Stentplasty for symptomatic intracranial atherosclerotic disease after failed medical therapy

Purpose Endovascular treatment of intracranial atherosclerotic disease (ICAD) remains challenging due to procedural risks and stroke recurrence. Prior trials have favored aggressive medical therapy. In patients refractory to medical therapy, “stentplasty” using expandable and retrievable devices may provide a safer alternative to ballon angioplasty by allowing controlled, submaximal vessel dilation without flow arrest. We present a two‐center experience using these devices for treating symptomatic ICAD refractory to maximal medical therapy. Methods Patients with symptomatic high‐grade stenosis (>70‐99%) who failed medical therapy, and underwent “stentplasty” with the Tigertriever and Comaneci devices were included. Demographic data, periprocedural complications, and radiological and functional outcomes were evaluated and reported. Results Eighteen patients were treated, of whom 16 (89%) presented with acute ischemic stroke and 2 (11%) with transient ischemic attacks. The median admission NIHSS score was 9 (IQR 6‐21). Stentplasty alone resulted in successful reperfusion (mTICI ≥ 2b‐3) in 11 patients (61%); the remaining 7 patients (39%) required rescue therapy with permanent stenting. Median stenosis was reduced from 95% (IQR 92‐99%) pre‐treatment to 50% (IQR 48‐66%) after stentplasty, and further to 10% (IQR 10‐19%) in those receiving permanent stents. One periprocedural complication occurred (6%), involving distal embolization during stenting. The median improvement in NIHSS from admission to discharge was 5 points (IQR 0‐8). No patients experienced recurrent ischemic stroke or reocclusion during follow‐up and all patients achieved a modified Rankin Scale score of 0‐2 at 90‐day follow‐up (range 30‐180 days). Conclusion Stentplasty using expandable and retrievable devices appears to be a safe and effective treatment option for patients with symptomatic ICAD refractory to medical therapy. While many cases can be successfully treated with stentplasty alone, a subset may require adjunctive permanent stenting to achieve optimal recanalization. image Figure 2. (A) CT perfusion of a patient with intermittent right‐sided paresis and aphasia. There is reduced cerebral blood flow in the left middle cerebral artery territory. (B) Antero‐posterior digital substraction angiography (DSA) revealing severe >90% stenosis (arrowhead) of the proximal left middle cerebral artery (MCA). (C) The Comaneci retrievable device was used to perform multiple stentplasties in the proximal MCA and terminal internal carotid artery. (D) Post‐ stentplasty DSA showing significant improvement in left MCA stenosis (arrowhead) and restoration of distal flow.