Primary versus elective percutaneous transluminal angioplasty with stenting for symptomatic intracranial atherosclerotic stenosis: a 18-centre retrospective cohort study using the pEGASUS-HPC stent

INTRODUCTION: To describe the safety and effectiveness of percutaneous transluminal angioplasty with pEGASUS-HPC stenting (PTAS) for symptomatic intracranial atherosclerotic stenosis (sICAS) and compare primary versus elective use. PATIENTS AND METHODS: We retrospectively included consecutive adults with sICAS ≥50% treated with pEGASUS-HPC PTAS at 18 neurovascular centres (May 2021-February 2025). Primary PTAS was defined as treatment during non-large-vessel-occlusion acute ischaemic stroke (AIS); Elective PTAS was performed at least 7 days after the qualifying ischaemic presentation for recurrent symptoms or haemodynamic compromise despite intensive medical therapy. Outcomes included technical success (post-treatment stenosis ≤50% without intraprocedural complications), in-hospital major complications (intracerebral haemorrhage, AIS or death), restenosis and functional status, measured by the modified Rankin Scale (mRS) at last follow-up. RESULTS: Among 141 patients (Primary 71; Elective 70), median post-treatment stenosis was 23.0%; technical success was 94.3% (90.1% vs 98.6%; P = .063). In-hospital major complications occurred in 7.1% (12.7% Primary vs 1.4% Elective; P = .017), driven by intraprocedural in-stent thrombosis (9.9% vs 0%; P = .013). At last follow-up (median 9 months), restenosis ≥50% was observed in 14.3% (7.8% vs 19.7%; P = .10) and mRS <3 in 84.7% (82.1% vs 87.1%; P = .61). New diffusion-weighted imaging lesions were seen in 39.2% of 79 patients with early MRI, without group differences. DISCUSSION: In this multicentre cohort, pEGASUS-HPC PTAS provided substantial luminal gain, moderate restenosis and good mid-term functional outcomes overall. Elective use in medically refractory sICAS was associated with very low major complication rates, whereas primary use during AIS carried significantly higher thrombotic and haemorrhagic risk.