Predictors of Unfavorable Outcome in Intracranial Angioplasty and Stenting in a Single-Center Comparison: Results from the Borgess Medical Center-Intracranial Revascularization Registry

Abstract

BACKGROUND AND PURPOSE:Intracranial angioplasty and stent placement are used to treat intracranial atherosclerotic disease. The 2 interventions have not been directly compared.

Reviving Intracranial Angioplasty and Stenting “SAMMPRIS and beyond”

“…The authors attributed this lower complication rate to decrease in frequency of large dissections at the angioplasty site. The findings were later confirmed in a major case series demonstrating that large dissection following angioplasty was associated with a statistically significant occurrence of stroke in the periprocedural period, and restenosis at follow-up (29). In SAMMPRIS, operators were encouraged to down size the balloon angioplasty by 0.5 mm, but this was not a requirement, nor was the slow inflation axiom.…”

The Technique of Endovascular Intracranial Revascularization

“…As discussed previously in the rationale for technique, we observed early in our experience that excessive or rapid stretching of the vessel and use of a balloon approaching the diameter of the vessel in size lead to intimal damage; intimal damage can lead to acute or subacute thrombosis, occlusion and/or stroke (8–10), and intimal dissection leads to recurrent stenosis (10). The resultant changes in technique have significantly reduced the incidence of complications.…”

“…We attribute these results mainly to the decrease in significant dissection following angioplasty. Dissection has been shown prospectively to be a statistically significant predictor of not only stroke in the periprocedural period but also of restenosis at the follow-up angiogram (10). These facts confirmed our observational impression and affirm our mantra of “avoiding dissection at all costs.”…”

“…In this instance, this was further driven by the belief that complications could outweigh any minor benefit for stroke prevention, later confirmed by SAMMPRIS (4). Observations led to certain conclusions: (a) procedural simplicity fosters procedural success, (b) excessive or rapid stretching of the vessel leads to intimal damage (8), (c) selecting a balloon approaching the size of the vessel more frequently leads to dissection, (d) intimal damage can lead to acute or subacute thrombosis, occlusion and/or stroke (8–10), and (e) intimal dissection leads to recurrent stenosis (10). It was, and is, our belief that the diseased vessel lacks flexibility and is more fragile and brittle.…”

“…Self-control is very important; one way to accomplish this is to very slowly inflate the balloon to <1 atm and/or when the balloon can be barely seen, set the indeflator down, and walk away. Even when stenting is performed, minimizing underlying vessel wall damage is still the goal since intimal damage can cause secondary intimal hyperplasia with resultant restenosis (9, 10). Therefore, we still inflate very slowly but admittedly faster than with angioplasty.…”