Basilar artery stenosis: Technical tips for endovascular revascularization

The SAMMPRIS Trial concluded that medical treatment of intracranial stenosis was safer than intracranial stenting. The key reasons for a poor outcome with stenting were significantly more perioperative ischemic strokes and higher rates of intracerebral hemorrhages. To the contrary, WEAVE trial showed significantly lower morbidity and mortality when stenting was performed one week following the ictus. We describe the technical approach for safe basilar artery stenting through radial approach. A middle aged male presented with recurrent posterior circulation symptoms despite being on dual antiplatelet therapy. A right radial approach was undertaken. A 5f radial sheath was exchanged for an AXS infinity LS (Stryker Neurovascular, Ireland) 6 f sheath after priming the radial artery. Using a quadri-axial approach, 0.014' Traxcess microwire (Microvention Inc, Tustin, USA), 0.017' Echelon microcatheter (Microtherapeutics.inc. Ev3 Neurovascular, USA), 0.038 DAC (Stryker Neurovascular USA) & 5F Navien (Microtherapeutics.inc. Ev3 USA), the Infinity sheath was taken into the V2 segment of the right vertebral artery. The 5F Navien (tri-axial approach) was taken upto the distal V4 segment of the vertebral artery. The 3d rotational angiography directed runs revealed > 95 % stenosis of mid basilar segment. No significant ostial stenosis of side branch was noted and in view of long segment plaque angioplasty followed by deployment of self-expanding stent was planned. The microcatheter (0.017') and microwire (Traxcess 0.014') was navigated across the stenosis. Thereafter, an exchange maneuver was performed to allow for sequential slow balloon angioplasty with 1.5 mm × 15 (Maverick, Boston Scientific) and 2.5 mm× 15 (Trek, Abbott costa rica) coronary balloon. Following that a CREDO 4 × 20 mm stent (Acandis GmbH., Pforzheim Germany) was deployed across the stenosis. All exchange maneuvers were performed under biplane fluoroscopy and microwire was kept under watch. The patient was on aspirin and clopidogrel and activated clotting time was maintained around 250 s throughout the procedure. A closure device was applied post procedure. Blood pressure was monitored in neurointensive care unit and patient was discharged on the third day following procedure. Right radial approach, distal position of the sheath, distal position of the guiding catheter, careful analysis of the 3d rotational angiography for risk of side branch occlusion, biplane fluoroscopy during exchanges and slow angioplasty were the key safety checks during procedure.