The Use of Aspiration Catheter Systems for Embolic Protection during Intracranial Vertebral Artery Angioplasty and Stenting

Abstract

Background: Posterior circulation strokes comprise approximately 20-25% of all strokes of ischemic origin. Strokes affecting this area carry a significantly higher risk for subsequent stroke or death as compared to anterior circulation strokes. Embolic protection device (EPD) use for carotid artery stenosis has translated into percutaneous interventions of proximal vertebral artery (VA) stenosis. However, the use of EPDs when treating intracranial lesions has yet to be studied and may not be feasible as the vessel caliber is frequently smaller than in existing devices. Objective: The aim of this study is to describe a proximal aspiration technique used during the treatment of intracranial VA and basilar artery (BA) atherosclerotic disease. Methods: Proximal embolic protection was utilized during the treatment of intracranial VA/BA stenosis with angioplasty and stenting in patients with medically refractory disease. Results: Three patients with severe symptomatic posterior circulation stenosis refractory to medical management were treated with angioplasty and stenting utilizing proximal aspiration. Pre- and post-treatment angiograms and MRIs were compared. Treated vascular stenoses were significantly improved, without new neurological deficits or ischemic injury identified on imaging. Conclusions: The proposed technique of proximal embolic protection may help overcome the challenge of embolus propagation inherent to the treatment modality that was encountered during the treatment of intracranial VA/BA stenosis.

Successful Endovascular Bailout Strategy for Retained Accunet Embolic Protection Device During Vertebral Artery Stenting

“…Additionally, diffusion weighted imaging at 42 h post-stenting showed two hyperintense lesions in two patients (3.3%) with EPD use vs. 15 lesions in 13 patients (18.6%) without EPD use ( p < 0.01) ( 5 ). Similar results and technical success of EPD use in VA stenting have been shown in multiple studies ( 6 , 9 , 14 , 15 ).…”

“…Posterior circulation strokes comprise up to 20–25% of all ischemic strokes, with an associated mortality rate as high as 30% ( 5 , 6 ). It is estimated that ~20% of these cases involve atherosclerosis of the VA, frequently occurring proximally as it arises from the subclavian artery ( 7 ).…”

“…Cremonesi et al demonstrated successful EPD use in 440 of 442 patients who underwent carotid artery stenting with no peri-procedural deaths reported and an overall complication rate of 3.4% ( 13 ). EPD use in VA stenosis is less reported given the tortuosity and smaller vessel caliber, thus making EPD use in the VA technically challenging in comparison to its use in the carotid artery ( 6 , 14 ). However, the potential benefit of preventing intraoperative embolization and devastating posterior circulation stroke still exists ( 6 ).…”

“…EPD use in VA stenosis is less reported given the tortuosity and smaller vessel caliber, thus making EPD use in the VA technically challenging in comparison to its use in the carotid artery ( 6 , 14 ). However, the potential benefit of preventing intraoperative embolization and devastating posterior circulation stroke still exists ( 6 ). Geng et al compared the clinical outcomes of stent placement with and without EPD use for the treatment of symptomatic atherosclerotic VA ostial stenosis in 127 patients.…”

Use of Embolic Protection Devices in Peripheral Interventions

“…Vertebrobasilar circulation strokes compromise approximately 20-25 % of all ischaemic strokes. 6 Strokes affecting the posterior circulation carry a higher risk of recurrent stroke and death as compared with anterior circulation strokes, especially during the first seven days following a stroke or transient ischaemic attack (TIA). 7 The five-year risk of subsequent stroke, after a vertebrobasilar stroke or TIA, has been reported to be 22 %.…”