Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions
- Department of Radiology and Imaging Sciences, Division of Neurointerventional Radiology, Salt Lake City, Utah, USA
- Ochsner Clinical School, University of Queensland, Brisbane, Australia
- Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
Daniel L. Cooke
Department of Radiology and Biomedical Imaging, Division of Neurointerventional Radiology, University of California San Francisco, San Francisco, California, USA
DOI:10.4103/sni.sni_255_17Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Matthew D. Alexander, Jeffrey M. Rebhun, Steven W. Hetts, Matthew R. Amans, Fabio Settecase, Robert J. Darflinger, Christopher F. Dowd, Van V. Halbach, Randall T. Higashida, Daniel L. Cooke. Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions. 20-Nov-2017;8:284
How to cite this URL: Matthew D. Alexander, Jeffrey M. Rebhun, Steven W. Hetts, Matthew R. Amans, Fabio Settecase, Robert J. Darflinger, Christopher F. Dowd, Van V. Halbach, Randall T. Higashida, Daniel L. Cooke. Technical factors affecting outcomes following endovascular treatment of posterior circulation atherosclerotic lesions. 20-Nov-2017;8:284. Available from: http://surgicalneurologyint.com/surgicalint-articles/technical-factors-affecting-outcomes-following-endovascular-treatment-of-posterior-circulation-atherosclerotic-lesions/
Background:Atherosclerotic disease of the vertebrobasilar system causes significant morbidity and mortality. All lesions require aggressive medical management, but the role of endovascular interventions remains unsettled. This study examines such endovascular interventions for vertebrobasilar atherosclerosis.
Methods:Retrospective review was performed of prospectively maintained procedure logs at three hospitals with comprehensive neurointerventional services. Patients with angiographically-proven stenosis undergoing elective stent placement were selected for analysis of demographic factors, lesion characteristics, and treatment details. Multivariate analysis was performed to evaluate for associations with ischemic stroke, death, and functional status as measured by modified Rankin scale at multiple intervals.
Results:One hundred and twenty-three lesions were treated in 110 patients. A total of 43 (58.1%) lesions caused stroke, while 66 (89.2%) caused transient ischemic attacks (TIAs). Forty lesions (32.5%) were at the vertebral origin; 97 (60.2%) were intracranial. A total of 112 (91.1%) were treated successfully. 4 (3.3%) of 10 (8.1%) procedural complications were symptomatic. Intracranial lesions were associated with death at 1 and 2 years (OR 24.91, P 2 at last contact (OR 12.83, P P = 0.046) and mRS >2 at last contact (OR 0.234, P = 0.018) when angioplasty was performed with a device other than that packaged with the stent.
Conclusion:Endovascular treatment of vertebrobasilar atherosclerosis can be performed safely, particularly for vertebral origin lesions. Higher rates of technical failure and complication may be acceptable for certain intracranial lesions due to their refractory nature and the morbidity caused by such lesions. Treatment should be tailored to features of each individual lesion.
Keywords: Angioplasty, atherosclerosis, ischemic stroke, stenting
Atherosclerosis of the vertebrobasilar system accounts for a significant portion of ischemic strokes. The optimal role for endovascular therapies remains uncertain, particularly with respect to intracranial disease, in light of poorer outcomes of the stenting cohort in the SAMMPRIS trial.[
Under IRB-approved protocols, medical records were retrospectively reviewed by searching prospectively maintained procedure databases at a large academic medical center and two affiliated hospitals, all with high volume comprehensive neurointerventional services. All patients with stenosis of the vertebral or basilar arteries were identified. From this group, patients undergoing elective angioplasty or stent deployment were selected. Patients with luminal narrowing due to disease processes other than atherosclerosis were excluded. Patients in whom an intervention was attempted but unsuccessful were included in an intention to treat analysis.
Information was gathered according to the guidelines of the Standards Committee of the Society for NeuroInterventional Surgery for investigations of endovascular treatment of intracranial atherosclerotic disease.[
Timing and type of clinical and imaging follow up were determined by the primary interventionalist; no uniform protocol existed between practitioners. The most recent date of contact was determined for long-term follow up. For those patients with available records, the Social Security death index was queried to screen for deaths among patients lost to follow up.[
One hundred and twenty-three lesions in 110 patients were treated between August 1998 and August 2013 and met inclusion criteria. Patient demographics, lesion characteristics, and treatment features are summarized in
Results of univariate analysis are summarized in Supplemental Tables
Temporal inflection points reflecting changes in outcomes identified by recursive partitioning are summarized in
In multivariate analysis, statistical significance persisted for the association of intracranial lesion location with death at 1 year (OR, 24.91; 95% CI, 2.746–226.0; P < 0.001), death at 2 years (OR, 24.91; 95% CI, 2.746–226.0; P < 0.001), and mRS >2 at last contact (OR, 12.83, 95% CI, 2.567–641.0; P < 0.001). When stent deployment was performed, statistically significant inverse relationships were noted between use of an angioplasty balloon other than that packaged with a stent with death at last contact (OR, 0.303; 95% CI, 0.094–0.979; P = 0.046) and mRS>2 at last contact (OR, 0.234; 95% CI 0.070–0.780; P = 0.018).
In the United States, intracranial atherosclerosis causes 10–15% of ischemic strokes, and is the etiology of up to half of stroke in populations outside of the U.S.[
Twenty-five to forty percent of ischemic strokes are in the posterior circulation.[
Surgical treatments for posterior circulation atherosclerosis have shown no benefit or are prohibitively morbid.[
Technical failure was associated with poor outcomes regardless the stent type (balloon-mounted vs. self-expanding, biliary vs. coronary vs. intracranial). Additionally, the need to consider treatment of these lesions on a case-by-case basis is reflected in the multiple device types operators preferred over many years. Attempts to simplify and generalize devices belie the importance of planning each treatment individually to best fit lesion characteristics. This is suggested by the improved outcomes when using an angioplasty balloon other than that packaged with a stent, a statistically significant relationship that persisted in multivariate analysis.
In addition to selecting the proper devices, understanding the inherent risks of different lesions is important. Intracranial lesion location was a strong predictor of poor outcomes, with statistical significance in the multivariate models for association with death at one year and two years, as well as mRS>2 at last contact. Success rates were lower for these lesions compared to extracranial disease (85.1% vs. 98.0%, respectively), and all procedural complications in the current analysis occurred during treatment of intracranial lesions. Additionally, presence of tandem stenoses was predictive of adverse events in univariate analysis. Such outcomes, which are concordant with findings elsewhere, should be taken into account when considering endovascular treatment of intracranial posterior circulation atherosclerosis.[
Whereas endovascular treatment of intracranial lesions carries inherent risks, such treatment of extracranial disease, particularly at the vertebral artery origin, is relatively safe. Prior studies have demonstrated high rates of technical success and few procedural complications.[
Endovascular device technology continues to advance, as does medical management. This study found that better outcomes occurred following publication of the SPARCL trial, after which time statin treatment for cervicocerebral atherosclerosis became standard at our medical center. Indeed, we have previously reported the beneficial impact of statin treatment on our cohort of patients treated with angioplasty or stenting.[
Given the above findings and discussion, endovascular treatment of atherosclerosis in the posterior circulation can be achieved with high levels of technical success and good outcomes. However, further investigation is needed considering limitations of this current study, most of which are due to retrospective design and selection bias inherent in studying only patients for whom treatment was elected. Lack of prospectively developed follow-up protocols limited data capture within early post-procedure periods and the similarly limited assessment of follow up imaging. Additionally, this study reflects over sixteen years of interventions and includes patients treated with methods formerly considered appropriate but not currently standard of care. As such, adverse technical events might be lower for interventions performed with contemporary techniques and equipment.
Endovascular treatment of atherosclerosis of the vertebrobasilar system can be performed with high rates of technical success and few complications. This is particularly true for lesions of the extracranial vertebral arteries, for which endovascular treatment should be sought for lesions refractory to medical management. Higher rates of failure and complication may be acceptable for intracranial lesions refractory to medical care due to the poor natural history prognosis of such lesions and the morbidity inherent to infarctions in this territory.
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Conflicts of interest
There are no conflicts of interest.
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