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Advanced Neurology Rescue stenting in mechanical thrombectomy

3.1. Technical and pathological considerations self-expanding stents may be preferred as they would self-

The overall vessel imaging assessment before intervention expand to the anatomy of the lesion within which they are
may help determine the presence of an underlying ICAS deployed.
with multiple vessel involvement (extracranial and There are several circumstances in which balloon
intracranial ICA), an intimal flap or a double lumen in the angioplasty alone is preferred in patients with refractory
case of IAD. Lesion length must be appropriate for the LVO. In ICAS-LVO patients who are on concomitant use
29
devices available to the clinician. of anticoagulation (e.g., atrial fibrillation and mechanical
RS requires additional manipulation of the target heart valve), stenting is usually avoided as much as
vessel, increasing the risk of vessel injury and perforation. possible to avoid multiple antithrombotics (antiplatelet
In addition, reperfusion hemorrhages have been described and anticoagulant), which may increase the bleeding risk
in cases receiving RS, necessitating periprocedural blood to the patient. If one is confronted with a patient with
pressure management. 80-82 RS may not provide benefit in recalcitrant ICAS-LVO despite standard thrombectomy
patients with intracranial hemorrhage as it may increase passes, then balloon angioplasty would be preferred
the risk of perfusion injury in the stenosed vessels. for these patients. In patients who have concerns about
intracranial hemorrhage (low ASPECTS, recent IVT) with
The posterior circulation presents unique barriers multiple antithrombotics, balloon angioplasty may also be
for refractory MT, making the application of RS more preferred for these patients.
complex. With the anatomy’s eloquence, perforator vessels,
and a higher risk of complications, it is important to plan 3.2.2. Devices
and carefully weigh the potential benefits and risks of
RS according to the patient’s clinical presentation. When Studies have investigated different stent devices used in
unstable plaque is suspected, there may be an increased intracranial stenting including the Apollo stent, Wingspan
risk of reocclusion, and therefore, RS may be warranted. 59 stent, Solitaire stent, and other self-expanding stents such
as Neuroform Atlas (Stryker Neurovascular) to determine
3.2. Endovascular techniques and stents used the most effective rescue measure for LVO after refractory
Multiple techniques have been explored in RS, including MT. 26,83 At present, only a single device is the U.S. Food
the use of both self-expanding stents, BMSs, drug-eluting and Drug Administration (FDA)-approved for stenting
coronary stents, and stents labeled for intracranial use. of symptomatic ICAS (without LVO): the Wingspan
25
However, there is limited evidence regarding the relative (Stryker) stent. The Wingspan stent is a bare metal self-
efficacy of different devices and stenting methods, and expanding stent delivered following balloon percutaneous
no devices have been directly compared in head-to-head transluminal angioplasty (PTA) by the Gateway balloon
trials. Ultimately, the choice of the stent will depend on catheter. The Wingspan stent has been studied for primary
various factors, including the interventionalist’s preference, non-emergent intracranial stenting in the SAMMPRIS and
available devices, cost, vessel tortuosity, the patient’s CASSISS trials. 84,85
hypercoagulable status, and lesion morphology. Multiple coronary stents are used off-label for
intracranial stenting including the Resolute Onyx, Onyx
3.2.1. Techniques
Frontier, and XIENCE Skypoint. The Resolute Onyx and
In our opinion, there are several factors that may affect the Onyx Frontier (Medtronic) are the second-generation
decision to use self-expanding versus BMSs in patients with drug-eluting BMSs used for coronary interventions.
ICAS-LVO lesions. BMSs are more difficult to navigate than Recently, its off-label use in neuro-intervention has
self-expanding stents because of the additional element of shown promising results in observational studies. 86,87 The
the balloon, which increases the stiffness of the system XIENCE Skypoint stent off-label use has been reported,
and the difficulty of intracranial navigation. BMS is often highlighting technical feasibility, long-term safety, and
favored in patients with short lesion length, low tortuosity, efficacy. 71
and arterial vessel diameter >2 mm considering that the
smallest BMSs are approximately 2 mm in size. The use of 3.3. Alternative rescue therapies
an intermediate catheter is often helpful in delivering the Various alternative rescue strategies have been proposed,
BMS close to the target artery. including pharmacological interventions such as IA or

Self-expanding stents are preferred in patients who intravenous (IV) infusion of glycoprotein IIb/IIIa receptor
have longer lesions and more tortuous anatomy and lesions inhibitors (GPI), or mechanical interventions; adjunctive
that are <2 mm in diameter. If there is a mismatch in the PTA or balloon angioplasty; double solitaire stent retriever;
diameter of the proximal and distal end of the lesion, then and Y-stent rescue thrombectomy. 88-93

Volume 3 Issue 3 (2024) 5 doi: 10.36922/an.3950