranial in-stent restenoses: predilatation with a drug eluting balloon, followed by the deployment of a self-expanding stent. Cardiovasc Intervent Radiol. 2013; 4. 36(2):346–352. PMID: 22869043.

36. Yoon W, Seo JJ, Cho KH, Kim MK, Kim BC, Park MS, et al. Symptomatic middle cerebral artery stenosis treated with intracranial angioplasty: experience in 32 patients. Radiology. 2005; 11. 237(2):620–626. PMID: 16192322.

37. Zhang L, Huang Q, Zhang Y, Deng B, Liu J, Hong B, et al. A single-center study of Wingspan stents for symptomatic atherosclerotic stenosis of the middle cerebral artery. J Clin Neurosci. 2013; 3. 20(3):362–366. PMID: 23228656.

38. Zhou Y, Yang QW, Xiong HY. Angioplasty with stenting for intracranial atherosclerosis: a systematic review. J Int Med Res. 2012; 2. 40(1):18–27. PMID: 22429342.