J Korean Neurosurg Soc.  2019 Sep;62(5):536-544. 10.3340/jkns.2019.0087.

Long Term Outcome of In-Stent Stenosis after Stent Assisted Coil Embolization for Cerebral Aneurysm

• Kim SJ
• Kim YJ
• Ko JH

• KMID: 2457943
• DOI: http://doi.org/10.3340/jkns.2019.0087

Abstract

OBJECTIVE
The objective of this study was to evaluatelong-term radiologic prognosis and characteristics of in-stent stenosis (ISS) after stent assisted coiling (SAC) for cerebral aneurysm and analyze its risk factors.
METHODS
Radiological records of 362 cases of SAC during 10 years were retrospectively reviewed. Patients were included in this study if they had follow-up angiogram using catheter selected angiography at least twice. All subjected were followed up from 12 months to over 30 months. Of 120 patients, 123 aneurysms were enrolled. Patient data including age, sex, aneurysm size, neck size, procedural complication, kinds of stent, ISS associated symptom, ruptured state, location of ISS, degree of ISS, radiologic prognosis of ISS, follow-up period of time, and medical comorbidities such as hypertension, diabetes mellitus (DM), dyslipidemia, and smoking were collected.Statistical comparisons of group clinical characteristics were conducted for the total population.
RESULTS
Among 123 casesof aneurysm, 22 cases (17.9%) of ISS were revealed on follow-up angiography. Multiple stenting was performed in three cases and intra-procedural rupture occurred in two cases. Most cases were asymptomatic and symptomatic stenosis was identified in only one case. Sixteen cases were ruptured aneurysm. Mild stenosis was observed in 11 cases. Moderate stenosis was found in eight cases and severe stenosis was identified in three cases. Mean timing of identification of ISS was 8.90 months. The most common type was proximal type. Most cases were improved or not changed on follow-up angiography. Only one case was aggravated from mild stenosis to occlusion of parent artery. Mean follow-up period was 44.3 months. We compared risk factors and characteristic between ISS group and non-ISS group using univariate analysis. Multiple stenting was performed for three cases (13.6%) of the ISS group and four cases (4.0%) of the non-ISS group, showing no statistical difference between the two groups (p=0.108). Additionally, the proportion of patients who had more than two risk factors among four medical risk factors (hypertension, DM, dyslipidemia, and smoking) was higher in the ISS group than that in the non-ISS group, the difference between the two was not statistically significant either (31.8% vs. 12.9%, p=0.05).
CONCLUSION
Clinical course and long-term prognosis of ISS might be benign. Most cases of ISS could be improved or not aggravated. Control of medical co-morbidity might be important. To the best of our knowledge, our study had more cases with longer follow-up period of time than other reports.

Keyword

Intracranial aneurysm; Stents; Long term adverse effects; Risk factors

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Angiography
Arteries
Catheters
Comorbidity
Constriction, Pathologic*
Diabetes Mellitus
Dyslipidemias
Embolization, Therapeutic*
Follow-Up Studies
Humans
Hypertension
Intracranial Aneurysm*
Long Term Adverse Effects
Neck
Parents
Prognosis
Retrospective Studies
Risk Factors
Rupture
Smoke
Smoking
Stents*
Smoke

Figure

• 

  Fig. 1. Aggravated case of ISS (Case 15). A : Immediate post-embolization angiography shows nearly completely occluded aneurysm without any lesion around the stent. B : Mild ISS in the proximal portion of stent is revealed on follow-up angiography 6 months later. C : Post-embolization 12-month angiography shows an occlusion of middle cerebral artery from the portion of ISS. ISS : in-stent stenosis.

• 

  Fig. 2. Improved cases of ISS (Case 17). A : Well-occluded aneurysm without in-stent complication is seen on immediate post-embolization angiography. B : Angiography shows severe ISS (>50%, white arrowheads) in the proximal portion of the implanted stent. C : A recovery from severe to mild stenosis (black arrowheads) is identified on follow-up angiography at 28 months post embolization. ISS : in-stent stenosis.

Reference

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