Multiple predictors of in-stent restenosis after stent implantation in symptomatic intracranial atherosclerotic stenosis

Abstract

OBJECTIVE This study aimed to identify predictors of intracranial in-stent restenosis (ISR) after stent placement in symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS The authors retrospectively collected data from consecutive patients who suffered from symptomatic ICAS and underwent successful stent placement in Beijing Tiantan hospital. Eligible patients were classified into “ISR,” “indeterminate ISR,” or “no-ISR” groups by follow-up digital subtraction angiography or CT angiography. A multivariate logistic regression model was used to explore the predictors of intracranial ISR after adjustments for age and sex. In addition, ISR and no-ISR patients were divided into two groups based on the strongest predictor, and the incidence of ISR, recurrent stroke, and symptomatic ISR was compared between the two groups. RESULTS A total of 511 eligible patients were included in the study: 80 ISR, 232 indeterminate ISR, and 199 no-ISR patients. Elevated high-sensitivity C-reactive protein (hs-CRP; odds ratio [OR] 4.747, 95% confidence interval [CI] 2.253–10.01, p < 0.001), Mori type B and C (Mori type B vs Mori type A, OR 3.119, 95% CI 1.093–8.896, p = 0.033; Mori type C vs Mori type A, OR 4.780, 95% CI 1.244–18.37, p = 0.023), coronary artery disease (CAD; OR 2.721, 95% CI 1.192–6.212, p = 0.017), neutrophil/lymphocyte ratio (NLR; OR 1.474 95% CI 1.064–2.042, p = 0.020), residual stenosis (OR 1.050, 95% CI 1.022–1.080, p = 0.001) and concurrent intracranial tandem stenosis (OR 2.276, 95% CI 1.039–4.986, p = 0.040) synergistically contributed to the occurrence of intracranial ISR. Elevated hs-CRP (hs-CRP ≥ 3 mg/L) was the strongest predictor for ISR, and the incidence of ISR in the elevated hs-CRP group and normal hs-CRP group (hs-CRP < 3 mg/L) was 57.14% versus 21.52%, respectively, with recurrent stroke 44.64% versus 16.59%, and symptomatic ISR 41.07% versus 8.52%. CONCLUSIONS Elevated hs-CRP level, NLR, residual stenosis, Mori type B and C, CAD, and concurrent intracranial tandem stenosis are the main predictors of intracranial ISR, and elevated hs-CRP is crucially associated with recurrent stroke in patients with symptomatic ICAS after intracranial stent implantation.

Correspondence on “Comparison of drug-coated balloon with conventional balloon for angioplasty in symptomatic intracranial atherosclerotic stenosis” by Tanget al

“…On the other hand, the rate of remedial stent implantation in this study was lower than that in our previous studies 3 4. As we know, elastic recoil after balloon dilation (DCB or CB) is more obvious than after stent, so the residual stenosis might be higher after only balloon dilation, which is also a significant marker of long-term restenosis 5. Therefore, remedial stent implantation might be a reasonable choice for those with obvious residual stenosis.…”

Peri-therapeutic multi-modal hemodynamic assessment and detection of predictors for symptomatic in-stent restenosis after percutaneous transluminal angioplasty and stenting

“…Previous studies had made some efforts to explore the risk factors for ISR and sISR, however, no definite consensus was reached. Some reported that increased residual stenosis independently predicted recurrent stroke ( 10 , 38 , 39 ). Conversely, a meta-analysis showed a close relationship between lower residual stenosis and higher incidence of sISR, which might be true because lower residual stenosis implied greater arterial and endothelial injury that promoted inflammation and plaque progression thus simulating ISR ( 40 ).…”

“…In-stent restenosis (ISR) after PTAS was associated with almost 80% of postprocedural ischemic stroke events ( 10 ). The 1-, 2-, and 3-year rate for symptomatic ISR (sISR) in the SAMMPRIS trial (Stenting and Aggressive Medical Management for the Prevention of Recurrent Stroke in Intracranial Stenosis) were 9.6, 11.3, and 14.0%, respectively, ( 11 ) and 10.9% in the US Wingspan Registry trial ( 9 ).…”

Joint High Level of Oxidized Low‐Density Lipoprotein and High‐Sensitivity C‐Reactive Protein are Associated With Recurrent Stroke and Poor Functional Outcome in Minor Stroke or Transient Ischemic Attack

“…Previous studies have found that elevated oxLDL has been associated with increased plaque instability in patients undergoing carotid endarterectomy 22 and high levels of hs‐CRP have also been proved to be significantly associated with stroke recurrence in patients with symptomatic intracranial atherosclerotic stenosis after intracranial stent implantation. 23 In addition, endothelial dysfunction is the first step in the development of an atherosclerotic plaque and local inflammation. 24 OxLDL and hs‐CRP can also affect the clinical outcome of stroke by damaging endothelial cells.…”