J Korean Neurosurg Soc.  2021 Mar;64(2):198-206. 10.3340/jkns.2020.0146.

Preliminary Experience of Neuroform Atlas Stenting as a Rescue Treatment after Failure of Mechanical Thrombectomy Caused by Residual Intracranial Atherosclerotic Stenosis

• Yi HJ
• Sung JH
• Lee DH

• KMID: 2513850
• DOI: http://doi.org/10.3340/jkns.2020.0146

Abstract

Objective
: The low-profile Neuroform Atlas stent can be deployed directly without an exchange maneuver by navigating into the Gateway balloon. This retrospective study assessed the safety and efficacy of Neuroform Atlas stenting as a rescue treatment after failure of mechanical thrombetomy (MT) for large artery occlusion.
Methods
: Between June 2018 and December 2019, a total of 31 patients underwent Neuroform Atlas stenting with prior Gateway balloon angioplasty after failure of conventional MT caused by residual intracranial atherosclerotic stenosis (ICAS). Primary outcomes were successful recanalization and patency of the vessel 24 hours after intervention. Secondary outcomes were vessel patency after 14 days and 3-month modified Rankin Scale. Peri-procedural complications, intracerebral hemorrhage (ICH), and 3-month mortality were reviewed.
Results
: With a 100% of successful recanalization, median value of stenosis was reduced from 79.0% to 23.5%. Twenty-eight patients (90.3%) showed tolerable vessel patency after 14 days. New infarctions occurred in three patients (9.7%) over a period of 14 days; two patient (6.5%) underwent stent occlusion at 24 hours, and the other patient (3.2%) with delayed stent occlusion had a non-symptomatic dot infarct. There were no peri-procedural complications. Two patients (6.5%) developed an ICH immediately after the procedure with one of them is symptomatic.
Conclusion
: Neuroform Atlas stenting seems to be an effective and safe rescue treatment modality for failed MT with residual ICAS, by its high successful recanalization rate with tolerable patency, and low peri-procedural complication rate. Further multicenter and randomized controlled trials are needed to confirm our findings.

Keyword

Angioplasty; Atherosclerosis; Thrombectomy; Stents; Stroke; Neuroform atlas

Figure

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  Fig. 1. Illustration of the Neuroform Atlas stent with W-shaped cells and alternating cell count per row. Pictures were provided courtesy of Stryker.

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  Fig. 2. An example of a case with balloon angioplasty and intracranial stenting using the Neuroform Atlas stent followed by mechanical thrombectomy for basilar artery (BA) occlusion with stenosis. A : Initial angiography revealed BA trunk occlusion. B : Severe stenosis of the BA trunk was confirmed by angiography with the Trevo stent retriever deployed. C : Angiography after Trevo stent retrieval also showed BA trunk stenosis status. D : Balloon angioplasty was performed for the severe stenotic lesion of BA trunk with a 2.5×15 mm sized Gateway balloon (black dot arrow : Gateway balloon). E : Serially, a 3.0×21 mm-sized Neuroform Atlas stent was delivered directly through the lumen of the angioplasty Gateway balloon. Follow-up angiography after Neuroform Atlas stent deployment revealed significantly improved BA trunk stenosis (white and black arrows : distal and proximal markers of the Neuroform Atlas stent, respectively). F : Maximum intensity projection coronal image of computed tomography angiography with perfusion performed 24 hours after the intervention showed tolerable BA flow with the Neuroform Atlas stent.

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  Fig. 3. Representative case of balloon angioplasty with the Gateway balloon and Neuroform Atlas stent deployment followed by mechanical thrombectomy in internal carotid artery (ICA) stenosis with occlusion. A and B : After mechanical thrombetomy with the stent retriever, follow-up angiography showed severe stenosis of the left distal ICA. C and D : Over-the-wire balloon (3.0×15 mm sized Gateway balloon) was delivered to the lesion of left distal ICA stenosis by Traxcess micro-wire guidance (black dotted arrow : Gateway balloon). E and F : Balloon angioplasty at the stenotic lesion was performed with a Gateway balloon (black dotted arrow : Gateway balloon). G and H : Neuroform Atlas stent (4.0×24 mm) was delivered directly through the lumen of the angioplasty balloon without the need for an intracranial exchange maneuver (white and black arrows : distal and proximal markers of the Neuroform Atlas stent, respectively).

Reference

References

1. Alexander MJ, Zauner A, Chaloupka JC, Baxter B, Callison RC, Gupta R, et al. WEAVE trial: final results in 152 on-label patients. Stroke. 50:889–894. 2019.

2. Baek JH, Kim BM, Kim DJ, Heo JH, Nam HS, Yoo J. Stenting as a rescue treatment after failure of mechanical thrombectomy for anterior circulation large artery occlusion. Stroke. 47:2360–2363. 2016.

3. Bracard S, Ducrocq X, Mas JL, Soudant M, Oppenheim C, Moulin T, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 15:1138–1147. 2016.

4. Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P, et al. Stent placement in acute cerebral artery occlusion: use of a selfexpandable intracranial stent for acute stroke treatment. Stroke. 40:847–852. 2009.

5. Ciccio G, Robert T, Smajda S, Fahed R, Desilles JP, Redjem H, et al. Double stent assisted coiling of intracranial bifurcation aneurysms in Y and X configurations with the Neuroform Atlas stent: immediate and mid term angiographic and clinical follow-up. J Neurointerv Surg. 11:1239–1242. 2019.

6. Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, et al. Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial. Lancet. 383:333–341. 2014.

7. Feng Z, Duan G, Zhang P, Chen L, Xu Y, Hong B, et al. Enterprise stent for the treatment of symptomatic intracranial atherosclerotic stenosis: an initial experience of 44 patients. BMC Neurol. 15:187. 2015.

8. Fiorella D, Levy EI, Turk AS, Albuquerque FC, Niemann DB, Aagaard-Kienitz B, et al. US multicenter experience with the wingspan stent system for the treatment of intracranial atheromatous disease: periprocedural results. Stroke. 38:881–887. 2007.

9. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 387:1723–1731. 2016.

10. Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 359:1317–1329. 2008.

11. Humphries W, Hoit D, Doss VT, Elijovich L, Frei D, Loy D, et al. Distal aspiration with retrievable stent assisted thrombectomy for the treatment of acute ischemic stroke. J Neurointerv Surg. 7:90–94. 2015.

12. Jankowitz BT, Hanel R, Jadhav AP, Loy DN, Frei D, Siddiqui AH, et al. Neuroform Atlas Stent System for the treatment of intracranial aneurysm: primary results of the Atlas Humanitarian Device Exemption cohort. J Neurointerv Surg. 11:801–806. 2019.

13. Leischner H, Flottmann F, Hanning U, Broocks G, Faizy TD, Deb-Chatterji M, et al. Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg. 11:439–442. 2019.

14. Levy EI, Rahman M, Khalessi AA, Beyer PT, Natarajan SK, Hartney ML, et al. Midterm clinical and angiographic follow-up for the first Food and Drug Administration-approved prospective, single-arm trial of primary stenting for stroke: SARIS (stent-assisted recanalization for acute ischemic stroke). Neurosurgery. 69:915–920. discussion 920. 2011.

15. Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ, et al. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke. 40:3552–3556. 2009.

16. Maegerlein C, Mönch S, Boeckh-Behrens T, Lehm M, Hedderich DM, Berndt MT, et al. PROTECT: PRoximal balloon Occlusion TogEther with direCt Thrombus aspiration during stent retriever thrombectomy - evaluation of a double embolic protection approach in endovascular stroke treatment. J Neurointerv Surg. 10:751–755. 2018.

17. Mocco J, Hanel RA, Sharma J, Hauck EF, Snyder KV, Natarajan SK, et al. Use of a vascular reconstruction device to salvage acute ischemic occlusions refractory to traditional endovascular recanalization methods. J Neurosurg. 112:557–562. 2010.

18. Salik AE, Selcuk HH, Zalov H, Kilinc F, Cirak M, Kara B. Medium-term results of undersized angioplasty and stenting for symptomatic high-grade intracranial atherosclerotic stenosis with enterprise. Interv Neuroradiol. 25:484–490. 2019.

19. Tsai JP, Hardman J, Moore NZ, Hussain MS, Bain MD, Rasmussen PA, et al. Early post-humanitarian device exemption experience with the Neuroform Atlas Stent. J Neurointerv Surg. 11:1141–1144. 2019.

20. Ulfert C, Pham M, Sonnberger M, Amaya F, Trenkler J, Bendszus M, et al. The Neuroform Atlas Stent to assist coil embolization of intracranial aneurysms: a multicentre experience. J Neurointerv Surg. 10:1192–1196. 2018.

21. Woo HG, Sunwoo L, Jung C, Kim BJ, Han MK, Bae HJ, et al. Feasibility of permanent stenting with solitaire FR as a rescue treatment for the reperfusion of acute intracranial artery occlusion. AJNR Am J Neuroradiol. 39:331–336. 2018.

22. Yi HJ, Hwang G, Lee BH. Variability of platelet reactivity on antiplatelet therapy in neurointervention procedure. J Korean Neurosurg Soc. 62:3–9. 2019.

23. Yi HJ, Sung JH, Lee DH, Yang SH, Hong JT. A useful diagnostic method to reduce the in-hospital time delay for mechanical thrombectomy: volume perfusion computed tomography with added vessel reconstruction. J Neurosurg. 2018; [Epub ahead of print].

24. Yoon W, Kim SK, Park MS, Kim BC, Kang HK. Endovascular treatment and the outcomes of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Neurosurgery. 76:680–686. discussion 686. 2015.

25. Yu SC, Leung TW, Lee KT, Wong LK. Learning curve of Wingspan stenting for intracranial atherosclerosis: single-center experience of 95 consecutive patients. J Neurointerv Surg. 6:212–218. 2014.

26. Zaidat OO, Wolfe T, Hussain SI, Lynch JR, Gupta R, Delap J, et al. Interventional acute ischemic stroke therapy with intracranial self-expanding stent. Stroke. 39:2392–2395. 2008.

27. Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke. 44:2650–2663. 2013.

28. Zhao H, Zhang J, Gu D, Shi Z, Pan J, Geng Y, et al. Tirofiban facilitates the reperfusion process during endovascular thrombectomy in ICAS. Exp Ther Med. 14:3314–3318. 2017.

29. Zhao LB, Park S, Lee D, Lee DH, Suh DC. Mechanism of procedural failure related to wingspan. Neurointervention. 7:102–108. 2012.