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Rescue intracranial stenting for acute large vessel occlusion using an Orsiro Mission drug-eluting balloon-mounted
Krishna Amuluru1, Andrew Denardo1, John Scott1
1Division of Interventional Neuroradiology, Ascension St. Vincent Medical Center, Goodman Campbell Brain and Spine, Carmel, Indianapolis, IN, USA.
Insights
Intracranial atherosclerotic disease (ICAD) can complicate large vessel occlusion (LVO) stroke treatment. Balloon-mounted stents (BMS) offer advantages over self-expandable stents (SES) for ICAD, including easier deployment in challenging anatomy.
Area of Science:
- Neuroendovascular surgery
- Cerebrovascular disease
- Interventional neurology
Background:
- Intracranial atherosclerotic disease (ICAD) is a significant cause of ischemic stroke, particularly in certain ethnic populations.
- Large vessel occlusion (LVO) stroke treatment with thrombectomy can be complicated by ICAD, leading to recanalization failure or re-occlusion.
- Current endovascular strategies for ICAD include angioplasty and stenting, with a shift towards balloon-mounted stents (BMS).
Purpose of the Study:
- To describe the successful use of Orsiro Mission balloon-mounted stents (BMS) in two cases of large vessel occlusion (LVO) stroke with immediate re-occlusion due to intracranial atherosclerotic disease (ICAD).
- To highlight the technical considerations and advantages of BMS, such as the Orsiro Mission, in managing complex ICAD cases.
- To contribute to the neurointerventional literature by presenting a novel application of BMS for acute LVO with ICAD.
Main Methods:
- Case report of two patients with LVO stroke secondary to ICAD.
- Interventional treatment involving angioplasty and acute placement of Orsiro Mission balloon-mounted stents (BMS).
- Detailed description of catheter selection and positioning techniques for navigating challenging anatomy with stiff BMS systems.
Main Results:
- Successful deployment of Orsiro Mission BMS in both cases, achieving vessel patency and resolving immediate re-occlusion.
- Demonstrated the brevity of BMS deployment and the effectiveness of specific intermediate catheter techniques.
- The use of BMS facilitated successful reperfusion despite complex intracranial atherosclerotic disease.
Conclusions:
- Balloon-mounted stents (BMS), such as the Orsiro Mission, are effective bailout devices for managing immediate re-occlusion in large vessel occlusion (LVO) stroke patients with intracranial atherosclerotic disease (ICAD).
- Careful selection and positioning of intermediate catheters are crucial for navigating stiff BMS systems in tortuous intracranial vasculature.
- BMS may offer advantages in terms of radial force and potentially lower rates of in-stent restenosis compared to self-expandable stents (SES) in ICAD.
Abstract:
Intracranial atherosclerotic disease (ICAD) is one of the most common causes of acute ischemic stroke and accounts for 33-50% of strokes in Asian, Hispanic, and black populations.(1) In patients with ICAD undergoing thrombectomy for large vessel occlusion (LVO), some may demonstrate obstinate inability of recanalization, immediate re-occlusion of the target vessel, and/or underlying high-grade stenosis preventing adequate perfusion. Bailout endovascular strategies for suspected ICAD include angioplasty and/or acute intracranial stenting with self-expandable stents (SES). Balloon-mounted stents (BMS), such as the Orsiro Mission, are increasingly being used by neurointerventionalists rather than SES given the relative ease of deployment and avoidance of an exchange maneuver to re-cross the lesion after angioplasty. Furthermore, BMS have higher radial force compared to SES, lending to advantageous dilatation.(2) Finally, the use of BMS may be associated with lower rates of in-stent restenosis compared with SES.(2, 3) However, BMS deployment can be technically challenging given the length and stiffness of the systems, especially in patients with tortuous anatomy and/or with distal occlusions. We present two cases of LVO complicated by immediate re-occlusion necessitating acute Orsiro Mission stent placement, which has not been described in the neurointerventional literature. The cases demonstrate the brevity of deployment and the importance of intermediate catheter selection and positioning, which allows easier navigation of the stiff BMS systems.
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