AJR 2000; 175:1367-1369
© American Roentgen Ray Society
Primary Basilar Artery Stenting
Immediate and Long-Term Results in One Patient
Michel Piotin1,
Raphaël Blanc1,
Rajmannar Kothimbakam1,
Didier Martin2,
Ian B. Ross1 and
Jacques Moret1
1
Service de Neuroradiologie Interventionnelle,
Hôpital de la Fondation Ophtalmologique Adolphe
de Rothschild, 25-29 rue Manin, 75940 Paris Cedex 19, France.
2
Service de Neuroradiologie, Hôpital
Général, 3 rue
du Faubourg, Raines, 21033 Dijon, France.
Received March 3, 2000;
accepted after revision May 1, 2000.
Address correspondence to J. Moret.
Introduction
We describe a patient in whom primary stenting without balloon predilation
resolved a symptomatic atherosclerotic stenosis of the mid basilar artery for
which long-standing medical therapy failed to resolve neurologic symptoms. At
the 7-month follow-up examination, the patient had no recurrent neurologic
impairment, and follow-up angiograms showed total patency of the stented
arterial segment without restenosis.
Subject and Methods
A 42-year-old man was referred to our institution for angioplasty of a
basilar artery stenosis. The stenosis was responsible for three successive
ischemic attacks over a 10-month period. The second ischemic episode left the
patient dysarthric and hemiparetic on the right side; however, he
progressively regained complete motor power. MR images revealed an infarct on
the left side of the pons and a mid basilar artery stenosis. Six months later,
the patient, who had been undergoing treatment with warfarin, was readmitted
for acute central vestibular syndrome. A cerebral angiogram revealed the
previously documented basilar artery stenosis that was unchanged. The
patient's clinical condition improved with IV heparin and acetylsalicylic acid
(250 mg daily); then he was given warfarin and acetylsalicylic acid again.
Three months later, the patient returned for angioplasty of the basilar artery
stenosis.
The procedure was performed with the patient under general anesthesia. On
the frontal subtracted view, a 70% stenosis of the arterial lumen was noted
over a 3.5-mm segment (Fig.
1A); on the lateral view, the vessel width was reduced by 60% over
a 4-mm segment, according to the criteria of the North American Symptomatic
Carotid Endarterectomy Trial (Fig.
1B). The stenosis appeared to be eccentric on the lateral
projection. The stenosed arterial segment was located on the caudal aspect of
an 11-mm-long atherosclerotic basilar segment. Both posterior communicating
arteries were patent, providing blood flow to the posterior cerebral arteries
territory. A small filling defect, corresponding to a nonobstructing clot, was
seen in the P1 segment of the left posterior cerebral artery just above the
origination of the superior cerebellar artery
(Fig. 1A). After the insertion
of a 6-French femoral sheath, 5000 U of heparin were injected IV followed by a
continuous infusion of 3000 U/hr to obtain an activated clotting time at 200
sec. Two hundred fifty milligrams of acetylsalicylic acid and 10 mg of
abxicimab (Reopro; Eli Lilly, Indianapolis, IN) were also given IV. A 6-French
90-cm guiding catheter (Envoy; Cordis Endovascular, Miami Lakes, FL) was
placed into the V2 segment of the left vertebral artery. A 0.014-inch
guidewire (Transcend; Medit-tech/Boston Scientific, Natick, MA) was then
navigated across the basilar artery stenosis, and the guidewire tip was
secured into the left posterior cerebral artery
(Fig. 1C). The
balloon-expandable coronary stent (AVE GFX-2; Arterial Vascular
Engineering-Medtronic, Santa Rosa, CA) had a diameter of 3.5 mm and a length
of 18 mm; it was advanced over the guidewire to cover the stenosed segment.
Inflation of the balloon up to 8 atm (_Pa) was performed for 30 sec, and
deployment of the stent was completed.
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Fig. 1A. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Left vertebral angiogram (frontal projection) shows
basilar artery stenosis (solid arrow). Stenosis was part of
11-mm-long atherosclerotic arterial segment (arrowheads). Clot is
seen at origin of left posterior cerebral artery (open arrow).
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Fig. 1B. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Left vertebral angiogram (lateral projection) shows
basilar artery stenosis to be slightly eccentric (arrow).
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Fig. 1C. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Radiograph shows navigation of 0.014-inch guidewire
and AVE GFX-2 stent (Arterial Vascular Engineering-Medtronic, Santa Rosa, CA)
into left vertebral artery. Guidewire tip was secured in left posterior
cerebral artery (arrowhead). Stent was smoothly navigated into loops
of distal vertebral artery (arrows).
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Results
A control angiogram showed the stent mesh covering the entire
atherosclerotic basilar segment and excellent basilar artery patency, with no
residual stenosis. The distal clot located at the junction of the left P1 and
superior cerebellar artery was no longer present. Twenty minutes later, a
second control angiogram confirmed the excellent anatomic result (Figs.
1D and
1E). The proximal margin of the
stent extended 1 mm into the left vertebral artery, covering the right
vertebral artery outflow; however, its patency was not impaired
(Fig. 1D). No complications
occurred during or after the stent deployment. For 3 days after the operation,
a full dose of heparin was administered. The femoral sheath was left in place
for 24 hr to enable immediate arterial access in case of neurologic
deterioration. The same day, 250 mg of aspirin and 500 mg of ticlopidine were
administered and continued for 6 months. The patient was discharged from the
hospital 4 days after the procedure. He still suffers from the sequels of his
second ischemic attack, but no new neurologic symptoms have developed. At the
7-month follow-up examination, the control angiogram showed excellent patency
of the basilar artery (Fig.
1F).
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Fig. 1D. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Final left vertebral control angiogram (frontal
projection) shows stent deployed into basilar artery (arrowheads). No
residual stenosis is visible. Proximal end of stent protrudes into right
vertebral artery lumen without flow impairment (arrow). Distal clot
is not visible.
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Fig. 1E. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Final left vertebral control angiogram (lateral
projection) shows stent deployed into basilar artery (arrowheads). No
residual stenosis is visible.
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Fig. 1F. —42-year-old man with recurrent symptoms of basilar ischemia
despite medical therapy. Follow-up angiogram (frontal projection) obtained 7
months after A and B shows excellent stent patency.
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Discussion
To prevent acute basilar artery thrombosis and its catastrophic
consequences, anticoagulation and antiplatelet therapy have been considered. A
recent randomized study suggested that the administration of prescription
drugs is inadequate [1].
Further atheromatosis progression was not stalled by long-term anticoagulative
therapy, and stroke rates reported for patients with basilar artery stenoses
undergoing such therapy were as high as 10% per year, leading to the
conclusion that aggressive therapy (i.e., angioplasty) should be considered,
especially for high-grade stenoses.
Although basilar artery angioplasty presents special technical challenges,
intracerebral percutaneous transluminal angioplasty is performed. During
angioplasty, vessel tortuosity and compromise of the brainstem perforators
originating from the basilar artery are problems that are less common with
proximal stenosis. The reasons for a slow and undersized dilation of the
stenosis are to protect the vessels that do not have supporting tissue in the
event of a sudden rupture, intimal dissection, acute vasospasm, and
thrombosis. However, the likelihood of such potentially dramatic complications
may be minimized by stent implantation, which also allows a more aggressive
anatomic correction [2].
Abciximab is more effective than aspirin and heparin in the prevention of
acute thrombosis during coronary angioplasty
[3]. This therapy was effective
in a patient who underwent local intraarterial cerebral thrombolysis and
angioplasty for acute basilar artery thrombosis
[4]. Abxicimab, a chimeric
antibody to the human platelet glycoprotein IIb/IIIa complex, inhibits
platelet aggregation—a biologic phenomenon that plays a key role in
abrupt vessel occlusion after angioplasty. However, antithrombotic medication
in cerebral angioplasty has not been standardized, and antiplatelet regimens
administered during and after intracranial stenting remain empirical. On the
basis of coronary angioplasty experiences in which inhibition of the platelet
glycoprotein IIb/IIIa complex with abciximab reduces acute ischemic
complications [5], we used an
IV Reopro bolus during stent implantation followed by 6 months of oral aspirin
and ticlopidine. Glycoprotein IIb/IIIa complex blockade for stenting offers
almost complete inhibition of platelet aggregation and can bridge the delayed
onset of ticlopidine and aspirin. The use of abciximab and stent implantation
may also confer complementary long-term clinical benefits for patients
undergoing intracranial angioplasty, similar to benefits for patients
undergoing coronary stenting
[6].
The choice of the stent was dictated by its capability to negotiate vessel
tortuosities. Not many stents conform to the technical requirements of length
and flexibility to facilitate navigation into tortuous vessels and smoothly
cross the stenotic lesion without inadvertent stent retention. Because of its
flexibility and its very low profile, the AVE GFX-2 stent was the most
suitable stent.
Two reports have suggested that stent-assisted angioplasty may represent a
viable therapeutic option for vertebral artery and basilar artery atheromatous
stenoses [2,
7]. The operators performed
prestenting balloon angioplasty to predilate the lesions. Then they delivered
the balloon-expandable stent. Predilation carries a higher risk of intimal
dissection and distal embolization caused by plaque fracture. The geometry of
the new generation of coronary stents should enable the treatment of stenotic
lesions without presenting angioplasty.
For stenting, the risk of impairing small perforating vessels is probably
not higher than with angioplasty because of the wide interstices and thin
struts. Theoretically, and in keeping with the coronary artery stenting
experience, stenting seems to be a logical step in the treatment of
intracranial arterial stenosis.
References
-
The Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) study
group. Prognosis of patients with symptomatic vertebral or basilar artery
stenosis. Stroke
1998;29:1389
-1392[Abstract/Free Full Text]
-
Lanzino G, Fessler RD, Miletich RS, Guterman LR, Hopkins LN.
Angioplasty and stenting of basilar artery stenosis: technical case report.
Neurosurgery
1999;45:404
-407[Medline]
-
Lefkovits J, Ivanhoe RJ, Califf RM, et al. Effects of platelet
glycoprotein IIb/IIIa receptor blockade by a chimeric monoclonal antibody
(abciximab) on acute and six-month outcomes after percutaneous transluminal
coronary angioplasty for acute myocardial infarction: EPIC investigators.
Am J Cardiol
1996;77:1045
-1051[Medline]
-
Wallace RC, Furlan AJ, Moliterno DJ, Stevens GH, Masaryk TJ, Perl J
II. Basilar artery rethrombosis: successful treatment with platelet
glycoprotein IIB/IIIA receptor inhibitor. AJNR
1997;18:1257
-1260[Abstract]
-
The EPISTENT investigators. Evaluation of platelet IIb/IIIa
inhibitor for stenting: randomised placebo-controlled and
balloon-angioplasty-controlled trial to assess safety of coronary stenting
with use of platelet glycoprotein-IIb/IIIa blockade.
Lancet
1998;352:87
-92[Medline]
-
Lincoff AM, Califf RM, Moliterno DJ, et al. Complementary clinical
benefits of coronary-artery stenting and blockade of platelet glycoprotein
IIb/IIIa receptors: evaluation of platelet IIb/IIIa inhibition in stenting
investigators. N Engl J Med
1999;341:319
-327[Abstract/Free Full Text]
-
Joseph GJ, Goldstein J, Cloft H, Tong F, Dion J. Endovascular
stenting of atherosclerotic stenosis in a basilar artery after unsuccessful
angioplasty. AJR
2000;174:384
-385
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Introduction
Subject and Methods
