Transient in-stent stenosis: a common finding after flow diverter implantation

Mühl-Benninghaus, Ruben; Haußmann, Alena; Simgen, Andreas; Tomori, Toshiki; Reith, Wolfgang; Yılmaz, Ümüt

doi:10.1136/neurintsurg-2018-013975

Cited by 27 publications

(22 citation statements)

References 24 publications

(10 reference statements)

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“…Reviewing the literature, we found a number of studies reporting occurrences of comparable stent-related, segmental vasospasms in a variety of extra-cranial arteries [16,17,18], as well as cerebral vessels [10,11,19,20,21,22,23,24]. Considering those reports and our findings in the context of recent studies reporting the yet unexplainably high incidence of delayed type, non-procedure-associated ischemic lesions after flow diverter implantation [4,5], we postulate that device-induced segmental vasospasm plays a significant role in the genesis of these lesions.…”

Section: Discussionmentioning

confidence: 99%

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Schob

Richter

Scherlach

et al. 2019

JCM

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Flow diversion (FD) is a novel endovascular technique based on the profound alteration of cerebrovascular hemodynamics, which emerged as a promising minimally invasive therapy for intracranial aneurysms. However, delayed post-procedural stroke remains an unexplained concern. A consistent follow-up-regimen has not yet been defined, but is required urgently to clarify the underlying cause of delayed ischemia. In the last two years, 223 patients were treated with six different FD devices in our center. We identified subacute, FD-induced segmental vasospasm (SV) in 36 patients as a yet unknown, delayed-type reaction potentially compromising brain perfusion to a critical level. Furthermore, 86% of all patients revealed significant SV approximately four weeks after treatment. In addition, 56% had SV with 25% stenosis, and 80% had additional neointimal hyperplasia. Only 13% exhibited SV-related high-grade stenosis. One of those suffered stroke due to prolonged SV, requiring neurocritical care and repeated intra-arterial (i.a.) biochemical angioplasty for seven days to prevent territorial infarction. Five patients suffered newly manifested, transient hemicrania accompanying a compensatorily increased ipsilateral leptomeningeal perfusion. One treated vessel obliterated permanently. Hence, FD-induced SV is a frequent vascular reaction after FD treatment, potentially causing symptomatic ischemia or even stroke, approximately one month post procedure. A specifically early follow-up-strategy must be applied to identify patients at risk for ischemia, requiring intensified monitoring and potentially anti-vasospastic treatment.

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Section: Discussionmentioning

confidence: 99%

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Schob

Richter

Scherlach

et al. 2019

JCM

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“…It is hypothesized to be caused by thrombus development and inflammation leading to endothelialization and followed by late phase smooth muscle cell formation. 6 Cilostazol's mechanism of action and pharmacology may help explain its utility in instent stenosis.…”

Section: Discussionmentioning

confidence: 99%

“…23 The challenge is to determine which patient is at risk of becoming symptomatic from in-stent stenosis and what are the predisposing factors. Fortunately, the natural history of most in-stent stenosis appears to be benign and transient, 6,7 but this conclusion is based on limited data influenced by a small number of case series and likely underreporting. It may be difficult to justify additional endovascular treatment, such as balloon angioplasty, for in-stent stenosis given the potential hemorrhagic complications of treating an already diseased segment compared to the reported natural history, 5 but if cilostazol proves to be a useful adjunct in antiplatelet therapy in flow diversion then only the safety profile of the medication needs to be considered.…”

Section: B a Cmentioning

confidence: 99%

“…3,4 Additionally, instent stenosis has been reported in a number of case reports and case series with relatively high incidence. [5][6][7][8] Alternative antiplatelet options to standard DAPT, including ticagrelor and prasugrel, have been investigated to mitigate the risks of thromboembolic complications in cerebral aneurysms treated with flow diversion. 2 However, cilostazol has not been well studied in this setting.…”

Section: Introductionmentioning

confidence: 99%

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Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel

et al. 2021

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In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.

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“…27 However, with longer follow-up in-stent stenosis might resolve spontaneously, and thus the rate will be lower. 28,29 Limitations of the study The limitations of this study are a relatively small number of patients, and a short follow-up period. However, the results of our preliminary experience of the treatment of complex MCA aneurysms using the TFD are encouraging.…”

Section: In-stent Stenosismentioning

confidence: 95%

Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters

Yang

Luo

et al. 2020

Interv Neuroradiol

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Background The safety and efficacy of the TuBridge flow diverter in treating middle cerebral artery aneurysms remains unknown. In this study, we report our preliminary experience treating complex middle cerebral artery aneurysms using the TuBridge flow diverter. Methods A prospectively maintained database of intracranial aneurysms treated with the TuBridge flow diverter was retrospectively reviewed, and patients with middle cerebral artery aneurysms were included in this study. Demographics, aneurysm features, complications, and clinical and angiographic outcomes were assessed. Evaluation of the angiographic results included occlusion grade of aneurysm (O’Kelly–Marotta grading scale), patency of jailed branch(es), and in-stent stenosis. Results Eight patients with eight middle cerebral artery aneurysms were included in this study. The mean aneurysm size was 11.8 ± 6.8 mm. There were no procedure-related complications and there was no morbidity or mortality at a mean follow-up of 11.3 ± 3.6 months. All patients had follow-up angiograms at a mean of 7.5 ± 4.0 months after surgery. Of the eight patients, there was 1 (12.5%) O’Kelly–Marotta grading scale A, 3 (37.5%) O’Kelly–Marotta grading scale B, 1 (12.5%) O’Kelly–Marotta grading scale C, and 3 (37.5%) O’Kelly–Marotta grading scale D. Of the seven patients with jailed branch, the blood flow of jailed branch was unchanged in 4 (57.1%), decreased in 2 (28.6%), and occluded in 1 (14.3%). In-stent stenosis was mild in 2 (25%) patients and moderate in 1 (12.5%) patient. Conclusion Midterm results suggest that endovascular treatment of middle cerebral artery aneurysms using the TuBridge flow diverter is safe and associated with good outcomes. The TuBridge flow diverter may be an option for complex middle cerebral artery aneurysms that are difficult to treat with either clipping or coiling.

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Transient in-stent stenosis: a common finding after flow diverter implantation

Abstract: In-stent stenosis is a common finding on short term follow-up after the treatment with flow diverters but improves over time.

Cited by 27 publications

References 24 publications

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Delayed Stroke after Aneurysm Treatment with Flow Diverters in Small Cerebral Vessels: A Potentially Critical Complication Caused by Subacute Vasospasm

Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel

Endovascular treatment of complex middle cerebral artery aneurysms using TuBridge flow diverters

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